WhiteCoat

Should JCAHO Regulate Family Visitation?

I had a whole story ready to post about another very sick child that we treated, but decided to leave a more general issue instead.

When there are critically ill patients, the staff has to think quickly and act quickly. Interruptions are counterproductive to our job during those times. Think about trying to concentrate on something – whether it be driving and trying to find a street address, talking on the phone, or trying to figure out a crossword puzzle – and being interrupted by your kids. The interruptions knock you off track from the task at hand.

There was a 6 month old who was critically ill in our department. With children, tasks such as starting IVs and intubating them are more difficult, and you also need to check the dosages of medications that they’re being given since pretty much all medications for children are weight-based. All the medical providers really need to focus.

So how do we manage a situation in which the parents are interrupting the care of their infant child?

I understand that seeing all of these things happen to your child is a scary experience. I understand that parents want to be there with their sick children. I’m a parent. I’ve seen it with my children.

Should the physician trying to save a child’s life stop what he or she is doing to explain to the parents what is happening – which may affect the survival of the child – or should the physician get done what needs to be done and talk to the parents later?

Some parents are very good about staying out of the way and just watching what is happening. But some parents will push you out of the way to stand next to the child, holding the child’s arm and caressing the child’s head when you really need access to the arm and the head.

If the family’s expectations are not met while you’re trying to save the child’s life – whether it is because you didn’t answer questions to the family’s satisfaction, whether you asked them to do something they didn’t want to do, or whether you said something to the staff that the family took the wrong way, then you may find yourself at the end of a complaint to hospital administration.

If you everything necessary to meet the family’s expectations, but doing so causes delays in caring for the child and the child suffers a bad outcome, then you may find yourself at the end of a malpractice lawsuit.

I know that some people will suggest “meeting in the middle.” That is fine and usually works well in most situations.

However, there are times when “meeting in the middle” doesn’t work, and those times may cost a child his or her life.

Should we excuse all family members from the room during critical care moments to decrease the likelihood of medical errors related to interruptions?

If we’re talking about “patient safety issues,” situations like this occur a lot more frequently than some of the other things that JCAHO tries to regulate.

Does JCAHO need to regulate family visitation?

29 Responses to “Should JCAHO Regulate Family Visitation?”

  1. Matt says:

    JCAHO lacks the authority to regulate family members even if it wanted to do so.

    • WhiteCoat says:

      JCAHO may not be able to regulate the actions of family members, but it can regulate hospital policies about family members.
      If “no families in the room during a code” becomes a JCAHO safety initiative, then every hospital that is certified by JCAHO will have to produce a piece of paper showing that there were no family members in the room during each and every code.

  2. Dr. J says:

    I am a big believer in bring family into the resus room for critical cases. I work in a medium sized community hospital much of the time with 1 doc coverage so there is never an extra person to just stand with the family and explain things. I have rarely had family members interfere with care. I usually put the family member near the foot of the bed if I need head and arms access and tell them to hold the foot so the ill person knows they are there. On the odd time the family has directly interfered with care I have gently moved them back to where I want them, told them their loved one is near to death and that we are working hard to save them. So far I have never had to kick anyone out, though I have had a few people leave because they were overwhelmed.
    I personally think this is an evolving area of care with no clear ‘standard of care’ as of yet.
    Dr. J

  3. Ben S says:

    Hire a commentator to do on-the-fly announcing of what’s going on.

  4. Gene says:

    Dr. J has some excellent points. Right now, I’m in a largish teaching hospital and when a Peds resus (or trauma) happens, a large group decends. We have an excellent child life team (ED based) or a social worker (depending on the day, the time, who’s around, etc) who tends to do the “explaining” to the family of what is going on. We also will often have the Peds resident from the PICU come down as part of the “code” team, and they also often talk to the family and narrate as the Peds ED team works. I’ve been in smaller hospitals before and I’ve sometimes stopped for the 10-20 seconds it takes to say, “Your child is very sick and we are going to put in a breathing tube, start some IVs, and give her medicines. You are welcome to stay in the room.” I’ve never had a parent or family stop me from treating their child in an emergency and despite the emotion, have never had a parent freak out when I tell them I will tell them everything after their child is stabilized.

