Open access Brief report

Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2019-000302 on 12 August 2019. Downloaded from [Link] on September 11, 2019 by guest. Protected by
Family satisfaction in the trauma and surgical
intensive care unit: another important
quality measure
Tom Maxim, Agustin Alvarez, Yvonne Hojberg, Derek Antoku, Chioma Moneme,
Andrew Singleton, Caroline Park, Kazuhide Matsushima

►► Additional material is Abstract to individual patient preferences, needs, and values

published online only. To view Background  A growing body of research has explored and ensuring that patient values guide all clinical
please visit the journal online
([Link] x.​doi.o​ rg/​10.​1136/​patient satisfaction as one of the healthcare quality decisions.”1 Indeed, hospitals are now required to
tsaco-2​ 019-​000302). measures. To date, scarce data are available regarding demonstrate higher quality, patient-centered care at
family experience in the trauma and surgical intensive a lower cost, in addition to conventional outcome
Surgery, University of Southern care unit (TSICU). The purpose of this study was to measures such as mortality rate, complication rate,
California, Los Angeles, and length of hospital stay.2 Thus, a growing body of
describe and analyze the results of a family satisfaction
California, USA
survey in the TSICU. research has explored patient satisfaction as one of
Correspondence to Methods  Family members of patients at a level 1 the healthcare quality measures.3 4 Recent literature
Dr Kazuhide Matsushima, trauma center were invited to participate in this study has shown that high patient satisfaction is correlated
Surgery, University of Southern after 72 hours of intensive care unit stay. Participants with higher surgical quality and efficiency of care
California, Los Angeles, completed a modified version of the Family Satisfaction as well as low mortality.5 6 However, in the trauma
CA 90007, USA; ​kazuhide.​ and surgical intensive care unit (TSICU), patients
in the Intensive Care Unit questionnaire, a validated
matsushima@m ​ ed.​usc.e​ du
survey measuring family satisfaction with care and are critically ill and may be unable to participate in
This article was presented at the decision-making. Data collection spanned from April decisions regarding their care, often leaving family
13th Annual Academic Surgical 2016 to July 2017. Patient characteristics were compiled members to take on the role of surrogate deci-
Congress in Jacksonville, Florida, from the medical record. Quantitative analysis was sion-maker.7 8
January 31, 2018.
performed using a 5-point Likert score, converted to a In recent years, several types of survey tools have

copyright.
Received 9 February 2019 scale of 0 (poor) to 100 (excellent). been developed and used to better assess family
Revised 1 May 2019 Results  The overall response rate was 78.6%. Of the satisfaction as a proxy for measuring the quality
Accepted 24 July 2019 103 family members for 88 patients, most were young of healthcare in the intensive care unit (ICU).9–13
(median age: 41 years) and female (75%). Language One of them is the Family Satisfaction in the Inten-
fluency was 44.6% English-only, 31.7% Spanish-only, sive Care Unit (FS-ICU), a validated questionnaire
and 23.8% bilingual. Mean summary family satisfaction developed by the Canadian Researchers at the End
scores (±SD) were 80.6±26.4 for satisfaction with care, of Life Network in 2003 and revised in 2006.10 11
79.3±27.1 for satisfaction with decision-making, and Studies using the FS-ICU tool have demonstrated
80.1±26.7 for total satisfaction. Respondents were that family satisfaction in the ICU is consistently
less satisfied with the frequency of communication high in adults, children, and Hispanic popula-
with physicians (70.7±27.4) and language translation tions.14–17 Data remain scarce on the utility of the
(73.2±31.2). FS-ICU to evaluate the level of family satisfaction
Discussion  Overall family satisfaction with the care in the TSICU. As for other types of ICU patients,
provided to patients in the TSICU is high, although family is a key component of the healing team for
opportunities for improvement were noted in the critically ill trauma and surgical patients. It may
frequency of communication between physicians and follow that a highly satisfied family member will be
family and language translation services. Further quality better prepared to provide support for their loved
improvement projects are warranted. one, participate in the decision-making process,
Level of evidence  Care management study: level V. and perhaps positively influence patient care. The
purpose of this study was to describe and analyze
the results of a family satisfaction survey conducted
in the TSICU. We developed two hypotheses for
Introduction this study: first, that it would be feasible to conduct
Medicine is a field of continual progress, spurred a family satisfaction study in the TSICU using a
on by innovation and constantly seeking to improve largely prevalidated survey, and second that the
© Author(s) (or their itself. Beyond the technological advances and scien-
employer(s)) 2019. Re-use survey could identify areas for improvement in
permitted under CC BY-NC. No tific breakthroughs that have shaped the standard patient care within the study facility.
commercial re-use. See rights of care, a fundamental shift in the definition of
and permissions. Published quality healthcare arrived with the release of the
by BMJ. Institute of Medicine’s report, Crossing the Quality Methods
To cite: Maxim T, Chasm: A New Health System for the 21st Century.1 Study design and population
Alvarez A, Hojberg Y, et al. Among the six key areas for improvement detailed This was a prospective observational study
Trauma Surg Acute Care Open in this report is patient-centered care, defined as conducted from April 2016 to July 2017. Patients
2019;4:e000302. “providing care that is respectful of and responsive admitted to one of four acute care surgery services
Maxim T, et al. Trauma Surg Acute Care Open 2019;4:e000302. doi:10.1136/tsaco-2019-000302 1
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Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2019-000302 on 12 August 2019. Downloaded from [Link] on September 11, 2019 by guest. Protected by
Data collection and statistical analysis
The results of the modified FS-ICU 24 were compiled in a secure
web application system, REDCap (Research Electronic Data
Capture). Quantitative analysis of the FS-ICU was performed
using a 5-point Likert score, converted to a scale of 0 (poor) to
100 (excellent), as described previously.10 The average score and
SD were computed for each variable, as well as summary scores
for satisfaction with care (FS-ICU/Care), satisfaction with deci-
sion-making (FS-ICU/DM), and total composite score (FS-ICU/
Total).11

