Support grows for more family access in ED

Staffing shortage is biggest hurdle

Very few hospitals have policies that allow family access during resuscitation and other treatment in the ED, even though research has shown that the public overwhelmingly desires it and a growing number of emergency physicians and nurses support the idea. The holdup is that allowing more family access requires the involvement of trained staff members, and hardly any facilities have staff to spare these days.

But advocates of family access say that requirement doesn’t have to be an absolute roadblock to doing what they refer to as "the right thing." Some creativity and flexibility can improve family access even in a short-staffed ED, they say.

Only 5% of U.S. hospitals have written policies permitting such access during CPR or invasive procedures, according to a new survey cosponsored by the Emergency Nurses Association (ENA) in Des Plaines, IL, and the American Association of Critical Care Nurses (AACN) in Aliso Viejo, CA. About a quarter of responding nurses say family presence still is prohibited for resuscitation and invasive procedures, despite urging of professional organizations to allow access, says Dorrie Fontaine, RN, DNSc, FAAN, president-elect of AACN and associate dean for academic programs at the University of California at San Francisco School of Nursing.

The ENA has encouraged more family access for almost 10 years, but EDs have been slow to adopt the practice, says Kathy Robinson, RN, president of ENA and emergency medical services program manager for the Pennsylvania Department of Health. There is growing interest, she says, but still much room for improvement.

"A decade of research shows that the presence of family members during invasive emergency procedures can be helpful to families, health care providers and the patients themselves," Robinson says. "Yet despite growing support for family presence during emergency procedures, too many physicians and other health care practitioners resist adopting this practice."

Fontaine sees more willingness among clinicians to accommodate families in the ED. The trend is part of a larger change in health care and consistent with other efforts to allow families in treatment areas, she says. It used to be much more common for physicians to resist the idea of family access with claims that family members would get in the way and impede proper treatment.

That argument still is cited by some, but not nearly as much as before, she says.

"Only few years ago obstetricians were saying Over my dead body will the father or anyone else be in there while I’m delivering a baby,’" she says. "Now there’s nowhere in the country where you don’t have fathers in there helping deliver and right in the middle of everything that is happening. People are more comfortable with the overall idea of family presence."

So why do so few EDs have a policy and allow family access? The same reason you can’t do a lot of things that otherwise sound like a good idea: short staffing. The American College of Emergency Physicians doesn’t have a formal stance on the issue, but Stephen Epstein, MD, MPP, spokesman for ACEP and clinical operations director at Beth Israel Deaconess Medical Center in Boston, says he generally favors allowing more family access. However, Epstein says he understands why so few EDs can make it happen. Like most EDs, his is chronically short-staffed and can’t spare a nurse to escort the family in the ED treatment areas.

Resources are restricted, and ED managers can’t do all they would like to do, Epstein says. Many physicians agree that it’s a great idea, if they have the nursing staff, he says. "But when the ED is already maxed out with patients and too few staff, the patient is our first responsibility, and this becomes something they would like to do but just isn’t a priority," Epstein says.

Staffing is such a significant issue because it is imperative that you provide a trained escort for the family members. Even the strongest advocates of family access agree that you can’t simply let the family come in and watch. A trained escort, preferably a nurse, should be at the family members’ side making sure they don’t interfere with treatment, helping them understand what is happening, and watching for any physical reactions such as fainting.

For that reason, many ED managers nix the idea entirely when they’re already dealing with a nursing shortage. But Epstein and Fontaine say that’s a mistake to automatically assume you can’t provide more family access. They suggest two strategies that might work for you:

Strategy 1: Use someone other than a nurse as the family escort.

An ED nurse is by far the best choice for this job, but someone else might suffice. Fontaine suggests that a social worker or clergy might escort the family, and Epstein says an emergency medical technician or even a lab tech might work. In any case, the person should be trained specifically in how to escort families in ED treatment areas.

There is a limit to how flexible you can be, however. Epstein notes that hospital volunteers probably are not sufficiently trained and experienced for this type of work.

Strategy 2: Allow family access when you can, but accept that you can’t sometimes.

Family access does not have to be all or nothing, he says. If you don’t have the staff to do it all the time, establish a policy that you will allow family access as much as you can. That may not be a perfect solution, but it is far better than not even trying to allow family access because you are short-staffed.

"You can develop a policy that says when the ED is not too busy and you have appropriate staff, you should allow family access," Epstein says.

"The policy is key because, otherwise, you’ll have family kept out of the room even on a slow night, just because there’s no policy guiding people to say it’s OK," he adds.

Selected References

  • MacLean SL, Guzzetta CE, White C, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: Practices of critical care and emergency nurses. Am J Crit Care 2003; 12:246-257.
  • Emergency Nurses Association. Family presence at the bedside during invasive procedures and/or resuscitation. Resolution. 1993; 93, 2.
  • Robinson S, MacKenzie-Ross S, Campbell-Hawson G, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet 1998; 352:614-617.

Sources

For more information, contact:

  • Stephen Epstein, MD, MPP, Clinical Operations Director, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215. Telephone: (617) 667-7000.
  • Dorrie Fontaine, RN, DNSc, FAAN, 101 Columbia, Aliso Viejo, CA 92656-4109. Telephone: (949) 362-2000.
  • Kathy Robinson, RN, 915 Lee St., Des Plaines, IL 60016-6569. Telephone: (800) 900-9659.