Family Matters

Elizabeth Ahmann, ScD, RN Deborah Dokken, MPA

Parental Presence in Pediatric Trauma Resuscitation: One Hospitals Experience

Reylon Meeks

Although parental presence during medical resuscitation of children has been a common practice for years, the same opportunity has rarely been available for families in pediatric trauma resuscitation. Blank Childrens Hospital is an exception; for three years, the hospital has had a successful program for family presence in pediatric trauma resuscitation. Beginning with the efforts of one nurse, a task force was established that developed guidelines for this practice in conjunction with nursing and allied health staff, as well as trauma surgeons. Chaplains were approached and then trained to serve as family support persons during trauma resuscitation. Families have been receptive to and pleased with the opportunity to be present during trauma resuscitation of their children.

a rental presence during medical resuscitation of children has been a common practice for years (see Table 1). Pediatricians have welcomed families into the resuscitation room with a dying child, providing p a re nts or other family members with the opportunity to s t roke the child, hold his or her hand, say goodbye, and begin the initial stages of grief. However, the same opport unity has rarely been available for families in pediatric trauma resuscitation. Instead, during trauma resuscitation, parents and families are frequently held at bay, placed in private family rooms, left to wait for information on their child and wonder what is happening to their child behind closed doors. In some cases, the child dies in the trauma room, and p a re nts are then allowed to see their child after the child has been pronounced dead. A move is now afoot to bring f a m i l y - c e n t e re d practices to trauma resuscitation. This art icle will illustrate how one hospital put family presence during pediatric trauma resuscitation into practice. Blank Childrens Hospital in Des Moines, Iowa, has embraced the concept of family presence during medical resuscitation since the early-to-mid 1990s with no adverse events. In the spring of 1999, a pediatric nurse from Blank Childrens was a witness at the scene of her own parents motor vehicle accident. When they were rushed to an emergency department, she followed and insisted on being pre sent in the resuscitation rooms with them. Staff at that hospi-

Table 1. H i s t o ryof Parental Presence during Medical Resuscitation of Children

1959 Platt report recommends presence of parents in the hospital setting (Ministry of Health, 1959). 1960s and 70s Due to efforts of the womens movement, fathers are allowed in delive ry rooms. 1982 Doyle and colleagues (1987) documented several individual instances in which family members insistence led to them being allowed to be present for a short time during trauma resuscitation with a chaplain present to support them. 1990 Addenbrookes Hospital in Cambridge studies the psychological effects on a person witnessing adult resuscitation. Two groups were randomly chosen, one offered the ability to attend the resuscitation. Three months post-resuscitation, individuals excluded from the resuscitation suffered more psychological damage.The study was stopped early when health care wo rkers became convinced of the benefits of family presence in resuscitation (Robinson, Mackenzie-Ross, Hewson, Egleston, & Prevost, 1998). 1992 Hansen and Strawser (1992) reported on a study of the emotional needs of the family; 76% of family members believed their gri eving was made easier by their presence in the resuscitation room. 1993 Emergency Nurses Association endorses family presence during resuscitation and invasive procedures (Emergency Nurses Association, 1993, 1995). 1994 Dallas, Texas. A nurse helps the mother of a severely injured son witness the resuscitation. Media provides nationwide coverage. Medical community begins to speak out on the issue (Meyers, 2000). 2000 American Heart Association supports the design of family presence during resuscitation in the pediatric population (American Heart Association & International Committee on Resuscitation, 2000). 2000 Increasing number of articles begins to surface in the literature regarding family presence during medical resuscitation, but a void remains regarding trauma resuscitation.

Reylon Meeks, PhDc, RN, is a Clinical Nurse Specialist, Blank Childrens Hospital, Des Moines, IA.