Results
During a 15-month study period, a total of 2150 patients were
admitted to the TSICU. Of 131 family members approached,
103 family members submitted questionnaires for 88 patients
Figure 1  Family satisfaction with care response distribution (response rate: 78.6%). Eighty-seven out of 103 surveys
(number of responses). (1) Concern and caring by the ICU staff for the (84.5%) were completed by family members of the 74 trauma
patient. (2) Symptom management: pain. (3) Symptom management: patients enrolled in this study. Among the cohort of trauma
breathlessness. (4) Symptom management: agitation. (5) How well the patients, 66 patients had one family survey respondent, 5
ICU staff showed an interest in family member’s needs. (6) How well patients had two respondents, 2 patients had three respon-
the ICU staff provided emotional support. (7) The teamwork of all the dents, and 1 patient had five respondents. Sixteen surveys
ICU staff who took care of the patient. (8) The courtesy, respect, and were completed by family members of 14 patients admitted
compassion given to family member. (9) How well the nurses cared for the management of emergency general surgery disorders;
for the patient. (10) How often the nurses communicated with family 13 patients each had one survey respondent, whereas 1 patient
member about the patient’s condition. (11) How well doctors cared for had three submissions. The median age of study patients was
the patient. (12) Atmosphere of the ICU. (13) Atmosphere of the ICU 37.5 years and 71.6% were male. Of 74 trauma patients,
waiting room. (14) How satisfied was the family member with the level 83.7% sustained blunt injuries. Overall, inmortality rate was
or amount of care received by the patient. ICU, intensive care unit; N/A, 6.8% and the median ICU stay was 11 days. Family respon-
not applicable. dents were mostly young (median age 41, IQR 29–56) and
female (75%). Forty-five percent had been involved as family