    So what happened, WC?

    • WhiteCoat says:

      The family was upset with me because while I was helping start IVs, getting intraosseous needle ready, ordering meds, intubating, I wasn’t answering all their questions. They also apparently were upset because when the dad asked me what I was doing at one point, I told him that I was “trying to keep his son alive.”
      We got the child stabilized and flew him out to the children’s hospital.
      I sympathize with the families. I’ve been in the same situation as they have in the past.
      But unlike your experiences, I’ve had multiple families freak out on me during emergencies when we let them back in the rooms.
      That’s the purpose of the post. Once families are in rooms it is difficult to get them out. Should it be like the airlines where a couple of people acting irresponsibly ruin things for everyone? Shoe bomber makes everyone get their shoes scanned. Underwear bomber makes everyone get felt up or scanned.
      What do we do about families that interfere with proper patient care – especially in emergencies?

      • Nurse K says:

        1. Make sure there is someone with knowledge of codes assigned to the family. Having a peds code w/ no one assigned to the family is a recipe for chaos. Charge nurse, nursing supervisor, critical care charge nurse, someone.
        2. I personally believe in “escorted” viewing of codes, if the family is wanting to watch. Families shouldn’t be watching a code with no one there to explain what’s going on. This is especially true for peds, but should be true for adults too.
        3. If people are insisting on being right there in the middle of everything, a solid ‘we are doing everything we can to save your son’s life, and we need you to step back so we can work’ should be tried. Most people probably don’t realize they’re interfering because they have no clue WTF is going on.
        4. Worst case scenario, I am all for removing family members from the room forcibly. What’s worse? A hysterical, screaming dad being removed from the room that results in a better outcome or a hysterical dad getting in your way resulting in a poorer outcome? This may need to involve security/police, etc.

  5. SeaSpray says:

    Speaking as a parent …I would NOT want to be regulated out of my child’s room. That being said …I would absolutely want staff to do everything they could ..without interference.

    I like the idea of holding the child’s foot …still having *a point of contact* saying soothing or encouraging things to the child and/or silently pray …if that would not interrupt concentration for staff. Or stay out of the way in the corner and speak soothingly to the child or pray silently, if any words would even come to mind in that kind of stressful, heart wrenching situation. No one can really know what they would do …depending on circumstances.

    Mistakes do happen and staff needs to be able to do their job without unnecessary interruption/distraction.

    With time being of the essence in a critical situation,the medical staff should be able to call the shots. But …I would hope they would know when it is important for the parent to be there and not routinely block parents just because they can.

    I give all of you (medical staff in various departments)so much credit for doing the difficult work you do in these high stress situations. Thank God for people like you. :)

  6. Tracy2 says:

    I’ve been in a room for a code (not a child). It would have broken my heart (and probably required a mule team) to get me out of there.

    Emotion aside – what about the fact that a parent (or anyone so designated for any patient) is the legal healthcare power of attorney? They are allowed to make decisions for the patient, if the patient is unable.

    How is the healthcare proxy supposed to make decisions, if they are not in the room, and don’t know what’s going on?

    Is there a legal consideration here?

  7. Hueydoc says:

    Can we press charges against parents and family who interfere ? Causing the child’s death or contributing to it ? In 30 years, I’ve had a few patients families hauled out by security, throw punches at me, etc…. Fortunately it’s rare, however

  8. Guiac says:

    I would agree with the sentiments that it is good to have family in the room. Personally I’ve never run into the situation you described though I have had a family member who sycnopized and got a lac. Its ideal to have someone with them but if its not possible I still think the benefits outweigh the risks.

    WC – In your case call security/demand that they get out. IMO they have the right to be there only if they’re aren’t acting like you described

    Tracy2 – Legal rights are tricky matters in these situations – we are legally obligated to treat the child and in my CME legal courses have basically been told by lawyers to always err on the side of everything possible. There some exceptions of course(children with chronic problems, unlikely to improve with predetermined plans). A good analogy is a pediatric trauma victim who is also a Jehovah’s witness will still get blood over their parents objections in a live-death situation.

