Resuscitation Events Research Articles

Cultural aspects of death notification following cardiopulmonary resuscitation.

To explore the lived experience of resuscitation team members involved in notifying family members when a patient dies following a resuscitation event in an Iranian cultural context. Death notification to the family is indeed a difficult and an important issue for resuscitation team members. The way health professionals deliver news to family members should incorporate elements of sensitivity, timing and adequate clinical explanations with emphasis on the efforts made by the professionals during the resuscitation. A phenomenological study. Over a period of 5months (June 2016-November 2016) eleven nurses and six physicians were interviewed using an in-depth interview process applying Van Manen's hermeneutic phenomenological approach for data collection and analysis. The participants were recruited from six tertiary hospitals in Tabriz, Iran. There were two main themes that emerged from the data analysis including: "contributing factors on the impact of notification" and "notification strategies". A further 13 subthemes emerged under the main themes. Several culturally related issues emerged with the participants feeling more comfortable informing male rather than female relatives about the death of the patient following a resuscitation. Notifying family members of a patient's death is a stressful and culturally sensitive task for the resuscitation team members. The nature of the patient's presenting condition, together with the various resuscitation interventions can result in relatives responding unpredictably. Providing health professionals with the appropriate training and skills to effectively communicate with family members will ensure that the families' level of preparedness, understanding and cultural beliefs are taken into consideration.

Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan.

ObjectivePatients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect.DesignA controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions.SettingA 2000-bed medical centre in TaiwanParticipantsHospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods.Main outcome measuresProportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality.ResultsThe pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared.ConclusionsThe seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.

Communicating resuscitation. The importance of documentation in cardiac arrest.

Objectives:To primarily assess documentation during in-hospital cardiopulmonary arrest resuscitation and to secondarily observe cardiopulmonary resuscitation event and outcome variables.Methods:A retrospective review of 360 code blue forms and medical records at King Fahad General Hospital, King Abdulaziz General Hospital (Almahjar), and Althghar Hospital in Jeddah was performed between 2015 to 2016.Results:Survival to discharge rates and neurological outcomes were not documented at all. Other undocumented variables include gender 9 (2.5%), nationality 12 (3.3%), code blue announcement time 130 (36%), initial rhythm 10 (2.8%), time to airway placement 154 (57.2%), time to cardiology arrival 181 (50.27%), and time to anesthesia arrival 145 (40.27%).Conclusion:We strongly recommend the use of standardized cardiopulmonary arrest sheets among all hospitals and follow up of neurological outcomes and survival to discharge as outcome variables.

Out-of-hospital cardiac arrest in the home: Can area characteristics identify at-risk communities in the Republic of Ireland?

BackgroundInternationally, the majority of out-of-hospital cardiac arrests where resuscitation is attempted (OHCAs) occur in private residential locations i.e. at home. The prospect of survival for this patient group is universally dismal. Understanding of the area-level factors that affect the incidence of OHCA at home may help national health planners when implementing community resuscitation training and services.MethodsWe performed spatial smoothing using Bayesian conditional autoregression on case data from the Irish OHCA register. We further corrected for correlated findings using area level variables extracted and constructed for national census data.ResultsWe found that increasing deprivation was associated with increased case incidence. The methodology used also enabled us to identify specific areas with higher than expected case incidence.ConclusionsOur study demonstrates novel use of Bayesian conditional autoregression in quantifying area level risk of a health event with high mortality across an entire country with a diverse settlement pattern. It adds to the evidence that the likelihood of OHCA resuscitation events is associated with greater deprivation and suggests that area deprivation should be considered when planning resuscitation services. Finally, our study demonstrates the utility of Bayesian conditional autoregression as a methodological approach that could be applied in any country using registry data and area level census data.

Rapid response systems for paediatrics: Suggestions for optimal organization and training.

Resuscitation and cardiac arrest events in the paediatric population are rare occurrences. Improving outcomes from such events continues to be a difficult challenge. Rapid response systems and teams have been integrated into many hospitals in an effort to facilitate early identification and management of patients at risk for clinical deterioration. Optimizing education in the form of team training is a major component of successful team performance. Simulation-based team training, is a key educational supplement for existing standardized resuscitation courses. This position statement describes the evidence supporting rapid response systems and teams as well as simulation-based team training and provides recommendations for implementation in hospital care for paediatric patients.

