Quality Management Initiative

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Parental Presence on Induction
Quality Management Initiative
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PPI Quality Management Initiative Team
Liz Winters, Operations Director Surgery Philipp
Mossdorf, Anesthesia Jarmila Kim,
Anesthesia Leslie Hall, Anesthesia Jane McDonald,
Clinical Leader Perioperative Services Valerie
Anderson, Clinical Manger Perioperative
Services Carole Reid, RN DCS, PACU, OR Sandra
Rowe, RN OR Marran Mason, RN OR Chair Leigh
Johnson, Child life
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Where we started

• Parental Presence on Induction is an initiative
  that
• Originated from several requests from Family
  Forum to increase parental participation
  throughout the perioperative areas.
• Is the second stage of parental presence in PACU.
• Embraces CHEOs mandate to provide Family Centered
  Care.

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Mission Statement
In the CHEO Operating Room there is no program or
consistent practice related to parental presence
on induction. Parents have requested enhanced
opportunities to be present during the anesthesia
induction of their child.   This team will
develop, implement, and evaluate a program with
educational components and supports suitable to
perioperative staff, patients and families.
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Peer Reviews
In preparation for the development of CHEOs
Parental Presence on Induction Program we sought
information on the practices of other pediatric
hospitals across Canada. We found variation in

• The number of parents who are permitted into the
  OR.
• The level of structure associated with the
  practice of PPI.
• The amount of education provided to families and
  how the information is presented.

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Key Points in Research

• PPI increases parental satisfaction
• Children ages 0-1y found not to benefit from PPI.
  Parents of this age group also not found to
  benefit.
• Highly anxious parents create highly anxious
  children.
• The provision of consistent and thorough
  education is found to lessen parental anxiety and
  increase parental satisfaction.
• Parents are found to be emotional whether they
  are present for induction or are separated from
  their child at the OR doors.

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Challenges to PPI

• The efficient organization of potentially 5-7
  first cases of the morning.
• The physical set-up of DCS or OR waiting area is
  not ideal for parents to dress for induction.
• Physical layout in some of the ORs is difficult
  to accommodate parents at the bedside.
• Some staff may feel the program is disruptive to
  the flow of the OR.
• There will be not additional staffing resources
  available to implement the program.
• Noise in PACU, image presented by staff

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Positive Aspects of PPI

• Positive impact on the family unit
• Parental satisfaction may be heightened
• CHEO will be one of the few Canadian pediatric
  sites to offer a planned PPI program
• Supports CHEOs mandate of family centered care.
• Family Forum supports the initiative
• Perioperative nurses have a positive attitude
  about the program and believe in its benefits
• Parents can be a calming support for their
  children through induction

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Program Draft
Inclusion Criteria Children

• Who are booked for elective surgery
• Who are over the age of 1 year
• Who have a parent or support person who has
  expressed interest in accompanying the child into
  induction.
• Whose parent has received preparation for the
  induction experience.

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Exclusion Criteria

• Children
• Who express or display body language that
  indicates that they do not want a parent to be
  present
• Who have a known or suspected difficult airway
• Who have a need for rapid sequence induction
• Who are medically unstable
• Other factors that the anesthesiologist feels
  would jeopardize the health of the child
• Family Members/Support Persons
• Who express discomfort or uneasiness about
  participating in the program

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Traffic Flow of Parents Through the OR
Once anesthesia has given consent for a parent to
accompany his/her child into the OR the parent
will dress in downgraded gown, hat, mask and
booties in the multipurpose room beside the
interview room at the OR. An identified escort
(nurse, PSA, child life specialist, surgical
resident, etc.) should be introduced to the
parent at that time. Flow into the ORs will be
counterclockwise. When parents exit the ORs they
will continue in a counterclockwise direction
except those leaving ENT and Dental who will
backtrack to the interview room.
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Traffic Flow cont.
The escort will stay near the parent or support
person during induction then accompany them back
to the OR interview room. OR doors should be kept
closed at all times when the stretcher enters
the room the door should be closed behind until
the patient is ready to be moved to PACU.
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Potential escorts for parents

• PSA
• Nurse (DCS, PACU, OR)
• Surgical resident, surgeon
• Child life specialist

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Potential forms/sources of parental education

• Video
• Pamphlet
• Virtual tour
• PAC nursing and anesthesia
• DCS child life and nursing
• Posters
• Mailouts

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Family Questionnaire
1 I was well prepared for the anesthetic
induction experience.  Strongly disagree 1 2 3
4 5 Strongly agree   2 The pamphlet
was Clear Strongly disagree 1 2 3 4 5
Strongly agree Easy to understand Strongly
disagree 1 2 3 4 5 Strongly agree Helpful
Strongly disagree 1 2 3 4 5 Strongly
agree     3 I felt my presence was helpful to my
child/youth.  Strongly disagree 1 2 3 4 5
Strong agree    4 If given the opportunity, I
would accompany my child/youth into the operating
room again.  Strongly disagree 1 2 3 4 5
Strongly agree    Comments
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Anesthesia Nursing Questionnaire
In addition to scoring the following items, the
anesthesiologist and nurse took note of who
accompanied the child (mother, father, or other),
who escorted the parent in and out of the OR,
time of entry into the OR, and type of induction
(mask or I.V.) used. Childs level of
upset Calm 1 2 3 4 5 very upset   Childs
level of cooperation Cooperative 1 2 3 4 5
uncooperative   Parents reaction Calm 1 2 3
4 5 very upset    Comments
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Trial Findings

• 33 Completed Family Questionnaires
• 31/33 would participate again if given the
  opportunity 93.9
• 19/33 gave perfect scores 57.5
• 28/33 gave scores of 4 5 84.8
• 29 Completed Anesthesia Questionnaires
• 19/29 gave scores of 1 2 65.5
• 24 Comleted Nursing Questionnaires
• 16/24 gave scores of 1 2 66.6
• 6 Families Declined Participation

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Next Steps
Consideration of volunteer resources staffed to
assist with escorting parents in and out of the
ORs. Presentation of findings to Family Forum,
OR Committee, Anesthesia, Nursing (OR, PACU, DCS).