The Role of Family in Cardiopulmonary Resuscitation

Based on the data presented, do you think the EARLY SAVE program has been effective in improving early recognition and response to clinical deterioration in your hospital? Why/ why not?

Based on the data presented, the EARLY SAVE program was partially effective in improving recognition and response to clinical deterioration within the hospital. The application of the program reduced the number of patients who could not be resuscitated and therefore died from about 25 to 10. During the same course, the number of patients who were transferred to the intensive care unit also significantly decreased pointing out to the effect of increased educational training among nurses on how to recognize and respond to various issues related to clinical deterioration.  The number of patients who remained within the high dependency unit remained the same while the number of patients within the ward increased suggesting that nurses and other healthcare providers were spending more time monitoring the condition of patients before releasing them or choosing to admit them to either the high dependency unit or intensive care unit.

The effect of the program is dubbed as being partially effective due to the amount of resources which were spent and the observed outcomes. The use of more resources would have been expected to significantly and in some cases completely increased the response to clinical deterioration. The number of patients who died is still high, and the number of patients being admitted to the intensive care unit is also considered to be high. The measure seems to have no effect on the high dependency unit where nurses check the health status of individuals. When specific amounts of resources are spent within the clinical system or when an intervention such as EARLY SAVE was introduced, the sole purpose was to reduce mortalities significantly as well as to recognize areas which required outmost changes quickly. Although a decrease in reducing fatalities across the clinical system and increasing the number of patients who are admitted within the intensive care unit all point out to the effectiveness of the current program, the static nature of patients within the HDU section and the amount of resources spent in the program indicate more measures need to be effected for the program to become fully effective.

How might the data obtained pre and post the EARLY SAVE program be used by the hospital when reporting against National Safety and Quality Health Service (NSQHS) Standard 9: Recognising and responding to clinical deterioration in acute healthcare?

             The National Safety and Quality Health Service (NSQHS) Standard 9 provides essential information on factors which contribute to failure in recognizing and responding to clinical deterioration of patient condition to include lack of knowledge of symptoms signaling deterioration, lack of skills by healthcare providers in managing deteriorating patients, failure to communicate all clinical concerns with other healthcare providers during the handover process and failure in monitoring physiological observations consistently as well as the absence of a formal system in responding to clinical deterioration.  The hospital could report on some aspects including their ability to reduce failures associated with poor recognition system as well as their ability to be within the standards provided by the National Safety and Quality Health Service (NSQHS). For example, they could report that the EARLY SAVE programs managed to reduce specific failures related to poor recognition and response to clinical deterioration using a number of approaches. First, nurses were educated in identifying the required signs and symptoms associated with various condition of critical care and as a result, more patients were accurately identified to be in need of intensive care. Secondly, communication between nurses and other physicians also improved during the handing over process signifying the presence of a formal system which ensures accurate care is provided. The clinical system also provided a statement indicating their support to promote recognition and response to patients with deteriorating conditions within their healthcare setting. Furthermore, healthcare provides ensured that appropriate and timely action was taken to reduce to fatalities within the clinical setting commonly associated with the failure to recognize specific conditions.  Lastly, the clinical system informed carers, patients and families on the available recognition and response system within the clinical system and how they contribute to timely care.

Part 2

Cardiopulmonary resuscitation is one of the most common events occurring with a relatively high frequency within the intensive care units and emergency department. The condition causes a great deal of stress to nurses, physicians and other medical providers nearby and they require an immediate sequence of actions to reverse the condition and ultimately prevent the death of an individual. Resuscitations are defined as rehearsed ballets commonly applied by healthcare providers. Anything that distracts the team of healthcare professionals from their total focus especially during a resuscitation event may pose a danger to the patient.  The presence of a distraught member of the family may distract the team from their total focus and in the process may pose a danger to the patient. This is the common belief by most physicians as to why family members should not be allowed in the resuscitation room. Is this the way to go about it?

