Is There a P l a c e for P a r e n t s in the Opera t ing R o o m ?

By Michael W.L. Gauderer, June L. Lorig, and Douglas W. Eastwood Cleveland, Ohio

�9 The presence of a parent in the operating room (OR) during induction of anesthesia is controversial. In order to assess the feasibility, safety, and acceptance of this prac- tice, we evaluated a near-4-year experience with 3,086 patients <15 years of age, who were operated on at a free-standing ambulatory surgical center. The age distribu- tion was: 1 to 23 months, 790; 2 to 5 years, 1,190; 6 to 10 years, 775; and 10 to 15 years, 331. The distribution of patients by service was: otorhinolaryngology, 1,597; pedi- atric surgery, pediatric urology, and plastic surgery, 948; ophthalmology, 443; orthopaedics, 72; and dental, 26. No premedlcation was employed. Anesthetic gases were delivered via a mask while the parent held or remained close to the child. Vascular access was established after the induction. Only five patients (tonsillectomy, four; cir- cumcision, one) were admitted to the base hospital and subsequently discharged. Advantages of parental presence in the OR during anesthesia induction are decreased psy- chological trauma (child), smoother induction (child), and decreased parental anxiety. Possible disadvantages include disruption of OR routine, unpredictability of parental behavior, and increased time and cost. Because of careful preoperative preparation of parents by the nurses and anesthetists, the first three problems rarely occurred. The cost of supplies used by each parent was minimal. Practi- cally all parents chose to accompany the child to the OR. The feedback during follow-up from those parents has been excellent. Nurses, anesthesiologists, and surgeons are enthusiastic about the program. In the examined set- ting, this approach has proven safe, simple, and effective. �9 1989 by W.B. Saunders Company.

INDEX WORDS: Ambulatory surgery.

B ECAUSE OF the development of safer anes- thesia, an expanding demand for hospital beds,

and greater acceptance by the public, ambulatory surgery is playing an increasing role in the delivery of routine surgical care to adults and children. Ambula- tory surgical centers were first developed in this country 20 years ago; however, it was not until 1980 that they became the subject of widespread interest. ~ It is estimated that outpatient surgery represented 40.4% of all operations performed in hospital-related settings in 1986.1 Ambulatory surgery is particularly well suited for a number of routine procedures in healthy children.

Although the concept of the presence of a parent in the operating room (OR) during anesthesia induction is not new, few publications address this issue. 25 In order to assess the feasibility, safety, and acceptance of this practice by parents and staff, we evaluated a 45-month experience with 3,086 patients < 15 years of age, who were operated on at a free-standing ambula- tory surgical center.

MATERIALS AND METHODS

At Case Western Reserve University, ambulatory surgical proce- dures in children are performed in two hospital settings (Rainbow Babies & Childrens, Cuyahoga Metropolitan General) and one free-standing surgical unit (Wright Surgery Center). The latter is within a nonhospital, multispecialty health care facility 4.5 miles from the children's hospital. It consists of four operating rooms and is staffed by two anesthesiologists, three nurse anesthetists, 17 nurses, two aides, and five clerks. The average annual number of operative procedures performed, including adults and children, is 4,200.

Patient selection occurs in the surgeon's office. Children with a high likelihood of postprocedure hospital admission, those whose parents seem emotionally unstable or otherwise unsuitable for this approach, are not candidates. A preoperative visit to the Center, a few days prior to the procedure, is available. All parents receive a preoperative telephone call. All parents (and children, if old enough), receive careful instructions from nurses and anesthetists in the waiting area, prior to entering the OR suite. This process usually takes about ten minutes and is done with the aid of a specially prepared photo album. One of the parents then dons a disposable gown, hat, mask, and shoe covers and accompanies the child to the OR.

No premedieation is used. Induction is performed via a mask to which different child-pleasing flavors may be applied. Younger children are held in the parents arms, older ones lie supine with the parent in close attendance. An anesthesiologist and a nurse anesthe- tist routinely participate in the administration of the anesthetic. Once the child is asleep, the parent is escorted to the waiting area. Monitors are applied and vascular access is then established. Upon termination of the procedure, the surgeon meets with the parents as the child is moved to the recovery room. The parents are then taken to the recovery room to be with the child as he/she awakens.