Rating teams’ non-technical skills in the emergency department: A qualitative study of nurses’ experience

IntroductionNon-technical skills (NTS) teamwork training can enhance clinicians’ understanding of roles and improve communication. We evaluated a quality improvement project rating teams’ NTS performance to determine the value of formal rating and debriefing processes. MethodsIn two Australian emergency departments the NTS of resuscitation teams were rated by senior nurses and medical staff. Key measures were leadership, teamwork, and task management using a valid instrument: Team Emergency Assessment Measure (TEAM™). Emergency nurses were asked to attend a focus group from which key themes around the quality improvement process were identified. ResultsMain themes were: ‘Team composition’ (allocation of resuscitation team roles), ‘Resuscitation leadership’ (including both nursing and medical leadership roles) and ‘TEAM™ ratings promote reflective practice’ (providing staff a platform to discuss team effectiveness). Objective ratings were seen as enabling staff to provide feedback to other team members. Reflection on practice and debriefing were thought to improve communication, help define roles and responsibilities, and clarify leadership roles. ConclusionUse of a non-technical skills rating scheme such as TEAM™ after team-based clinical resuscitation events was seen by emergency department nurses as feasible and a useful process for examining and improving multi-disciplinary practice, while improving team performance.

How do clinicians practise the principles of beneficence when deciding to allow or deny family presence during resuscitation?

To examine how clinicians practise the principles ofbeneficence when deciding to allow or deny family presence during resuscitation. Family presence during resuscitation has important benefits for family and is supported by professional bodies and the public. Yet, many clinicians restrict family access to patients during resuscitation, and rationales for decision-making are unclear. Secondary analysis of an existing qualitative data set using deductive category application of content analysis. We analysed 20 interview transcripts from 15 registered nurses, two doctors and three paramedics who had experienced family presence during resuscitation in an Australian hospital. The transcripts were analysed for incidents of beneficent decision-making when allowing or denying family presence during resuscitation. Decision-making around family presence during resuscitation occurred in time poor environments and in the absence of local institutional guidelines. Clinicians appeared to be motivated by doing "what's best" for patients and families when allowing or denying family presence during resuscitation. However, their individual interpretations of "what's best" was subjective and did not always coincide with family preferences or with current evidence that promotes family presence during resuscitation as beneficial. The decision to allow or deny family presence during resuscitation is complex, and often impacted by personal preferences and beliefs, setting norms and tensions between clinicians and consumers. As a result, many families are missing the chance to be with their loved ones at the end of life. The introduction of institutional guidelines and policies would help to establish what safe and effective practice consists of, reduce value-laden decision-making and guide beneficent decision-making. These findings highlight current deficits in decision-making around FPDR and could prompt the introduction of clinical guidelines and policies and in turn promote the equitable provision of safe, effective family-centred care during resuscitation events.

Implementation and effectiveness of a video-based debriefing programme for neonatal resuscitation.

Approximately 5%-10% of newly born babies need intervention to assist transition from intra- to extrauterine life. All providers in the delivery ward are trained in neonatal resuscitation, but without clinical experience or exposure, training competency is transient with a decline in skills within a few months. The aim of this study was to evaluate whether neonatal resuscitations skills and team performance would improve after implementation of video-assisted, performance-focused debriefings. We installed motion-activated video cameras in every resuscitation bay capturing consecutive compromised neonates. The videos were used in debriefings led by two experienced facilitators, focusing on guideline adherence and non-technical skills. A modification of Neonatal Resuscitation Performance Evaluation (NRPE) was used to score team performance and procedural skills during a 7 month study period (2.5, 2.5 and 2 months pre-, peri- and post-implementation) (median score with 95% confidence interval). We compared 74 resuscitation events pre-implementation to 45 events post-implementation. NRPE-score improved from 77% (75, 81) to 89% (86, 93), P < 0.001. Specifically, the sub-categories "group function/communication", "preparation and initial steps", and "positive pressure ventilation" improved (P < 0.005). Adequate positive pressure ventilation improved from 43% to 64% (P = 0.03), and pauses during initial ventilation decreased from 20% to 0% (P = 0.02). Proportion of infants with heart rate > 100 bpm at 2 min improved from 71% pre- vs. 82% (P = 0.22) post-implementation. Implementation of video-assisted, performance-focused debriefings improved adherence to best practice guidelines for neonatal resuscitation skill and team performance.

Design and Deployment of a Pediatric Cardiac Arrest Surveillance System.