The Family Matters section focuses on issues, information, and strategies re l evant to working with families of pediatric patients. To suggest topics, obtain author guidelines,or to submit queries or manuscri p t s, contact E l i z ab eth Ahmann, ScD, RN; Section Editor; Pediatric Nurs i n g; East Holly Avenue Box 56; Pitma n , NJ 080710056; (856) 2562300 or FAX (856) 2562345. 376

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Parental Presence in Pediatric Trauma Resuscitation: One Hospitals Experience tal initially refused her request, but finally gave in when she asked which of them would be satisfied remaining in the waiting room if they were in her shoes. This personal experience with a family members resuscitation led her to a determination to change practices re g a rding family pre sence during pediatric trauma resuscitation. This nurse began her eff o rts related to family presence during pediatric trauma resuscitation by discussing the issue with colleagues. A number of colleagues shared her views. Many had witnessed and been a successful part of family p resence in medical resuscitation. They wondered: why not trauma resuscitation? These discussions led to the development of a small committee of individuals from the Pediatric E m e rgency Department who met to strategize how to implement a change in practice toward family presence in the pediatric trauma resuscitation rooms. They became known as the Task Force on Family Presence of the Pediatric Emergency Department. Beginning with the leadership of one determined individual, an effort was underway to move parental presence into the trauma resuscitation rooms. The Task Force developed a survey that was distributed to nurses, re s p i r a t o ry therapists, residents, and physicians who worked in the Pediatric Emergency Department to ask about their reaction to the idea of family presence during trauma resuscitation (see Table 2). The Task Force distributed 143 surveys, and 124 were completed and returned (87%) with surprising results. Nursing and ancillary personnel, including respiratory therapists, emergency medical technicians, and health care technicians, were overw h e l mingly (92%) in favor of family presence after the primary assessment of the child was completed. Pediatricians generally held the same view as nursing personnel. Conversely, s u rgical residents and trauma physicians were not in favor of family presence until the child was either ready to be transported to a CT scan or admitted to the hospital. This difference in opinion appeared to relate to the amount of time medical personnel spent with families on a regular basis. Pediatricians and nursing personnel were already very comfortable with families being present in a variety of settings. The same was not true for trauma surgeons and surgical residents who typically had less family interaction. Some health care providers, such as surgical residents and trauma surgeons initially surveyed at Blank Childrens, have been less than enthusiastic about family presence in resuscitation. These providers cite multiple concerns about having families present in the resuscitation room, such as litigation risks, parent interf e re nce in pro c e d u res, and comfort levels of the health care provider (Osuagwu, 1995). A review of the literature does not support these concern s (Hanson & Strawser, 1992; Rattrie, 2000). The public appears to favor the idea of remaining with a loved one, adult or child, during resuscitation and invasive procedures, whether in the inpatient setting or the emergency department (Hanson & Strawser, 1992; Martin, 1991; Mitchell & Lynch, 1997), and many hospitals have reported that when family members are in the resuscitation room, the likelihood of litigation decreases (Goldsworth & Bailey, 1998). One way to look at the issue is who has more rights at the time of resuscitation of a child? Reluctant physicians or the family? T h e re f o re, the concerns of surgical residents and trauma s u rgeons were a potential barrier to address to explore the practice of family presence during pediatric trauma re s u s c itation. Trauma surgeons, as the main stakeholders and the individuals running any trauma resuscitation, would have to become willing to accept family presence during res us ci tation for it to happen. Fears and concerns needed to be PEDIATRIC NURSING/November-December 2009/Vol. 35/No. 6

Table 2. Staff Survey: Pediatric Trauma Resuscitation

1. 2. 3. 4. 5. Age: ________________________________________ G e n d e r: Male Female

Professional Title ______________________________ How long have you been in practice? ______________ How long have you cared for pediatric trauma patients? ____________________________________________ ____________________________________________

6.

Do you believe family members should be present during procedures perfo rmed during a pediatric tra u m a resuscitation? All Some None If so, which ones? _____________________________ ____________________________________________

7. 8. 9.

Do you believe family presence during pediatric tra u m a resuscitation is a right? Yes No Parents of children should be allowed to be present during all phases of trauma resuscitation? Yes No If my child were being resuscitated, I would want to be present. Yes No

10. List your concerns of family presence during pediatric trauma resuscitation. ___________________________ ____________________________________________ ____________________________________________ 11. List the benefits of family presence during pediatric tra uma resuscitation. ______________________________ ____________________________________________ ____________________________________________ 12. Do you feel family presence in pediatric trauma resuscitation would interfere with care? Yes No 13. I would be more likely to continue heroic efforts to resuscitate a pediatric trauma victim if family members were present. Yes No 14. Have you had an ex p e rience with family presence during a trauma resuscitation? Yes No Was it positive?_________ Negative? _________ 15. At what time during pediatric trauma resuscitation, if any, do you feel the family should be present? Never At completion of invasive procedures D u ring the entire resuscitation 16. Has any family member requested to be present duri n g a trauma resuscitation? Yes No If ye s, was the family member present during the resuscitation? ____________________________________ ____________________________________________ ____________________________________________

