Parental Presence During Procedures
CASE
A 7 year-old previously healthy male presents to the pediatric emergency department following a bicycle accident. The child was struck by an oncoming sedan traveling at approximately 20 miles per hour, causing him to fall off the bike onto his right side. There was no head strike or loss of consciousness. On arrival, the child is phonating, has intact peripheral pulses, and a Glascow Coma Scale of 15. He is noted to be dyspneic, with absent breath sounds on the right. You prepare to place a chest tube with supervision from your attending. This is your first time placing a chest tube. His mother requests to stay in the room for the procedure.
DIAGNOSIS
Traumatic hemothorax or pneumothorax
DISCUSSION
The conflict
Pediatric patients represent a uniquely vulnerable population. We deem these patients incapable of making medical decisions for themselves, deferring decision-making to the parent. However, during sedations and invasive procedures, family members are often asked to leave the room due to concerns that their presence may deter from the child’s care. Providers have varying thoughts on the appropriateness of parental presence during invasive procedures, leading to large practice variation. Those that are opposed to parental presence may fear they will interrupt care or cause anxiety for the provider performing the procedure, thereby increasing the risk of failure. In contrast, family members almost unanimously prefer to be present in the room or at least be given the option to stay for the procedure.
Parental perspective
While provider practice may vary, parents are nearly universally in favor of staying with their child during invasive procedures. In a comprehensive review of the literature surrounding parental presence during invasive procedures or resuscitation, all studies found parents wanted a choice of whether or not to be present. [1] Not only did parents want a choice, but 86% of parents believed it was their right to be present. Of parents who remained present during procedures, nearly all (94%) said they would choose to be present again.
Interestingly, parents who remain present during resuscitations tend to self-report better coping and adjustment to illness and death. In contrast, those not in the room report anxiety and, in instances of poor outcomes, have guilt surrounding their absence. Taken together, parents want to be present during invasive procedures and resuscitation, would choose to be present again, and would recommend that choice to others. [2]
Allowing families to be present during resuscitation and invasive procedures does not tend to result in disruptions in care. In a prospective study of 54 family members observing patients less than 18 years of age undergoing invasive procedures in the emergency department, only two “interfered with care events” occurred. [3] Further, family presence in trauma resuscitations has not been shown to cause a delay in arrival to CT scan or resuscitation completion (as defined by lab testing, procedures, x-rays, and secondary surgery). [4] In summary, parents want to be with their children during invasive procedures, and their presence is generally not disruptive to care.
Hospital staff perspective
While parents may be universally in favor of staying during resuscitations and invasive procedures, there is less of a consensus among medical professionals, with resident physicians seeming most resistant to the idea. In a survey, pediatric emergency department faculty, nurses, and residents were asked to rate their approval of family member presence (FMP) for a wide spectrum of procedures of varying invasiveness. [5] Authors found near unanimous approval for FMP in less invasive procedures. Interestingly, attending physicians and nurses were more likely than resident physicians to approve of family presence for more invasive procedures. Common disadvantages of having family present included anxiety in the room and detriment to the success of the procedure. Similarly, in a study of family presence during resuscitation and invasive procedures, more nurses (92%) and attending physicians (78%) supported family presence than did resident physicians (35%, P < .05). [6]
Another study surveyed residents’ perceptions of FMP during procedures. [7] While most residents were accepting of FMP, nearly half of residents reported that increased anxiety caused by FMP could result in procedure failure. While not reaching the level of statistical significance, there was a notable trend towards higher level of training being associated with increased comfort with FMP.
CASE RESOLUTION
While it is understandable that family presence may be anxiety-provoking for a resident performing a first-time procedure, there is little evidence to suggest that their presence interferes with care. That said, it is difficult to quantify the effect of parental presence on the resident’s success at a given procedure. Not only might family presence provoke anxiety, but it may reduce the likelihood of a resident getting the opportunity to perform a given procedure. While possible detriment to education may not be a sufficient reason to keep families away from their child’s bedside during invasive procedures, training programs must remain acutely aware of the effect this may have on the learning environment. More research is needed to evaluate the effect of parental presence on resident education.
TAKE-AWAYS
Most parents want a choice of whether or not to be present during a procedure or resuscitation
Family presence during invasive procedures and trauma resuscitations is generally not disruptive to patient care
Acceptance of family member presence was more common among attending physicians and nursing staff compared to resident physicians
More research is needed to evaluate the effect of family member presence on resident education
Author: Caroline Meehan, MD is a third year emergency medicine resident at Brown University/Rhode Island Hospital.
Faculty Reviewer: Jane Preotle, MD is the Assistant Program Director of Emergency Medicine at Brown University and Assistant Professor of Emergency Medicine and Pediatrics
REFERENCES
Dingeman, RS, Mitchell, EA, Meyer, EC, Curley, MA. Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature. Pediatrics. 2007;120:842–854
McAlvin SS, Carew-Lyons A. Family presence during resuscitation and invasive procedures in pediatric critical care: a systematic review. Am J Crit Care. 2014; 23(6):477–84
Sacchetti, A, Paston C, and Carraccio, C. Family Members Do Not Disrupt Care When Present during Invasive Procedures. Academic Emergency Medicine. 2005; 12: 477-479
Dudley NC, Hansen KW, Furnival RA, Donaldson AE, Van Wagenen KL, Scaife ER. The effect of family presence on the efficiency of pediatric trauma resuscitations. Ann Emerg Med. 2009;53(6):777–784.
Fein JA, Ganesh J, Alpern ER. Medical staff attitudes toward family presence during pediatric procedures. Pediatr Emerg Care. 2004; 20:224–227
Mangurten J, Scott SH, Guzzetta CE, Clark AP, Vinson L, Sperry J, Hicks B, Voelmeck W. Effects of family presence during resuscitation and invasive procedures in a pediatric emergency department. Journal of Emergency Nursing. 2006;32:225–233.
Bradford KK, Kost S, Selbst SM, Renwick AE, Pratt A. Family member presence for procedures: the resident’s perspective. Ambul Pediatr. 2005;5:294–297