    Huey – how many times has that happened in a true life or death situation? I’ve seen it plenty of times too but it seems to be the trolls who are pissed off that I won’t refill oxycontin for them and their families not the ones who are truly ill.

    • Hueydoc says:

      Parents tend to go nuts under severe distress- it’s hard to predict. I’ve even had one mother take a swing at me after telling her we got her daughter back after drowning ! One lawyer was trying to tell us how to run the code and wanted us to explain every medication BEFORE we gave it. I’ve also had families go crazy when we finally called a code , demanding we continue when it’s very obvious there was no chance.
      How would I behave if it were my child ? I hope I never have to find out .

      • Guiac says:

        Interesting – I suppose we base a lot on our own cases – I haven’t had those problems. I have had some family distressed when calling a code – my usual approach is to put an ultrasound on the heart before calling so as to prove there is no cardiac motion. Something about a family understanding that the heart isn’t beating anymore seems to penetrate the grief and make them understand

      • WhiteCoat says:

        … until the agonal rhythm shows up on the screen and everyone freaks out.
        It’s a neat idea and I bet it would work in most cases. Just the exceptions that make me wonder whether I’d try that approach on a regular basis.

  9. One may bet on at least one life threatening mistake every day in the hospital. So, even a know nothing parent can help save his child and prevent a staff error by simply asking, “What are you doing? How will that help?” If these 2 questions makes the staff double check the name, the weight, the dose and the reason for a medication, that will save lives and liability, not interfere.

    Every patient, child or adult, needs a family member at the bedside 24 hours a day, to ask those 2 questions, at every treatment time. I believe JCAHO generates massive, worthless gold plating costs. It should be sued and driven out of business for its expense, and incompetence. However, it can help by encouraging family questioning.

    • Hueydoc says:

      You’re joking- right ?

    • NurseBeth says:

      “Every patient, child or adult, needs a family member at the bedside 24 hours a day, to ask those 2 questions, at every treatment time”

      Absolutely! My Dad asked me (when Mom was in the hospital very ill), “What do folks do when they don’t have someone like you with them?” ………indeed……
      Staffing does not allow for adequate monitoring these days on the floor, and even in the ER we struggle to provide the best pt care.

  10. DefendUSA says:

    As a parent with a good deal of patient care under me- I would *want* to be there. But I understand the need to get the heck out.

    I had an experience where a kid comes in for a sick appt. and ends up leaving via ambulance…the docs are trained in this type of thing, and two of us were capable of contributing. The visit went from bad to worse. The parents went nuts, and we had no security…chaos ensued. It was horrible. You can’t take any of it back and it haunts them and sometimes, the caregiver.

    The boy died several days later, but not because of interference. He was just so ill that his little body couldn’t fight it. Bacterial meningitis with heart complications.

  11. throckmorton says:

    I had a little girls dad pass out during an IV start. She did great. The Dad got a crani to evacuate his subdural.

  12. Tracy2 says:

    Throckmorton – I suppose I am a bad person to be laughing – but I am – lots.
    I do hope Dad was ok of course.

  13. Mike Owens MD says:

    It is not an all or none situation. I keep all parents close by with constant updates and explanations of prognosis. When the “hyperacute” phase is over and it is a matter of continued resuscitation, I unequivocally allow them into the room ASAP.

  14. MS1 says:

    I’ve worked as a tech in a Level I Adult/Level II Peds Trauma for a year and a half now. We have codes all day long some days, but the docs/nurses are usually uninterrupted because we have dedicated “Patient Representatives” to tend to the families during any codes (and they take care of other stuff as well, too). If a family wants to be there, we usually delay their entry for about 5 minutes just to get the lines, monitor and tube in, tho. The patient reps usually explain what is going on, and generally the techs help out too, if we get some time.
    I’ve yet to see a family member try to jam past the rest of us anyways because with the resident(s), tech, 2 nurses, respiratory, med students and an attending (plus the trauma team if its one of those)… theres just no room at the bedside.
    Do I think the family should be in the room? Absolutely. They may be the only source of the all-important history, and I know thats what i would want. But the people that should be answering the questions should be those who are not directly involved in the care of that patient. Thats what consultation rooms are for. Hold your questions until the end, or ask one of the ancillary staff. We’ve seen this enough times to understand whats going on.