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Family Matters a d d ressed and built into a plan of implementation. Family p resence needed to be introduced to trauma surgeons, and consensus needed to occur among all personnel for the program to be successful. To take a direct step to address this barrier and build consensus, the Task Force on Family Presence from the Pediatric Emergency Department took the survey results to the hospitals Trauma Committee. The Trauma Committee was composed of trauma surgeons, chaplains, nurses, e m e rgency department physicians, pediatricians, and social services providers all intimately involved in the care of trauma patients. The committee was presented with the surv e y results and asked for their thoughts about family presence in trauma resuscitation. A lengthy discussion ensued, during which concerns were raised, literature citations shared, and relevant previous research findings explained. Discussion led to one trauma surgeon coming forw a rd to support the p rogram. This surgeon believed that family presence was going to be implemented re g a rdless of the wishes of the trauma surgeons, and decided it made more sense to be included rather than excluded from the decision-making p rocess. This surgeons decision became the pivotal point in moving forw a rd with family presence during pediatric trauma resuscitation at Blank Childrens Hospital. Once a physician stakeholder was identified, the Task F o rce on Family Presence began the process of developing guidelines regarding parent presence. This involved several steps: a review of the literature, identifying family support persons, involving nursing personnel in drafting guidelines, obtaining input and by-in from nursing and ancillary personnel, obtaining input and by-in from trauma surgeons, and training and obtaining input from family support persons. First, the Task Force reviewed the literature on family p resence. Based on a review of the literature, the idea of an individual dedicated to the needs of the family in the re s u scitation room surfaced. The Task Force decided that a family support person would be imperative for the program to be successful. The concept was that this individual could help bring families into the resuscitation room and stay with family members there to provide support as needed. As a second step, the Task Force on Family Presence a p p roached the Chaplains Department about the possibility of a chaplain serving as a family support person during trauma resuscitation. First, chaplains were introduced to the concept of family presence in the resuscitation room, and then their feelings and concerns were elicited. After discussion, the group agreed that chaplains would serve as the family support personnel during trauma resuscitation. The Task Force would train them once other stakeholders had participated in developing set plans. As a third step, nursing personnel from the Pediatric E m e rgency Department, some who were a part of the Task F o rce and others who had an interest in the project, began to map out the logistics of where families were going to stand and what they could and could not touch in the trauma rooms. The trauma rooms were diagramed in detail, and how families were to enter and exit the rooms was specified. Guidelines were also developed to address the time at which families were to enter the trauma room. There was consensus among nursing staff as to the pro c e d u re s to follow. Discussions were held as to the types of questions a family member might have, when the questions might be a d d ressed, and by whom. Once draft guidelines had been developed, all nursing and allied health personnel in the Emergency Department w e re brought together during a department meeting, and the Task Force presented the topic of family presence in resuscitation. Nurses were informed of the willingness of 378 chaplains to be the family support persons, and the Task F o rce shared the draft guidelines that had been developed for the process. Nurses had an opportunity to ask any questions they had about the plan. Questions surrounding implementation included the role of the Family Support Person, what to do if a family member was inappropriate prior to entering the resuscitation room or during the resuscitation, and how to tactfully address these issues. Fifth, once the Pediatric Emergency Department nurses and allied personnel had outlined and discussed a plan for family presence, trauma surgeons were asked for their input on the logistics of the project. Ideas were solicited and welcomed, and there was further discussion as to when the family might enter the room. They also determined when a family member might be disruptive or not appropriate for the environment, such as in cases of intoxication or aggressive behavior. Finally, once the final guidelines for welcoming parents into the resuscitation rooms were developed (see Table 3), chaplains were informed of the specific plans. The Task F o rce on Family Presence provided education to assist chaplains in their role as family support persons in the resuscitation rooms. Chaplains received education about and explanation of equipment and sounds in the resuscitation room. They were walked through the process of bringing a family into the room, where to stand, and the importance of staying with them during a procedure. Additionally, they were given the guidelines, asked for comments and further recommendations, and given a chance to voice any fears or concerns. Chaplains understood that they were not to leave the families unattended under any circumstances. If family members requested to leave the resuscitation room, the chaplain was to escort them to the family waiting room. After the guidelines were finalized and family support personnel trained, a final meeting between trauma surgeons, nursing and ancillary personnel, and chaplains was held to determine a start date, agreeable to all, for initiating family presence during pediatric trauma resuscitation at the hospital. Hospital administrators were aware and supportive of the program, and had no legal concern s . Finally, the Pediatric Emergency Department and its personnel were in a state of readiness for the first pediatric trauma patient to arrive. Personnel had agreed the family would be invited into the room after the primary assessment, and nurses promised to ask the surgeons if the invitation was overlooked. No formal policies were written re g a rding the consensus of family presence, but all staff agreed to hold their colleagues accountable for the effort. As the first pediatric trauma patient arrived, the process was put into motion. The child arrived with the family, and after an initial assessment and agreement from the trauma surgeons, parents were led to the trauma room by the family support person. The time spent determining the logistics was worthwhile because the initial experience was successful. Family members were grateful to be reunited with their child almost immediately, and the child was calm with the parent present. One success built on another, and the concept of family presence in the pediatric trauma resuscitation room was becoming a re a l i t y. T h ree years later, the program remains in place. Each family whose child faces emergency resuscitation is asked if they would like to see their child and is given an explanation of what might be seen and heard. Parents are given the option to be present, but not all choose to enter the resuscitation room. Staff members respect families decisions either way. Family members have been present during intubation, IV