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of an ICU patient in the past, and 60.8% reported living with
in the TSICU and their family members at LAC+USC Medical the patient. Language fluency was 44.6% English-only, 31.7%
Center, a level 1 trauma center, were invited to participate in Spanish-only, and 23.8% bilingual.
this study by research personnel after 72 hours of ICU stay. After Summary family satisfaction scores were calculated for the
eligible patients and their family (≥18 years old) were identified, standardized FS-ICU 24 items. The mean scores (±SD) were
research personnel provided information about the study and 80.6±26.4 for FS-ICU/Care, 79.3±27.1 for FS-ICU/DM,
distributed the survey. Subjects were informed that their partic- and 80.1±26.7 for FS-ICU/Total. Response distribution for
ipation was voluntary, their responses would not be seen by the each survey item is shown in figures 1 and 2. Individual items
patient’s care providers, and participation in this study would earning the highest scores were satisfaction with the amount
have no direct impact on their loved one’s care. Only family of time to make decisions and ask questions (91.8±27.5), the
members fluent in English or Spanish were approached for the skill and competence of ICU doctors (87.1±19.6) and nurses
study, with those fluent in both languages given the option of (86.0±23.1), and satisfaction with the concern and caring by
completing either version of the questionnaire. Survey recipients the ICU staff for the patient (86.8±21.5) and pain management
were instructed to complete the form at their convenience and (85.8±21.3). Conversely, lowest scoring items were satisfaction
return the questionnaire. If applicable, multiple family members with the level or amount of care provided (64.1±36.8), the
were given the opportunity to complete the survey form for each atmosphere of the waiting room (64.8±33.3), and the frequency
patient. of communication with doctors (70.7±29.5) (tables 1 and 2).
Eight supplementary items were also evaluated in this
survey, and the response distribution is shown in figure 3.
Survey instrument Family members were highly satisfied with the hospital policy
The FS-ICU 24 is a validated survey measuring family satisfac- on waiting times (85.9±21.1), less satisfied with social work
tion in the domains of satisfaction with care (14 items) and deci- (69.7±30.0) and spiritual services (69.4±29.0), and least satis-
sion-making (10 items).11 In addition to these 24 scored items, fied with the quality of hospital food for patients (51.4±31.8)
the survey includes a brief demographics section and three and family (60.1±30.7) (table 3). Seventy-six of 103 participants
short-answer questions for participant comments. The FS-ICU submitted qualitative responses, which were largely positive and
24 was modified for this study to include eight additional items reflective of the scored items on the survey. Several participants
on satisfaction with hospital food, translation services, hospital expressed gratitude to the medical staff and endorsed high satis-
visiting times, and interactions with ancillary staff. Although faction with the quality of care in the TSICU. Among the nega-
these supplementary questions had not been previously vali- tive comments, multiple responses called for improvements with
dated, they were included as baseline metrics of the TSICU’s the comfort/amenities of the waiting room and sleeping condi-
performance beyond that provided by the original FS-ICU 24. tions for family members, more frequent communication with
The instrument was made available to study participants in physicians, and a desire for more bilingual (English-speaking and
English and Spanish (online supplementary file 1 and 2). Spanish-speaking) staff.
2 Maxim T, et al. Trauma Surg Acute Care Open 2019;4:e000302. doi:10.1136/tsaco-2019-000302
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Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2019-000302 on 12 August 2019. Downloaded from [Link] on September 11, 2019 by guest. Protected by
Table 2  Family satisfaction with decision-making scores
Family satisfaction with decision-making Mean score SD
1. Frequency of communication with doctors 70.66 29.46
2. Ease of getting information 77.23 27.04
3. Understanding of information 79.95 23.07
4. Honesty of information 83.25 21.81
5. Completeness of information 80.75 24.20
6. Consistency of information 79.69 23.75
7. Inclusion in decision-making process 76.29 34.13
8. Support in decision-making process 74.22 27.35
9. Control of care over the patient 79.47 26.65
10. Enough time to address concerns and questions 91.76 27.49

Figure 2  Family satisfaction with decision-making response provided at our facility. Respondents acknowledged the skill of
distribution (number of responses). (1) How often doctors our providers and their ability to manage patients’ symptoms,
communicated with family member about the patient’s condition. (2) as these questions were among the highest-scoring items on the
Willingness of the ICU staff to answer questions. (3) How well the survey instrument. However, the results also present opportu-
ICU staff provided explanations that were easy to understand. (4) nities to address items with lower satisfaction; the frequency of
Honesty of information provided to family members about the patient’s family communication with physicians, the quality of language
condition. (5) How well the ICU staff informed family member of what translation services, and the comfort and amenities of the family
was happening to the patient and why things were being done. (6) waiting room are all candidates for improvement.
Consistency of information provided about the patient’s condition. (7) The results presented here are comparable with those of
Family member inclusion in the decision-making process. (8) Family prior studies using the FS-ICU survey instrument. Lam et al15
member support during the decision-making process. (9) Family member collected the FS-ICU questionnaire from 736 family members
feeling of control over the patient’s care. (10) Adequate time to have at a medical-surgical ICU in Hong Kong, and obtained summary
questions answered. ICU, intensive care unit; N/A, not applicable. satisfaction scores of 78.0±16.8 for FS-ICU/Care, 78.6±13.6
for FS-ICU/DM, and 78.1±14.3 for FS-ICU/Total. Another
study investigated family satisfaction at four ICUs in Germany,

copyright.
Discussion
receiving 215 completed surveys and finding summary scores
In this study, we sought to characterize family satisfaction in the
of 78.6±14.3 for FS-ICU/Care, 77.8±15.6 for FS-ICU/DM,
ICU in a population composed primarily of trauma and emer-
and 78.33±14.30 for FS-ICU/Total.14 Similarly, Stricker et al
gency general surgery patients. Our response rate of 78.6%
performed a multicenter study of Swiss ICUs, analyzing 996
was within the range of 27.8% to 84.0% reported in previous
surveys and finding summary scores of 79±14 for FS-ICU/
publications, supporting the hypothesis that a family satisfac-
Care, 77±15 for FS-ICU/DM, and 78±14 for FS/ICU-Total.18
tion survey is feasible in the TSICU.14 17 Our results demonstrate
A notable difference between our study and previous work
that overall family satisfaction in the TSICU is high; the three
is evident in the patient population; whereas others identi-
summary satisfaction scores derived from our survey instru-
fied patients exclusively in the medical ICU (MICU) or ICU
ment were all approximately 80 out of a possible 100 points,
patients with a diverse range of medical, surgical, cardiologic,
translating to a score between very good and excellent satis-
faction. These results offer reassurance of the high-quality care