  15. girlvet says:

    Although I understand the reason NOT to have the family in the room, its not realistic to think that a Mom and Dad are going to stay out of the room. At our place the charge nurse takes care of the family.

  16. WhiteCoat says:

    I have a few general comments for those who have commented so far.

    First, I think it’s great if your hospital is large enough to have ancillary staff to specialize in grief counseling on hand 24/7. Many small rural hospitals such as the one where I moonlight are lucky if they have an extra floor nurse who can come down and help with a critical patient – especially on nights. We need to compare apples to apples.

    Second, Supremacy Claus is absolutely right. Patient advocates prevent errors. However, asking those questions during an emergency situation would be counterproductive.

    • The mother is a surgeon, an expert in heparinization. She leaps to close the IV as the purple lump in the arm grows to baseball size in a minute. The patient has a new facial asymmetry and a mild hemiparesis with a limp, all suddenly. The blood was drawn from a foot vein. The pharmacy dosed the heparin assuming it came from a hep lock.

      Here is what is worse, this insider mother gets totally stonewalled that anything ever happened, when she asks that such miscommunication be prevented. The stonewalling is up to the MD president of an Ivy med school hospital. Nobody is suing anybody, just want procedures changed. They deny the request for a neurology consult for the facial asymmetry, which lasts 6 months, and is clear as day.

      I do not believe doctors should be sued. All the money comes from the care of other patients.

  17. NurseBeth says:

    But the pervasive feedback is……if family is allowed in, litigation is less……they need to feel/know that U did everything to save their loved one!
    Remember, it’s customer service, not outcomes, that drive the litigation……..I am so sorry to say…….

  18. Tracy2 says:

    The thing about the litigation is – I believe it’s anger. If someone kept me away from my loved one who died I would be furious. And yes, I would wonder if they made any mistakes. I’m sorry, but I feel it’s my right to be with a loved one, again, especially if I have the power of attorney.

    If you’re hysterical, of course that’s different.

    In my case, it was an old lady, not a child who I was with. Bless the staff’s heart, I was there for the whole code. When there was room, and she was awake, she held my hand. When she wasn’t responsive, or I needed to move, I moved. Her last conscious moment was holding my hand.

    In the end, I was the one to say they could stop. Last thing I could do for her.

    If someone had denied me those two things, I would have been furious. I’m not so likely to sue, but I can see how some people might.

    Oh yes, and there was a medical mistake in that code – which I pointed out. Didn’t change the outcome.

    • It is inappropriate for family to physically stand there and take up the space of an emergency person or to demand explanations during surgery or resuscitation.

      On the other hand most coded patients never make it out of the hospital, so little additional harm will come from questioning. Responsible family should be consulted before undertaking extreme measures, especially in those not likely to benefit, with a less than 50% chance of walking out under their own steam. Family demanding expensive, painful procedures with low success rates should be legally crushed and sued by the estate.

      Past age 80, only ordinary care should be allowed. Ordinary care includes surgery and radiation. Extended stays in ICU should be certified by the doctor to be likely to yield a discharge from the hospital with good function.

      About a quarter of Medicare money is spent on futile end of life care. That needs to end. It will cause massive unemployment in the places now providing worthless expensive care, but massive employment elsewhere as Medicare costs drop by a quarter. Impersonal death panels are murderers. However, the decision should be made between the patient before losing ability to decide and the personal physician. Put it in writing and enjoin any family trying to interfere with the agreement. Intermeddling family should be made to pay all legal costs.

  19. Teresa says:

    Do surgeons allow family in the OR? If not, why not? How is emergency medicine different from (emergency) surgery?

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