As with everyone’s pediatric sedation program, safety is our #1 priority. Allowing parents to be present during a sedated test and/or procedure lends the perception that safety will be compromised for the patient. On the flip side, parents often feel unsure sending the child with a team of doctors and nurses who the parent or child do not know to perform a test or procedure. What we found in our program is that the fear of the unknown was much worse than the reality for both the care team and the parents, and having a clear protocol created a win-win for everyone.
As the nurse manager, the number one complaint I received from patients’ families was the inability to be with their child during the sedation appointment. I empathized with this disappointment expressed by parents across a spectrum of emotions, from simple frustration to fury, when faced with a new, potentially life threatening diagnosis for their child. I found myself wondering if we could do better and knowing the answer was ‘yes.’
The journey for our program started with forming a group that included representation from nursing, physicians (we are a hospitalist-led program), patient family experience (we are blessed at our hospital to have a Parent Advisory Council (PAC)), the lead of PAC, and an actual parent whose child had been sedated with our service on more than one occasion. To start, we reviewed topics such as child development, parental rights, staff rights, and patient safety. Some of our conclusions were:
- children trust parents to protect them and are generally calmer and more trusting with this type of presence
- parents knowing they could not be present created anxiety that transferred to the patient before they were even separated
- although doctors and nurses are fantastic at distraction techniques and are fully capable of addressing the development needs of the child, the child wants the parent for this, not a stranger
- staff have a right to have control over the environment in order to provide the most safe care possible to the patient
- parents are unsatisfied with the explanation that it is safer without parental presence
- parents’ perception was that they were not allowed to be present because what was being done to the child was gruesome/awful (i.e. five people restraining the patient for IV placement while the child screamed the whole time, children crying/screaming throughout procedures, something was happening that the hospital staff wanted to keep the parent from having to witness, etc).
This was an eye-opening exercise for some members of the team.
The next steps were to run through our current process and what a future that included parental presence looked like. We started with the prescreening phone call and the information obtained and given during that call and looked at each step all the way through the discharge of the patient. Throughout this process, we used the A3 technique of the Five Whys; we would list a step and ask ‘why’ up to five times to answer each question and review each step. Thoughtful discussion occurred of why we did it “X” way – was the answer ‘because we have always done it that way’ or was there room for improvement that included having parental presence? The ultimate answer to the whole process was ‘YES’ – parents could be present and we could maintain a very safe program.
The next step was the development of a protocol and a script for all staff to be aware of and use. For our program, we determined that it was best for the sedation team and the patient family if two people, who could be any combination of parents/caregivers/support person (no minor children/siblings), could come into the presedation room and be present through screening, assessment, IV placement and procedure preparation. One person could then remain with the child during the sedated test or procedure. The other person would be brought back again during recovery until discharge. We outlined some general instructions for families as follows:
Your child’s safety is our top priority. You are welcome to stay during the test/procedure if you wish but are not required to. If you choose to stay, prior to the start of the sedation we will designate a chair for you to sit in. We require that you remain seated during the entire sedation and procedure/test so all the healthcare providers can ensure your child’s safety. If you cannot remain seated, that is ok – but so the sedation and procedure team are not distracted, it may be necessary to have someone escort you to the waiting room until the test/procedure is done. The sedation and procedure teams want to hear and address any questions you have, but we ask that you hold these questions until everything is finished so that the team can remain focused on your child’s sedation and procedure.
We have had tremendous success with implementing parental presence during all sedated tests and procedures. There has been no compromise to patient safety whatsoever as monitored by daily process review and by our Pediatric Sedation Research Consortium (PSRC) overall adverse event rates. Having a clear protocol and scripting helped staff kick off this program with consistency and confidence. Patients are happier, parents are happier, and this in turn has made the staff’s job easier so they are happier too. It has been years since I took a complaint about ‘not being able to be there for my child during a difficult/scary time.’ If your program does not include parental presence, I challenge you to ask yourself why and consider if your program would do better. I am very grateful that I did.