Effectiveness Of Early Save Program And Family Presence During Resuscitation: A Debate

Early Save Program

Question:

Discuss about the Nursing for Pre Early Save Program.

A large metropolitan hospital introduced ‘EARLY SAVE’ program to reflect best practice in early recognition and response to clinical deterioration.

Pre Early Save Program- Code Blue process for life threatening emergencies

Early Save Program- Education for clinical staff, more formalized Medical Emergency Team (MET) process and the introduction of an observation and escalation chart

To analyze the effectiveness of the EARLY SAVE program in improving early recognition and response to clinical deterioration, the data regarding the MET calls in the pre and post period needs to be analyzed. Firstly, 160 MET calls were made in the pre period and 360 in the post period. This means that the recognition and response process became wider after the EARLY SAVE program. The positive benefits of high rate of MET calls in the post program period are evident from the % of patients who remained in wards. Earlier 20% remained in the wards and after the EARLY SAVE program, the proportion of patients remaining in the ward increased to 50%.  This is a remarkable improvement signifying that burden of ICU team and resuscitation team reduced.

The positive benefits of the EARLY SAVE program is also understood from the difference in % of patients transferred to ICU and death in patients. In the pre period, the % of transfers to ICU was 35% and it reduced to 20% in the post program period. Secondly, number of deaths was 25% in the pre period and 10% in the post period. The MET calls in the both the pre and post period was mainly called for seizure, worsening respiratory infection, acute respiratory distress, suspected cardiac pain and alterations in vital signs indicating clinical deterioration. However, the impact of EARLY SAVE program was that % of people affected by different clinical deterioration reduced in the post period except worsening respiratory infection. The main reason for improvement in clinical outcome in majority of condition was that education was given to staffs regarding responding to clinical deterioration and use of observation and escalation chart enhanced the possibility of taking prompt response to deteriorating condition of patients. The research by Massey et al. (2017) has also proved that education and environmental factors enables health staffs to recognize and respond to patient deterioration. Specific clinical education and skills training enables staffs to quickly recognize and respond to patient deterioration.

Improving Clinical Deterioration Recognition and Response

The hospital can use the data in the pre and post EARLY SAVE program to report against NSQHS standard 9: Recognizing and responding to clinical deterioration in health care in the following ways:

• They can show the data regarding difference in results in the % of patients transferred to ICU and death in the pre and post program to prove the benefits of MET calls in early recognition and clinical response.
• They can defend no increase in HDU outcome post program by stating that with improvement in burden of ICU units, the need for escalation of care of moving to HDU was minimized.
• They can show the efficacy of formalized MET process by the increase in the number of patients remaining in the ward and not shifting to the ICU or HDU units. The advantage of a formalized MET process is that it has direct role in preventing cardiac arrest and this is evident in the case scenario as data revealed that only 60 Code Blue calls for cardiac or respiratory arrest were made in the post period compare to 140 in the pre period. The potential benefits of MET is appreciated by most hospitals and their staffs.

Resuscitation is an emergency clinical procedure to support and maintain breathing in a patient experiencing respiratory arrest or cardiac arrest. The main purpose of cardiopulmonary resuscitation (CPR) is to restore normal breathing and circulation in critically ill patient and maintain normal blood flow and oxygen to the heart, brain and other vital organs. As it is an invasive procedure, the norm is to escort family members out of the room due to fear of immediate and long term negative consequences for family members (Hill and Fuhrman 2008). However, this essay mainly supports the fact that family members should be allowed during the resuscitation of their loved ones in acute care setting. The essay presents appropriate discussion to prove the benefits of family presence in terms of psychological outcomes and avoiding conflicts and violence in acute health care setting.

The main rational to keep family members away during several attempts of resuscitation is that family member becomes exposed to high risk of emotional and physical sufferings during the procedure (Zavotsky et al. 2014). However, a contrasting evidence to support the presence of family members explains that they understand that the medical team took all possible steps to bring patients back to life and the complains regarding negligence in the event of death of their family members is reduced. In another way, it can be said that family members often have unrealistic expectations or suspicion about the behind the door resuscitation efforts and all doubts regarding the efforts put by the medical team may be made clear if family members are present during resuscitation efforts (Jabre et al. 2013). One barrier to allowing this new practice in resuscitation is that hospital staffs may not accept this new practice due to increase in emotional stress during the procedure.  However, a study done to assess the attitude of heath care professional working in Yale New Haven revealed that majority of staffs favored the option of family presence if any staff accompanies the family member to control their action during the procedure (Lederman and Wacht 2014). Hence, if this new procedure needs to be fully implemented in acute care setting, there is a need to work on drafting and implementing a protocol to follow while allowing family presence during resuscitation.