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Parental Presence in Pediatric Trauma Resuscitation: One Hospitals Experience

Ta ble 3. Guidelines for Family Presence in Pediatric Traumas, Blank Childrens Hospital
1. The Family Support Person (FSP) is designated to be with the family at all times. The FSP is a chaplain, social worker, or nurse. The FSP assesses the emotional status and readiness of the family for Family Presence. a. FSP greets the family upon their arri val to the Emergency Department. b. FSP notifies the medical team the family has arrived. c. FSP provides ongoing updates to the family regarding the patients status. d. FSP assesses the familys emotional status and potential for Family Presence in the trauma situation. e. FSP provides ongoing comfort measures with the family. Collaborate with the trauma team regarding the possibility for Family Presence. a. Assess the trauma situation. b. Assess the probability of Family Presence. c. Ascertain team members are aware the family is going to visit. d. Prepare the team for Family Presence. e. All team members prepare the room for Family Presence. After collaboration and agreement of trauma team regarding Family Presence, the FSP gives the family the option of being present with the patient. Guidelines to Family Presence include the following: a. All team members are aware before the family enters the room. The FSP may pose the question to the tra uma team as to whether they are ready for Family Presence. b. It is acceptable to enter the room, at the request of the t rauma team. Generally, this is after the ABCs have been assessed and procedures completed. 5. c. The family is always escorted by the FSP. d. Family members may choose the option of having the blinds raised if they prefer this option over being in the t rauma room. e. The family is informed that they cannot disturb the team or disrupt care. The family is prepared that they will be asked to leave and/or escorted out if needed. A s e c u rity officer will be available for assistance. f. Family visitors will consist of the patients parent and/or support person and maybe limited to 1 to 2 persons. g. The FSP will prepare the family to help them understand the patients condition before entering the patients room. The family will be made aware of what they will see, hear, smell, etc. h. The FSP will help clarify what the family is seeing or hearing. The FSP may pose the question, Is there anything I can explain for you? i. The family members are positioned, as directed by the primary nurse. Family members may touch and talk with the patient. j. Visits may be five minutes or less, depending on patients condition. k. The family may be asked to leave if the patients condition changes. l. The FSP keeps the family updated on the patients condition. The FSP may pose the question, Is there anything I can share with the family? Staff are given support. a. The Family Presence Committee will wo rk with the t rauma team to evaluate the process. b. Emotional debriefing for staff will be provided as needed.

2.

3.