RESULTS

F r o m O c t o b e r 1984 to J u l y 1988, 3 ,086 p e d i a t r i c

p a t i e n t s w e r e o p e r a t e d o n a t t h e C e n t e r . T h e a g e

d i s t r i b u t i o n was: 1 to 23 m o n t h s , 790; 2 to 5 yea r s ,

1,190; 6 to 10 years, 775; and 10 to 15 years, 331. The distribution of patients by service was: otorhinolaryn- gology, 1,597 (tympanostomy related, 1,204); pediat- ric surgery, pediatric urology, and plastic surgery, 948 (hernias/hydroceles, 378); ophthalmology, 443; ortho- paedics, 72; and dental, 26.

From the Division of Pediatric Surgery, Departments of Surgery and Anesthesia, and the Wright Surgery Center, Case Western Reserve University School of Medicine, Cleveland.

Presented at the 37th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, San Francisco, California, October 15-17, 1988.

Address reprint requests to Michael W.L. Gauderer, MD, Chief, Division of Pediatric Surgery, Rainbow Babies & Chitdrens Hospi- tal, 210t Adetbert Rd, Cleveland, OH 44106.

�9 1989 by W.B. Saunders Company. 0022-3468/89/2407-0022503.00/0

Journal of Pediatric Surgery, Vo124, No 7 (July), 1989: pp 705-707 705

706 GAUDERER, LORIG, AND EASTWOOD

One third of the parents came for a preoperative visit. In nearly all procedures, either the father or the mother accompanied the child to the OR and remained during the induction of general anesthesia. Selectivity led to complete participation in the pediatric surgical group. In the few short cases in which local anesthesia was employed, one of the parents was usually allowed to stay with the child during the entire procedure.

Induction has generally been very smooth and, although no scores were kept, it was estimated that crying or struggling occurred in about one out of 20 to 30 children. Visible parental anxiety was uncommon in the OR, hut teary eyes were common as parents were escorted to the waiting room. No parent had to be escorted from the OR because of undue anxiety; however, two parents developed syncope, with a prompt recovery.

We could not detect disruptions in the OR routine, safety related problems, or delays caused by parental presence. The added cost for the disposable isolation gown, hat, mask, and shoe covers was $1.39 (US currency) per parent. No serious complications occurred following the 3,086 procedures. Five children were transferred to the base hospital. In four, the operation was a tonsillectomy (causes: bleeding, laryn- geal edema, stridor, and excessive parental anxiety). The fifth child had bleeding from the frenulum follow- ing a circumcision. These transfers were without inci- dents, and no additional interventions were needed.

DISCUSSION

Active parental participation in the care of their children was established as early as 1925 at the Children's Hospital of Case Western Reserve Univer- sity, when the overnight stay was selectively practiced. Unlimited visiting hours were introduced in 1964, and rooming-in during the following year. Parents were initially permitted in the pediatric recovery room, which was especially staffed for this purpose in 1973. 6 Fathers were encouraged to be present during cesarean births after 1976. The concept of parents in the OR was first introduced at this medical school in 1984.

The Wright Surgery Center, being relatively small, efficient, and having a well-trained closely interacting staff, was well suited for the implementation of a program in which one of the parents accompanied the child to the OR, and remained during anesthesia induction.

Separation anxiety 7 can be a substantial psychologi- cal trauma, particularly in smaller children. The pres- ence of a parent during this trip into the unknown effectively reduces this stress. The effect of parental presence during anesthesia induction has been previ- ously studied, 2 and the positive features have been

confirmed by others. 35 A surprisingly high proportion of parents in our study expressed (unprompted) their satisfaction with this method during the postoperative visit. Practically all parents, when questioned if they would again accompany the child to the OR, responded aff• The response from older chil- dren and those requiring repeated procedures has been equally gratifying.

Possible disadvantages of this approach are disrup- tion of the OR routine, parent related accidents, increased wound infection rate, prolonged OR time, and increased cost. The OR routine has worked smoothly without interruption secondary to the pres- ence of parents. No infection-related problems could be identified. With the appropriate preoperative prep- aration, loss of time related to an additional person in the OR is avoided. The cost issue was previously addressed.

Although we were initially concerned about the added stress to the OR personnel, particularly the anesthesiologists and nurse anesthetists, no difficulties were encountered.

Although the present study does not quantitatively assess the advantages of this unique parent-child expe- rience, it clearly demonstrates the feasibility, safety, and acceptance of the approach. With appropriate selection and preoperative preparation, parental pres- ence in the OR during the induction of anesthesia is a positive factor in the delivery of surgical care to children. We feel that in this age of multiple choices in health care delivery, there is a place for parents during the induction of anesthesia in an appropriate setting.

ACKNOWLEDGMENT

The authors acknowledge the work, dedication, and enthusiasm of the WSC staff, including the anesthesiologists Drs William R. Green and Haiyee Lin, the nurse anesthetists, and the OR and recovery room nurses.