Table 1  Family satisfaction with care scores

Family satisfaction with care Mean score SD
1. Concern and caring by the ICU staff for the patient 86.76 21.50
2. Pain management 85.75 21.29
3. Breathlessness management 83.42 23.40
4. Agitation management 80.99 26.21
5. Consideration of your needs 82.35 23.89
6. Emotional support 80.75 25.46
7. Coordination of care 83.91 21.85
8. Concern and caring by the ICU staff for the family 82.77 22.85
9. Skill and competence of nurses 86.03 23.11 Figure 3  Supplementary satisfaction items response distribution
10. Frequency of communication with nurses 79.17 27.58 (number of responses). (1) Patient’s satisfaction with hospital food. (2)
Family member satisfaction with hospital food. (3) Language translation
11. Skill and competence of ICU doctors 87.12 19.58
services. (4) How language barriers between ICU care providers and the
12. Atmosphere of ICU 79.95 24.63
patient were handled. (5) Spiritual support services at the hospital. (6)
13. Atmosphere of ICU waiting room 64.80 33.28 Social work services provided to the patient and/or family member. (7)
14. Level or amount of care 64.11 36.80 Patient’s interaction with ancillary staff. (8) Hospital’s policy regarding
ICU, intensive care unit. visiting times. ICU, intensive care unit; N/A, not applicable.
Maxim T, et al. Trauma Surg Acute Care Open 2019;4:e000302. doi:10.1136/tsaco-2019-000302 3
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Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2019-000302 on 12 August 2019. Downloaded from [Link] on September 11, 2019 by guest. Protected by
overall satisfaction for the entire hospital stay. However, we
Table 3  Supplementary item family satisfaction scores
did not distribute surveys during the postdischarge period, as
Supplementary items Mean score SD the aim of this study was to determine the level of family satis-
1. Patient's satisfaction with food 60.09 30.66 faction with patient care during their ICU stay.
2. Personal satisfaction with food 51.37 31.76
3. Satisfaction with language translation services 73.16 28.22 Conclusions
4. How we dealt with language barriers 72.86 26.97 It is feasible to conduct a family satisfaction survey in the TSICU.
5. Satisfaction with spiritual support services 69.38 29.04 The modified FS-ICU survey tool can also be administered to
6. Satisfaction with social work services 69.69 30.02
family members of patients with critical care conditions managed
in the TSICU. Our results suggest that family members were
7. Satisfaction with ancillary staff 77.42 23.49
overall satisfied with the care provided in the TSICU. Nonethe-
8. Satisfaction with visiting times 85.92 21.10
less, the survey results were useful to identify opportunities for
improvement in patient care and subsequently develop quality
improvement programs.
or neurologic problems, the present study selected almost
entirely trauma and emergency general surgery patients. Contributors  Study concept and design: TM, AA, YH, DA, CM, AS, CP, KM. Data
Patients in the MICU are often elderly and suffering from collection and analysis: TM, KM, AA, YH, DA. Article writing: TM, CP, KM. Critical
chronic illness, so their hospital course may not be entirely revision: AA, YH, DA, CM, AS.
unexpected by family members. Conversely, patients in the Funding  The authors have not declared a specific grant for this research from any
TSICU are frequently young, previously healthy individuals, funding agency in the public, commercial or not-for-profit sectors.
and their sudden hospitalization may place a tremendous acute Competing interests  None declared.
burden on family decision-makers. We surmise that this may Patient consent for publication  Not required.
have influenced the role that family members played in the Ethics approval  The Institutional Review Board at the University of Southern
decision-making process. California granted approval for all activities performed in this study.
We think that the results of a family survey which covers Provenance and peer review  Not commissioned; externally peer reviewed.
several different aspects of patient care in the ICU can be
Open access  This is an open access article distributed in accordance with the
useful in initiating the quality improvement processes as a next Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
step. Our results suggested that there would be opportunities permits others to distribute, remix, adapt, build upon this work non-commercially,
for improvement in communicating with family members, and license their derivative works on different terms, provided the original work is
involving them in decision-making processes, and providing properly cited, appropriate credit is given, any changes made indicated, and the use
translation services. In fact, shortly after the results of our is non-commercial. See: [Link]

copyright.
survey were shared with members in the multidisciplinary
TSICU care team, we developed several quality improvement References
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Maxim T, et al. Trauma Surg Acute Care Open 2019;4:e000302. doi:10.1136/tsaco-2019-000302 5