Objective We aimed to increase detection of pediatric cardiopulmonary resuscitation (CPR) events and collection of physiologic and performance data for use in quality improvement (QI) efforts. Materials and Methods We developed a workflow-driven surveillance system that leveraged organizational information technology systems to trigger CPR detection and analysis processes. We characterized detection by notification source, type, location, and year, and compared it to previous methods of detection. Results From 1/1/2013 through 12/31/2015, there were 2,986 unique notifications associated with 2,145 events, 317 requiring CPR. PICU and PEDS-ED accounted for 65% of CPR events, whereas floor care areas were responsible for only 3% of events. 100% of PEDS-OR and >70% of PICU CPR events would not have been included in QI efforts. Performance data from both defibrillator and bedside monitor increased annually. (2013: 1%; 2014: 18%; 2015: 27%). Discussion After deployment of this system, detection has increased ∼9-fold and performance data collection increased annually. Had the system not been deployed, 100% of PEDS-OR and 50–70% of PICU, NICU, and PEDS-ED events would have been missed. Conclusion By leveraging hospital information technology and medical device data, identification of pediatric cardiac arrest with an associated increased capture in the proportion of objective performance data is possible.

Google Glass Video Capture of Cardiopulmonary Resuscitation Events: A Pilot Simulation Study

Video recording of resuscitation from fixed camera locations has been used to assess adherence to guidelines and provide feedback on performance. However, inpatient cardiac arrests often happen in unpredictable locations and crowded rooms, making video recording of these events problematic. We sought to understand the feasibility of Google Glass (GG) as a method for recording inpatient cardiac arrests and capturing salient resuscitation factors for post-event review. This observational study involved recording simulated cardiac arrest events on inpatient medical wards. Each simulation was reviewed by 3 methods: in-room physician direct observation, stationary video camera (SVC), and GG. Nurse and physician specialists analyzed the videos for global visibility and audibility, as well as recording quality of predefined resuscitation events and behaviors. Resident code leaders were surveyed regarding attitudes toward GG use in the clinical emergency setting. Of 11 simulated cardiac arrest events, 9 were successfully recorded by all observation methods (1 GG failure, 1 SVC failure). GG was judged slightly better than SVC recording for average global visualization (3.95 versus 3.15, P = .0003) and average global audibility (4.77 versus 4.42, P = .002). Of the GG videos, 19% had limitations in overall interpretability compared with 35% of SVC recordings (P = .039). All 10 survey respondents agreed that GG was easy to use; however, 2 found it distracting and 3 were uncomfortable with future use during actual resuscitations. GG is a feasible and acceptable method for capturing simulated resuscitation events in the inpatient setting.

Family Support During Resuscitation: A Quality Improvement Initiative.

Despite increasing support for family presence during cardiopulmonary resuscitation, a review of the literature revealed no published protocols or training curricula to guide hospitals in implementing a family support provider role. To develop a curriculum and train dedicated resuscitation team members whose role is to provide family support during in-hospital resuscitation events. An interdisciplinary team developed a 4-hour training session for the family support staff. The session included an introduction to the evidence for family presence during resuscitation and local data on resuscitations. The training was composed of 4 sections: (1) clinical aspects of resuscitation, (2) integration into the resuscitation team and steps for providing family support during resuscitation, (3) responding to families in distress, and (4) self-care practices. Before and after the training session, the participants completed surveys of self-rated knowledge and attitudes toward family presence during resuscitation. Fifty-nine social workers and 8 spiritual care providers were trained in 2015. There was a significant increase in all rated aspects of knowledge of the family support role and self-care strategies. Through the creation of an interdisciplinary curriculum, an institution can effectively train health care providers in a new resuscitation team role: the family support provider.

Can teamwork and situational awareness (SA) in ED resuscitations be improved with a technological cognitive aid? Design and a pilot study of a team situation display

Effective teamwork in ED resuscitations, including information sharing and situational awareness, could be degraded. Technological cognitive aids can facilitate effective teamwork. Objective: This study focused on the design of an ED situation display and pilot test its influence on teamwork and situational awareness during simulated resuscitation scenarios. Material and methods: The display design consisted of a central area showing the critical dynamic parameters of the interventions with an events time-line below it. Static information was placed at the sides of the display. We pilot tested whether the situation display could lead to higher scores on the Clinical Teamwork Scale (CTS), improved scores on a context-specific Situational Awareness Global Assessment Technique (SAGAT) tool, and team communication patterns that reflect teamwork and situational awareness. Results: Resuscitation teamwork, as measured by the CTS, was overall better with the presence of the situation display as compared with no situation display. Team members discussed interventions more with the situation display compared with not having the situation display. Situational awareness was better with the situation display only in the trauma scenario. Discussion: The situation display could be more effective for certain ED team members and in certain cases. Conclusions: Overall, this pilot study implies that a situation display could facilitate better teamwork and team communication in the resuscitation event.

Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury.

Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial-a comparative effectiveness study using an observational, cohort study design. PICUs in tertiary children's hospitals in United States and abroad. Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring). None. Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%). In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

Takotsubo Cardiomyopathy: Another Form of Cardiorenal Syndrome.

Takotsubo cardiomyopathy (TC) is a life-threatening syndrome with ambiguous pathophysiology. The interdependency between heart failure and kidney failure (KF) is well established, but the influence of KF on TC outcome is not known. This single-center cohort from January 2003 to September 2015 consisted of 114 consecutive patients with TC. They were divided into 2 groups according to the presence (n = 32, 29.6%) or absence (n = 76, 70.3%) of KF. The end point of this retrospective study was a composite of in-hospital events, all-cause mortality, rehospitalization due to heart failure, stroke, and recurrence of TC (mean follow-up: 5 years). Although there were no differences in baseline characteristics between patients with/without KF, we found a significantly higher mortality rate in those with KF, 1 (7.9% vs 21.8%, P < .05), 2 (11.8% vs 31.5%, P < .05), and 5 years (22.3% vs 43.7%, P < .05) after the index event. There were no differences in life-threatening arrhythmias, cardiogenic shock, cardiopulmonary resuscitation, and thromboembolic events in both groups at the index event. Patients with TC and KF have a much worse long-term prognosis. This is clinically relevant, but the mechanisms responsible remain to be determined.

Resident Leadership at Neonatal Resuscitations (Research Abstract)

A key goal of residency training is leading multidisciplinary teams in neonatal resuscitations. Resident competency in neonatal resuscitation program (NRP) and leadership skills may be compromised by insufficient exposure to neonatal resuscitation events.

Family support liaison in the witnessed resuscitation: A phenomenology study

BackgroundFamily-witnessed resuscitation remains controversial among clinicians from implementation to practice and there are a number of countries, such as Iran, where that is considered a low priority. ObjectiveTo explore the lived experience of resuscitation team members with the presence of the patient's family during resuscitation. DesignThe hermeneutic phenomenology. SettingsThe emergency departments and critical care units of 6 tertiary hospitals in Tabriz, Iran. ParticipantsThere were potentially 380 nurses and physicians working in the emergency departments and acute care settings of 6 tertiary hospitals in Tabriz. A purposive sample of these nurses and physicians was used to recruit participants who had at least 2 years of experience, had experienced an actual family witnessed resuscitation event, and wanted to participate. The sample size was determined according to data saturation. Data collection ended when the data were considered rich and varied enough to illuminate the phenomenon, and no new themes emerged following the interview of 12 nurses and 8 physicians. MethodsSemi-structured, face- to- face interviews were held with the participants over a period of 6 months (April 2015 to September 2015), and Van Manen’s method of data analysis was adopted. ResultsThree main themes emerged from the data analysis, including ‘Futile resuscitation’, ‘Family support liaison’, and ‘Influence on team’s performance’. A further 9 sub-themes emerged under the 3 main themes, which included ‘futile resuscitation in end-stage cancer patients’, ‘when a patient dies’, ‘young patients’, ‘care of the elderly’, ‘accountable person’, ‘family supporter’, ‘no influence’, ‘positive influence’, and ‘negative influence’. ConclusionsParticipants noted both positive and negative experiences of having family members present during cardiopulmonary resuscitation. Welltrained and expert resuscitation team members are less likely to be stressed in the presence of family. A family support liaison would act to decrease family anxiety levels and to de-escalate any potentially aggressive person during the resuscitation. It is recommended that an experienced health care professional be designated to be responsible for explaining the process of resuscitation to the patient’s family.

Team structure, skill mix and clinical outcomes.

The majority of presentations to Australian EDs are for semi-urgent and non-urgent complaints in the older adult. For these patient's treatment and care is typically delivered by loosely organised teams of professionals. While substantial research has examined the clearly defined, hierarchical team structures used during resuscitation events, little is known about the composition and functioning of teams involved in non-urgent patient care in ED. Investigation of these team dynamics can identify personal and professional factors involved in the delivery of this care and enable the design of teams that enhance patient outcomes.