REFERENCES

1. Politser, P: Ambulatory surgery: Some issues and consider- ations. Am Coil Surg Bull 73:26-29, 1988

2. Schulman JL, Foley JM, Vernon DTA, et al: A study on the effect of the mother's presence during anesthesia induction. Pediat- rics 39:111-114, 1967

3. Hannallah RS, Rosales JK: Experience with parents' presence during anesthesia induction in children. Can Anaesth Soc J 30:286- 289, 1983

4. Epstein BS, Hannallah RS: The pediatric patient, in Wetchler BV (ed): Anesthesia for Ambulatory Surgery. Philadelphia, Lippin- cott, pp 124-174

5. Johnston CC, Bevan JC, Haig M J, et al: Parental presence during anesthesia induction. AORN J 47:187-194, 1988

6. Dew TA, Bushong M, Crumrine R: Parents in pediatric recovery room. AORN J 26:266-273, 1977

7. Bowlby J: Separation anxiety. Int J Psychoanal 41:89-113, 1960

PARENTS IN THE OPERATING ROOM 707

Discuss ion

J. White (Loma Linda, CA)." I discussed this with my colleagues at Loma Linda, and I would like to empha- size that we are talking about not what surgeons do in the operating room, but what our anesthesiology col- leagues do. My concern is whether they are really in agreement with what Dr Gauderer is proposing. Our pediatric anesthesiologists are all in agreement. They believe that the presence of the parent promotes an expedient and pleasant induction. If this is so, where is the best place to do it? Often, we have induction rooms and there is a mad dash down the corridor to the operating table where the child can be monitored and the anesthetic induction completed. I think the solution presented here is the correct one. Start off right where you have all your monitoring equipment and all of your capabilities of responding to any kind of an emergency that may arise.

Several cautions have been raised. Would this increase the incidence of wound infection? The answer is, of course, no! I think everybody knows that wound infection comes from the patient's own skin and not from the atmosphere. The second concern is "the administration would never let us do this," and I would say that good administration should follow what is good for the patient. Once the parent is in the operat- ing room, will a persistent parent want to stay there through starting of the IV, and then through the operation itself? This is a concern. With such cautions, I believe Dr Gauderer's paper is very pertinent to what we do.

M.W.L. Gauderer (response): Dr White, thank you for your kind words. This approach is the brainchild of several individuals, particularly Dr Eastwood, one of our senior anesthesiologists. We looked at the problem of sepsis and found no increase as one would expect. There were no problems with the administration in our setting. However, I believe that what you said about not allowing parents to stay for the procedure itself is very important. The key aspects of this approach are (1) proper patient selection, (2) an appropriate setting, and (3) the parents have to be properly instructed. Our unit was well suited for this. This method is obviously

not for every team and not for every center. What I wanted to leave with you is the concept that it worked well for us.

J. Weitzman (Tarzana, CA): Although he didn't come right out and say it, I think Dr Gauderer 's program is primarily a marketing tool. A much easier way is, in the preinduction room, to give the child a little bit of rectal Brevitol, and the child can leave his mother's arms, fast asleep.

Dr Asher: We've had induction rooms in our operat- ing room for about 10 years, but we badgered our anesthesiologist into not telling the patients or their parents about the induction rooms. If they find out about it some way, then we let the parents go in. So in this selected group, the kind of picture we see is nothing at all like just shown. There is the crying parent, the screaming child, and a few anesthesiol- ogists and nurses trying to hold them down to do a job that ought to be done out of sight.

D. Schwartz (New Hyde Park, NY): We also have an outpatient unit that has now performed close to 5,000 operations in children. I asked our chief of anesthesia what his feelings were and got two answers. One was, it is just against administrative policy; they will not allow parents in the operating room area or preinduction area. His second comment was, "A ner- vous anesthesiologist is a bad anesthesiologist." Every individual has to make his own choices in his own hospital. I think some patients and families can handle it. Others cannot.

M.W.L. Gauderer (closing): This approach is not for everybody. You have to have an anesthesiologist who will stand behind it. You have to have nurses who stand behind it. Is it a marketing tool? Yes, it can be. On the other hand, you have to look at the history of our institution, where parents were permitted in the chil- dren's rooms as early as 1925. There was no need to do marketing then. The presented approach is just a continuation, an evolution of a concept. We as pediat- ric surgeons, along with our colleagues in anesthesia, should take the lead in this field, and take a good look at the psychological aspects of operating on children.