Issue 1: Family/Visitor Presence in the ER

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Problem definition:

Family members of patients in the ED feel powerless in the process of care. One of the major causes of this problem is the separation of the patient from their families.



Research:

There is a lot of research that shows having family members at the bedside in the ED is a positive thing for the patient, the family, and the hospital. Most families want the option to be at the bedside during invasive procedures (Boudaurex 2002). The Boudaurex article goes on to say that when given the option, most families will choose to be present at the bedside. Most family members surveyed said that being at the bedside during invasive procedures was a good thing for both themselves and the patients. However, there is not a consensus in literature that family members at the bedside during a procedure improves patient outcomes. The Boudaurex article also states that there has been a wide range of responses from ED practitioners.

One challenge with having family members at the bedside is practitioner acceptance. The Saccheti article studied the correlation between precitioner willingness to have family members at the bedside and other factors. The article showed that there is strong correlation between between the practitioners' opinion and the policy of the ED that they worked in. Practitioners who were used to having family members at the bedside generally supported this practice while those who haven't had family members at the bedside opposed it strongly. There was also a strong correlation between the thought of the practitioner and the policy of the ED that he or she was trained in.

A FAQ about family presence in the Emergency Department on the American College of Emergency Physicians website (www.ACEP.com) was very hesitant about the overall benefits of this practice. Three main drawbacks to family presence were stated:

1) Family members may be injured due to fainting during a procedure. Some of these family members have successfully sued the hospital 2) Family members have at times witnessed care that they believe to be sub-standard and used this for the basis of a lawsuit 3) Family presence presents a problem if at teaching hospitals due to the inexperience of some of the training practitioners.

Some positive comments were given on family presence in the ED, but the website does not say that this practice should be implemented everywhere, despite the literature stating the benefits for the family.

Overall, there is not significant literature on the effects of family members on patient outcomes. Up to date, most literature has focused on the benefits of the family members and the hospitals due to patient satisfaction and reduction of lawsuits.



Measuring the Problem:

1)Giving a patient satisfaction survey will give us an idea of the effectiveness of our improvement of this issue.

2) It may be helpful to administer a doctor/nurse survey as well to judge whether these methods help to improve the experience and/or outlooks of the staff towards the presence of family in the ER.

It is difficult to state what proxy measures, such as how many family members were present at the bedside, how often did they "get in the way", etc because this type of data is not recorded. For a comprehensive understanding of the effect of having family members at the bedside, new measures must be collected. However, tallying how often a practitioner feels that patients are in the way is not a scientific metric, and could be tedious and interfere with the practitioners train of thought. It may be that the only way to determine the benefit is through subjective survey data.



Resources:

Boudreaux, Edwin D, PHD, Jennifer L Francis, MA, and Tommy Loyacano, MPA. “Family Presence During Invasive Procedures and Resuscitations in the Emergency Department.” Annals of Emergency Medicine 40.2 (Aug. 2002): 193-205.

“Family Member Presence in the Emergency Department.” American College of Emergency Physicians. 2008. 11 Sept. 2008 <http://www.acep.org/patients.aspx?id=25904>.

Saccheti, Alfred, PHD. “Acceptance of Family Member Presence During Pediatric Resuscitations in the Emergency Department.” Pediatric Emergency Care 16.2 (Apr. 2002): 85-87.



COMMENTS: Ackerman "It has been shown that the presence of family during an ED visit helps to improve the patient experience and has also been shown to have a positive effect on recovery." - this is a very broad generalization that I don't think is really supported by the literature. Most of the literature of family/patient centered care has been done on the inpatient side (prolonged hospital stay) and on the outpatient side (particularly in managment of chronic diseases). The only research I am familiar with specific to the ED is in the area of family witnessed resusscitation and suspending of resusscitation - this is included in the American Hearta Association ACLS (advanced cardiac life support) guidelines. If I remember correctly their data was actually initially based on in hospital cardiac arrest (e.g. inpatients) and has been supported by additional research in out-of-hospital and ED setting.

That being said, the data is compelling in the settings were there is actually research and we (clinicians) need to try to incorperate the principles better into ED care.

How about some real measures - what percentage of the time that the patient was in the ED was there a family member at the bedside (probably shouldn't include time when no one was available). How many times did we make them leave? How often did the patient ask family to leave? How many times did family have to stand up etc because they wer "in the way"? How much time did clinicians spend answering questions before and after "the change"? (I suspect once physicians in particular incorperate more of the principles into the care they provide, the amount of time discussing actually would decrease overall - this is based on my own experience in trying to include families more).