4.

insertion, chest tube, nasogastric tube and Foley placement, and non-invasive diagnostic pro c e d u res without problems o c c u rring. The most invasive of procedures, such thoracotomy, have not yet been made available for family presence. Whether it will ever become an option is yet to be determined. Families have been informally questioned as to their thoughts on being present in the resuscitation room, and without hesitation, they are pleased to be a part of their childs resuscitation team. As an important note, parents who were present during the death of their child were grateful to have a last few minutes with the child. The program has grown over its three years, and for the most part, has been accepted. A few staff members still resist the initiative, and every time a new group of surgical residents enters the department or a new trauma surgeon is h i re d, an orientation to the process takes time, particularly if the experience is a new idea for the individual(s). Nonetheless, as time has gone on, surgeons, rather than only nursing or ancillary personnel, occasionally initiate the request for the parents to be brought into the resuscitation room. Additionally, families are being brought back earlier, and there have been no adverse events as a result of the families being present. As family presence in the hospital setting continues to change and evolve, opportunities for broader implementation abound. Given the right supports, family presence during trauma resuscitation can be successful and beneficial,

as experience at Blank Childrens Hospital demonstrates. Still, family presence in the trauma resuscitation room is not embraced in all settings. Further change toward a familycentered culture in health care settings is needed to support family presence in trauma resuscitation. Opportunities for re s e a rc h to examine this option are abundant, including examining family member responses to being in the resuscitation room and investigating the thoughts and feelings of children who have been resuscitated about family presence in the room. References
American Heart Association & International Liaison Committee on Resuscitation. (2000). Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 102(Suppl. 8), 136-139. Doyle, C.J., Post, H., Burn ey, R.E., Maino, J., Keefe, M., & Rhee, K.J. (1987). Family participation during resuscitation: An option. Annals of Emergency Medicine, 16(6). 673-675. Emergency Nurses Association. (1993). Resolution 93:02: Family pres ence at the bedside during invasive procedures and/or resuscita tion. Presented at the General Assembly of the Emergency Nurses Association, Des Plaines, IL. Emergency Nurses Association. (1995). Presenting the option for fam ily presence (program educational booklet) (2nd ed.). Pa rk Ridge, IL: Author. Goldswo rth, J.E., & Bailey, M. (1998). Your patient is undergoing resuscitation: Wheres the family? Nursing 28(9), 52-53.

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Hanson, C., & Strawser, D. (1992). Family presence during cardiopulmonary resuscitation: Foote Hospital emergency departments nine-year perspective. Journal of Emergency Nursing, 18(2), 104106. Martin, J. (1991). Rethinking traditional thoughts (letter). J o u rnal of Emergency Nursing, 17(2), 67-68. Meyers, T.A. (2000). Why couldnt I have seen him? The value of fa m ily presence. A m e rican Journal of Nursing, 100(2), 9. Ministry of Health. (1959). The welfare of children in hospital, report of the committee. London: The Platt Report. Mitchell, M.H., & Lynch, M.B. (1997). Should relatives be allowed in the resuscitation room? J o u rnal of Accidental Emergency Medicine, 1 4(6), 366-369. Osuagwu, C. (1995). Family presence during a code: More research needed on patients feelings (letter). J o u rnal of Emergency Nursing, 21(3), 196. Rattrie, E. (2000). Witnessed resuscitation: Good practice or not? Nursing Standard, 14(24), 32-35. Robinson, S.M., Mackenzie-Ross, S., Hewson, G.L., Egleston, C.V., & Prevost, A.T. (1998). Psychological effect of witnessed resuscitation on bereaved relatives. Lancet, 352(9128), 614-617.

Additional Readings
Andrews, R. (2004). Family presence during a failed major trauma resuscitation attempt of a 15-year-old boy: Lessons learned. J o u rn al of Emergency Nursing, 30(6), 556-557. Belanger, M.A., & Reed, S. (1997). A ru ral community hospitals ex p erience with family-witnessed resuscitation. J o u rnal of Emergency Nursing, 23(3), 238-239. Taliaferro, E., Klein, J.D., & Calvin, A. (2000). Family presence duri n g invasive procedures and resuscitation. The ex p e rience of family members, nurses, and physicians. A m e rican Journal of Nursing, 1 0 0(2), 32-43.

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