Practice team sees evidence-based way to improve ED care

Featured in the St. Louis Nursing News, November 5, 2007

On TV it happens like this: a patient wheels into the emergency room in cardiac arrest. The staff begins resuscitation procedures. The patient''s family arrives, begging to see their loved one, begging for information. “We''re doing everything we can,” they''re told. “Wait out here.” The frantic family is left to pace the waiting room wondering about their loved one''s fate.

In real life, an initiative in the Barnes-Jewish Hospital emergency department is aimed at allowing family members in certain circumstances to be present in the treatment room as doctors and nurses work to resuscitate patients whose hearts have stopped.

Barnes-Jewish is a 1,200-bed teaching hospital affiliated with Washington University School of Medicine. There were 77,847 visits to its ED in 2006. Barnes-Jewish was the first adult hospital in Missouri to be certified as a Magnet hospital.

The initiative has turned out to be beneficial, not only for families who want to be near their loved one at what may be the end of their life but for medical and support staff working on the resuscitation effort or "code."

The idea to allow family presence during resuscitation grew out of a workshop attended by Barnes-Jewish ED nurses on the evidence-based practice team, said team leader Jennifer Williams, APRN-BC, MSN. The team charged themselves with bringing procedures to the ED that had been proven through research to be "best practices."

The team, comprising nurses who actually work at the bedside in the ED, felt family presence during resuscitation would be a way to make a substantive, positive impact on the way patients and their families are cared for. While ED management and staff had to sign off on the initiative, it was up to the ED nurses to develop and implement the guidelines, educate fellow staff and monitor the results.

“We wanted to bring something to the bedside that would make a difference,” said Ryan Schneider, RN, BSN. “This was the first thing we thought of. We''re a teaching hospital. We should be at the forefront, and we knew there was research on this issue.”

Much of the medical community had long assumed family members would get in the way of a medical team working a code, or that the procedures, such as inserting breathing tubes, using a defibrillator to shock the patient, or even opening the patient''s chest, could be too traumatic for the family.

But research, including extensive case studies done at Foote Hospital in Michigan, didn''t support these conclusions. In fact, the research showed that families who were allowed to witness the resuscitation were almost unanimously grateful for the opportunity, and rather than getting in the way, could supply vital information that would aid the medical team''s efforts.

In order to implement family presence during resuscitation, the team first approached the nurse manager and patient care director. They were very supportive, Williams said. The ED medical director and hospital administration were also very receptive.

Next, the team developed guidelines – outlining when family presence is appropriate; determining the number of family members who can be in the room at one time; and describing how to proceed if the patient is unable to be resuscitated, the code is “called” and the patient is pronounced dead.

The team also met with representatives from the ED social work staff to discuss the feasibility and receptivity of the social work staff in evaluating families for the option of family presence, and for serving as the family facilitator in the patient care room during the resuscitation. They then created an information tool for the families on the guidelines for being in the patient room.

Then the team surveyed ED staff who participated in codes. Although the reaction was mostly positive, some staff members were hesitant, Williams said. They felt family would get in the way or distract medical staff. Or family would be reluctant to have the staff stop resuscitation efforts, even though the patient was not responding.

“A lot of people said it''s about time this was implemented,” said team member Lyndsey Nykiel, RN, BSN. “But some people were apprehensive.”

The team held a series of educational sessions to present the guidelines to ED staff before implementation, addressing fears about family interference with the help of published research.

The guidelines were implemented in the Barnes-Jewish ED in May. Since then, codes in which family members have been present have gone “as we predicted,” Williams said. Families have not interfered with code procedures and have been able to provide valuable information, such as medical history, medications the patient may be on or whether the patient has asked not to be resuscitated in the case of cardiac arrest.

“Some of the staff have commented that it''s actually easier with family in the room,” said Rik Denicke, RN, BSN.

As far as the fear that having family present would prolong codes, the opposite has happened, Williams said. Family members have asked medical teams to stop resuscitation procedures when they feel the procedures are futile.

The next phase of the initiative – following up with families four to six weeks after the code, and a second survey of the staff – hasn''t begun yet. But the team has received anecdotal reports that families have been grateful to be near their loved ones, and appreciated the opportunity to have some input during the experience.

The practice team, which in addition to Williams, Nykiel, Denicke and Schneider, includes Katie Jett, BSN, and Tricia Steffens, BSN, hopes to publish their experience to encourage other nurses to be active participants in changing how care is delivered.

“I think this is a good example of how nurses can be a driving force in implementing evidence-based medicine,” Schneider said. “We were faced with a burning question – could we implement family presence – and we found out this was something we could do.”