            A number of institutions have established policies which permit family presence during cardiopulmonary resuscitation within the intensive care unit and emergency department. The implication of such results has also been studied and reported in various medical research studies for over 20 years with papers concluding that the benefits outweigh the harms. Despite this evidence, surgeons still believe that allowing family members to be present during cardiopulmonary resuscitation is still a bad idea. Two recent systematic reviews evaluated the effect of health care provider and family support. The first systematic review reviewed a total of six studies including one qualitative study, one prospective observational study, and four retrospective studies and concluded that the presence of family members during cardiopulmonary resuscitation improves family coping and satisfaction levels (McAlvin & Carew-Lyons, 2014).  The second systematic study identified a total of 4 studies including one randomized controlled trial, two observational studies, and nine prospective studies and reported similar findings which indicate that resuscitation is greatly supported by both family members and staff (Porter, Cooper, & Sellick, 2013). Although both the two aforementioned reviews indicated that the family presence during resuscitation is one of the acceptable practices, neither study evaluated other aspects which may play have an effect including resuscitation quality, patient mortality and long-term psychological effects of attending such resuscitation events which are mostly out of the focus of clinical concern for most healthcare providers. Oczkowski, Mazzetti, Cupido, & Fox-Robichaud (2015) conducted a systematic review to determine whether the presence of family members during the resuscitation process had an effect on family member psychological outcomes, patient mortality and resuscitation quality. The study utilized a total of three randomized controlled trials and reviewers assessed the eligibility of the provided information as well as other aspects including the risk of bias as well as pooling evidence.  The results collected were classified into two key sections. Moderate quality evidence suggested that family presence during the resuscitation process does not affect the process among adults and in many cases may improve the psychological outcome among family members. Low-quality evidence suggested that family presence during resuscitation does not affect pediatric outcomes.  Based on the above evidence provided by systematic reviews which are considered to be the highest quality of evidence which could be used in any research paper, it is clear that presence of family members during the resuscitation process is essential to some positive health outcomes. The above systematic reviews have specifically focused on whether the presence of family members is required but have not provided reasons as to why it may be necessary to have family members within such settings.

            De Stefano et al., (2016) conducted a randomized controlled trial to investigate the specific themes offered by family members on why they need to be present during the resuscitation process. Some family members thought that their presence might help facilitate the process while other begun cardiac  massages before any emergency personnel had arrived within the clinical setting with the main aim of improving the health condition of the patient before the resuscitation process (De Stefano et al., 2016). Other believe that they would provide essential medical information which could sufficiently aid in the provision of care during such cases (De Stefano et al., 2016). Some family members wanted to be emotionally present while others turned up majorly to provide the required support which was critically needed during such periods (De Stefano et al., 2016). Others would want to be present to ensure that the medical team applied the correct medical information to their family members and in the process become satisfied with the course of treatment which was applied.

            The presence of family members during such events would also provide direct understanding as well as an appreciation of the resuscitation process and may essential in helping the family members understand and accept the patient’s death (De Stefano et al., 2016). In such cases, they would understand that everything was done to return their loved one to life by the medical team and would pacify the situation making it more possible for the available witness to start the loss process.

            From the above-provided information from various high-quality sources of evidence, it is essential that family members be present during most of the resuscitation events provided there is full agreement between family members and healthcare professionals providing the service. The presence of family members has been indicated to be associated with a number of benefits to the patient including the provision of adequate care and social support during the process as well as helping the family members accept the outcome of the resuscitation event.

References

De Stefano, C., Normand, D., Jabre, P., Azoulay, E., Kentish-Barnes, N., Lapostolle, F., … Adnet, F. (2016). Family presence during resuscitation: A qualitative analysis from a national multicenter randomized clinical trial. PLoS ONE, 11(6), e0156100. https://doi.org/10.1371/journal.pone.0156100

McAlvin, S. S., & Carew-Lyons, A. (2014). Family presence during resuscitation and invasive procedures in pediatric critical care: A systematic review. American Journal of Critical Care, 23(6), 477–484. https://doi.org/10.4037/ajcc2014922

Oczkowski, S. J., Mazzetti, I., Cupido, C., & Fox-Robichaud, A. E. (2015). The offering of family presence during resuscitation: a systematic review and meta-analysis. Journal of Intensive Care, 3(1), 41. https://doi.org/10.1186/s40560-015-0107-2

Porter, J., Cooper, S. J., & Sellick, K. (2013). Attitudes, implementation and practice of family presence during resuscitation (FPDR): A quantitative literature review. International Emergency Nursing, 21(1), 26–34. https://doi.org/10.1016/j.ienj.2012.04.002