Family Presence During Resuscitation

Another advantage of family presence during the resuscitation procedure is that patient’s relative can provide emotional support to patient and help them accept the reality of death. In case of death of patient, family members get the chance to be bid final goodbye to their loved ones and this can reduce suffering caused in the bereavement process. Pathological conditions like mourning or post-traumatic stress disorder (PTSD) can be minimized in family members by allowing them in the resuscitation. A randomized controlled trial with family members of patients undergoing cardiopulmonary resuscitation revealed that giving family members the option of witnessing resuscitation efforts significantly reduced the incidence of PTSD compared to standard procedure without family presence. Family members present were also associated with positive psychological outcome (Jabre et al. 2013).

Family presence during resuscitation is a debatable topic in health care. However, many recent evidence has pointed out to positive psychological outcomes for family members. While Jabre et al. (2013) pointed out to the impact of family presence in CPR in improving clinical indicator of PTSD, Tazarourte et al. (2014) explained that it reduced complicated grieving in family members after the death of their loved ones during the procedure. One research evidence in particularly is of great importance to develop the argument as it aimed to explore the experiences of those people who were present during a family member’s resuscitation. It helped to get direct insights about subjective factors that play a role in influencing psychiatric morbidity in family members. The study finding summarized about the theme of being actively involved in the resuscitation process, communication between the family member and the emergency team, perception of the reality of death, experience and reaction of witnessing the the resuscitation. As this argument is mainly focused on the reaction of relative to witnessing resuscitation, the study revealed feeling of relief and being satisfied with the action of the medical team. However, some family members were also affected by the aggressive technique and had a negative memory of viewing the CPR (De Stefano et al. 2016). Therefore, the main conclusion from the study is that positive effect in grieving has been found by offering patient’s family the choice of witnessing the resuscitation procedure.

The above evidence mainly paid attention to the view of family members and health care professionals in allowing patient’s relative to be present during the resuscitation process. However, one point that is missing is the perception of patients regarding the family presence during the invasive resuscitation procedure. Twibell et al. (2015) mainly paid attention to exploring adult inpatient’s view of family presence during resuscitation and it mainly revealed that maximum participants favored family presence, however the preference varied across patients according to the nature of family relationship and patient’s response. This research gave new insight that patients should be involved in deciding whether they would prefer family member’s presence during the procedure or not.

Based on different arguments with support from peer-reviewed research articles, the main conclusion from the essay is that family presence should be allowed during resuscitation considering the positive effect in psychological outcomes, expectations and ethical conflict. To fully implement this option for patients, the future implication for health practice is to establish a full protocol for implementing family presence option in CPR and involving patients in decision making related to family presence.

Reference

De Stefano, C., Normand, D., Jabre, P., Azoulay, E., Kentish-Barnes, N., Lapostolle, F., Baubet, T., Reuter, P.G., Javaud, N., Borron, S.W. and Vicaut, E., 2016. Family presence during resuscitation: a qualitative analysis from a national multicenter randomized clinical trial. PloS one, 11(6), p.e0156100.

Hill Jr, R. and Fuhrman, C., 2008. Presence of family members during resuscitation. Annals of emergency medicine, 52(3), pp.309-310.

Jabre, P., Belpomme, V., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., Tazarourte, K., Bouilleau, G., Pinaud, V., Broche, C. and Normand, D., 2013. Family presence during cardiopulmonary resuscitation. New England Journal of Medicine, 368(11), pp.1008-1018.

Lederman, Z. and Wacht, O., 2014. Family presence during resuscitation: attitudes of Yale-New Haven hospital staff. The Yale journal of biology and medicine, 87(1), p.63.

Massey, D., Chaboyer, W. and Anderson, V., 2017. What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nursing open, 4(1), pp.6-23.

Tazarourte, K., Jabre, P.,  Azoulay, E., Borron, S.W., Belpomme, V., Jacob, L., Bertrand, L., Lapostolle, F., Combes, X., Galinski, M. and Pinaud, V., 2014. Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensive care medicine, 40(7), pp.981-987.

Twibell, R.S., Craig, S., Siela, D., Simmonds, S. and Thomas, C., 2015. Being there: inpatients’ perceptions of family presence during resuscitation and invasive cardiac procedures. American Journal of Critical Care, 24(6), pp.e108-e115.

Zavotsky, K.E., McCoy, J., Bell, G., Haussman, K., Joiner, J., Marcoux, K.K., Magarelli, K., Mahoney, K., Maldonado, L., Mastro, K.A. and Milloria, A., 2014. Resuscitation team perceptions of family presence during CPR. Advanced emergency nursing journal, 36(4), pp.325-334.