When is a Cardiac Arrest Non-Cardiac?

A Medline (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA) search was performed using the subject headings "OHCA" and "Emergency Medical Services" (EMS). Studies were included if they reported prevalence of cardiac etiology among OHCA in the entire patient sample, or in all arms of a comparison study. Studies that either did not report etiology of OHCA, or that excluded all cardiac or non-cardiac etiologies prior to reporting clinical data, were excluded. Twenty-four studies were identified, containing 27 datasets of OHCA which reported the prevalence of presumed cardiac vs non-cardiac etiology. These 27 datasets were drawn from 15 different countries. The prevalence of cardiac etiology among OHCA ranged from 50% to 91%. No obvious patterns were found regarding database size, year of publication, or global region (continent) of origin. There exists significant variation in published rates of cardiac etiology among OHCAs. While some of this variation likely reflects different actual rates of cardiac etiologies in the sampled populations, varying definitions of cardiac etiology among prehospital personnel or varying implementation of existing definitions may also play a role. Different proportions of cardiac vs non-cardiac etiology of OHCA in a sample could result in entirely different interpretations of data. A more specific consensus definition of cardiac etiology than that which currently exists in the Utstein template may provide better guidance to prehospital personnel and EMS researchers in the future. Carter RM , Cone DC . When is a cardiac arrest non-cardiac? Prehosp Disaster Med. 2017;32(5):523-527.

Comparison of the Effects of Three Different Counting Methods on Cardiopulmonary Resuscitation Quality and Rescuer Fatigue

Background: Chest compression with adequate depth and number is one of the main indicators of high-quality cardiopulmonary resuscitation (CPR). Nevertheless, no proper counting technique is suggested to provide sufficient number of massages. Aim: To compare the effects of three techniques of chest compression counting on the quality of CPR and rescuer fatigue. Method: Inthis clinical trial, 30 rescuers (divided into three groups) performed all the three techniques of chest compression counting (without counting [common], alternate [counting from 1 to 10], and continuous [counting from 1 to 100]) in 90 different resuscitation events at Ghaem Hospital of Mashhad, Iran, in 2015. Rescuer fatigue was evaluated using visual analogue scale to evaluate fatigue, and quality of massage was evaluated by the level of end-tidal CO2 (ETCO2); massage was calculated in minutes. Data was analyzed in SPSS using ANOVA and Friedman test. Results: The mean age of the rescuers was 30.6±6.8 years. Based on Kruskal-Wallis test results, common, continuous, and alternate techniques were in descending order of fatigue level, and the common, alternate, and continuous techniques were in descending order of number of massages. In addition, according to ANOVA, the highest ETCO2 levels were observed in the alternate, continuous, and common techniques, respectively; the difference between the techniques was significant (P<0.001). Implications for practice: The use of alternate counting technique reduces rescuer fatigue, elevates ETCO2 during resuscitation, and makes approximating the number of massages to the number advised by the American Heart Association possible.

Family Presence During Resuscitation: A Double‐Edged Sword

To illuminate the meaning of the lived experiences of resuscitation team members with the presence of the patient's family during resuscitation in the cultural context of Iran. An interpretative phenomenology was used to discover the lived experiences of the nurses and physicians of Tabriz hospitals, Iran, with family presence during resuscitation (FPDR). A total of 12 nurses and 9 physicians were interviewed over a 6-month period. The interviews were audio recorded and semistructured, and were transcribed verbatim. Van Manen's technique was used for data analysis. Two major themes and 10 subthemes emerged, including destructive presence (cessation of resuscitation, interference in resuscitation, disruption to the resuscitation team's focus, argument with the resuscitation team, and adverse mental image in the family) and supportive presence (trust in the resuscitation team, collaboration with the resuscitation team, alleviating the family's concern and settling their nerves, increasing the family's satisfaction, and reducing conflict with resuscitation team members). Participants stated that FPDR may work as a double-edged sword for the family and resuscitation team, hurting or preserving quality. It is thus recommended that guidelines be created to protect patients' and families' rights, while considering the positive aspects of the phenomenon for hospitals. A liaison support person would act to decrease family anxiety levels and would be able to de-escalate any potentially aggressive or confrontational events during resuscitation. Well-trained and expert cardiopulmonary resuscitation team members do not have any stress in the presence of family during resuscitation. Resuscitation events tend to be prolonged when family members are allowed to be present.