Family-centered’ focus comes to the ED
A visit to the ED can be a crisis situation for any family, regardless of the severity of illness or injury. The concept of family-centered care has taken root in hospitals nationwide but until recently hasn’t focused on the ED. Several pediatrics EDs have embraced this family- oriented philosophy, which encompasses all aspects of emergency care.
Although the ED’s primary function is to handle life-threatening emergencies, serving the community is another responsibility. "There is growing awareness that family-centered concepts and saving lives are, in fact, very compatible," says Beverley H. Johnson, president of the Institute for Family-Centered Care in Bethesda, MD.
Involve family members
Ongoing quality improvement should be a collaborative effort with families who use the ED, says Johnson. "A big part of being family- centered is having families be part of shaping these services and inviting families who have used the ED to be part of the planning committee.
"You need to create a lot of opportunities for families to share their stories about experiences with emergency care with staff and administrators," says Johnson. "Having consumers on working committees helps you better understand the needs, priorities, and perspectives of patients and families. It puts you on an equal par with the people you serve and gives you a different perspective." Some EDs regularly invite family members to brown-bag luncheons and ask for their feedback.
Focus groups aren’t the answer, she says. "You ask them a question and write down the answer. The dialogue in task forces or committees is much more effective," she explains. "For example, if there is a task force on providing information to adolescents, you should include several staff members across different disciplines, as well as adolescents and family members," she says.
Patients and families who serve in advisory capacities should reflect the cultural makeup of the community. "Some of the people who are the heaviest users of the ED are often struggling with poverty and other difficult life situations," says Johnson.
One way families can help is educating residents about communication issues. "To communicate difficult information in a stressful situation is not just going to happen, so we have to teach it. It hasn’t been emphasized in resident training thus far," says Johnson. "There are a number of groups where families have taught physicians how to share bad news with them," she says. Several residency programs are using videotapes to improve their communications skills.
Design issues
The University of Virginia’s ED in Charlottesville invited parents of children with special needs to monthly meetings to plan its pediatrics ED in the late ’80s. "These were articulate people with very strong feelings about family-centered care, and we asked for their guidance," says Richard Christoph, MD, FAAP, director of pediatric emergency medicine. "Some of the input was a bit unrealistic given the contexts of the proposed project, such as a freestanding pediatrics ED, but other suggestions were very valuable and wound up being implemented," he says.
Following are some design issues to keep in mind when planning for families:
• Signage. This creates a powerful first impression of the ED. Signs should indicate clearly the route to the ED, both inside and outside the hospital, and be understandable to families who don’t read English. "I walk into some EDs, and right away there is very negative signage," says Johnson. One ED’s sign said, "Nurses wait here for disaster patient assignments." Johnson says "How often do you have a disaster? And yet the sign was right by the front door so everybody sees it when they walk in."
Another sign read, "Emergency Department Stop," with a stop sign and "All Patients Must See Nurse First. Please Sit on Bench Until Called by Nurse" in big red letters. "Patients are being herded; that’s not a respectful way to convey we’re here to help," says Johnson. "It creates a negative dynamic right away that patients are passive recipients of care and puts people on the defensive."
• Parking. This should be convenient and affordable for families. "Can the family see the entrance clearly? Do they have a place to park the car and quickly get in, or do they have to go out and move it in five minutes?" says Johnson.
• Separate areas. It’s ideal to have separate ambulance entrances, corridors, and treatment rooms for severely injured or ill children.
• Waiting areas. These should be large enough and comfortable, even if several adults and children accompany one child. Seating should accommodate children or adults with special needs or assistive devices and children who don’t feel well enough to sit up.
Toys and other play materials should be available for children of all ages and abilities, with a play area staffed by volunteers or child life staff. Some EDs have interactive toys in the waiting area so children don’t wander away.
• Observation units. There should be enough space for families who choose to remain with their children. "The needs of accompanying children need to be addressed," says Johnson. Exam, treatment, and procedure rooms should be designed to accommodate these parents. Parents or caretakers can provide support during wound management, spinal taps, or phlebotomy to reduce anxiety. (See story on parents remaining in the trauma room in the November 1996 issue of ED Management.)
It’s important to recognize that family members can provide valuable input. "If it’s a child with special needs, the mother and father are probably excellent sources of information. Ask and really listen to what the family is saying," says Johnson. "If organizing a code team, it’s very important that somebody on the staff be designated as the primary support person for families and facilitates information sharing with them."
• Separate pediatric areas. "If provided in the same space as adult care, the waiting and exam areas should be visually and acoustically separated from the adult area," says Johnson.
• Proximity to other departments. "Families should be able to easily find their way to other areas in the hospital, such as radiology, laboratory, pharmacy, and admitting," says Johnson.
• Convenience of services. Telephones, restrooms with diaper-changing areas, water fountains, vending machines, and breast-feeding rooms should be nearby. Signs should be clearly marked in the primary languages of the communities served by the hospital, and phone areas should be private and free of charge to families.
• Equipment and supplies. While these need to be easily accessible, they should be kept out of sight whenever possible to avoid raising unnecessary anxiety. "There should be closed storage for potentially frightening equipment and supplies," says Johnson.
Counsel/support family members
Systems should be in place to counsel family members and provide referrals for social services situations. "We have social workers around the clock on call and two that work specifically in the ED," says Jenny Crabtree, RN, BSN, a staff nurse in the ED at Cincinnati Children’s Hospital. In cases of domestic or sexual abuse, social workers work directly with the social services agencies of surrounding counties.
In crisis situations, the family will need support while the child’s immediate physical needs are being attended to. These may include social workers, chaplains, patient representatives, child life specialists, or translators. "We always have a chaplain on call who carries a trauma beeper," says Crabtree.
The staff social workers contribute to a weekly nursing newsletter. "They continuously inservice us with education us about social issues," says Crabtree "If a large family comes into the ED, the social workers help in getting them drinks and transporting them."
Counseling parents after sudden infant death syndrome is a new endeavor. "We recognized that nobody in this department is doing that, so we searched on the Internet for resources," says Crabtree. A pamphlet is being developed to provide outreach options for these parents."
Contact numbers for homelessness, domestic violence, and substance abuse should be readily available. "You can provide a list to a family member and suggest they call one of the groups on the list," says Johnson. Some EDs offer bereavement programs of their own.
In many cases, a grief-stricken individual won’t be able to digest this kind of information immediately. "You can call that family member a month later and let them know about these groups and also send a letter," says Johnson.
Staff members should be on hand to support families following the death of a child or other crises, such as the diagnosis of a serious illness or impairment. These communications should be discreet. "Pick a quiet place, such as a hallway," says Johnson. "It doesn’t have to take long, but you don’t have to do it standing up in a waiting room with 100 other people around."
Sensitivity to a family member’s concern or grief is important. "Be careful of the words you use and make eye contact, and remember your body language," she says. "Communicate that you’re supportive and really listening to their concerns."
Staff position descriptions and performance appraisals should stress the importance of working in respectful, supportive, and collaborative ways with patients and their families. "Sometimes people don’t realize the way they communicate has such a powerful impact," says Johnson.
Mechanisms should be in place to help staff in coping with the stresses inherent in working in the ED. "A staff lounge should be accessible for frequent short breaks, with opportunities to debrief following critical incidents," says Johnson.
Successful patient/staff interactions can build long-term relationships with the hospital. "Very powerful and long-lasting impressions are made because of an experience in the ED," says Johnson. "It could be a traumatic experience, but if patients and families are treated well and given support, that can go a long way towards building positive attitudes about health care and health care providers with that patient."
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