BarcelonaAnna Gual's son was four years old when he had to be operated on for carnots and tonsils at the Hospital Universitari de Terrassa. It was November 3, 2023. Gual entered the operating room lobby with the little boy in her arms. There, they both witnessed the sedation – intranasally – of a crying girl and then she was taken inside. One, two, three, four, five minutes. It was her turn. Pre-anesthesia medication is administered with the aim of reducing the anxiety of patients in pediatric operations. Unfortunately, and unlike that girl, the sedation did not have the desired effect on Gual's son: "He was so nervous that he kept crying." Two nurses then took him away: "They had to tear me from my arms to take him to the operating room; it was traumatic," she laments.
The ordeal was not over. The little boy woke up earlier than expected and "came out of the operating room crying, shouting 'Mommy, Mommy'". However, he still had to wait a few minutes: "The surgeon stopped me with her hand and said 'first, I'll tell you how the operation went'".
A month earlier, as soon as she found out that she would not be able to accompany her son until the induction of anesthesia, Gual filed a written complaint with the hospital and started a campaign on Change.org The petition, which has now reached 55,000 signatures, claimed the need to "accompany your child until he or she is completely asleep and also be the first person he or she sees when he or she wakes up." At the same time, he or she demanded a review of the protocols of all hospitals so that all families have this right.
Gual also filed a complaint with the Síndic de Greuges, responsible for guaranteeing the rights of children in accordance with the laws and the Convention on the Rights of the Child. In the complaint, he explained, he argued that "the rights of children cannot vary depending on the area where they live and, therefore, the hospital you are assigned to."
Vulnerable patients
All hospitals allow parents to enter the operating room for patients from groups of children who are considered vulnerable. These are those who suffer from autism, dementia and behavioural disorders, among others. They are the holders of the Cuídame Card. For the rest of cases, the right to family accompaniment to the operating room and in the resuscitation room depends on the management of each hospital.
Accés d’acompanyants a cirurgia pediàtrica
The San Juan de Dios Hospital is the oldest. Parents began to accompany their children to the major outpatient surgery operating theatres – where the patient goes home the same day of the operation – until the induction of anesthesia in 2004 and, since then, it has been progressively extended to allow it in all operating rooms. The Hospital del Mar announced in June 2020 that it had designed a new circuit to allow the presence of one of the parents without putting the sterility of the operating theatres at risk. The Taulí Hospital in Sabadell has been making it possible for two years and the Germans Trias i Pujol Hospital has allowed it since November 2023. The Josep Trueta Hospital in Girona, Arnau de Vilanova in Lleida, Juan XXIII in Tarragona or Virgen de la Cinta in Tortosa, all five managed by the Catalan Institute of Health (ICS), as well as the Sant Pau Hospital. They do not allow a family member to enter the operating room until the moment the children close their eyes before being operated on, but they do allow accompaniment as soon as they wake up, in the resuscitation room and most also to the room where the children are premedicated. However, Trueta is working on revising the protocol and sources from Sant Pau explain that this is an issue that "will be taken into account" in the framework of the various projects to improve the surgical block.
Juanjo Lázaro, head of anesthesia at San Juan de Dios: "We do not treat children but families, because the family is part of the treatment"
The Sant Joan de Déu Hospital was the first in Catalonia to allow parents into the operating room, back in 2004. But they didn't invent the formula. "In 1996, the American Zeev N. Kain wrote a scientific article in which he compared the surgical stress suffered by a child with the stress suffered by a soldier in the Vietnam War," explains Juanjo Lázaro, head of anaesthesia and the surgical area at the Sant Joan Hospital. In fact, he says that in the nineties many British hospitals already allowed it, and that by 2003 half of American hospitals did too.
"Those who are now 50 or 60 years old will surely remember having their tonsils removed while they were half awake," laments Lázaro. At San Juan de Dios, however, they try to make children have fun: "Children crying, surrounded by people dressed up in gowns and masks... It's terrorism." The hospital's motto is: "We don't treat children but families, because the family is part of the treatment."
However, support depends on the sensitivity of each hospital and, in addition, it must face the main resistance: "Professionals are very afraid of change, it has always been done this way." But she assures that this model should be exported because "it is what people need." "Here we see happy children."
Under review
At Mutua de Terrassa and the Terrassa University Hospital –also among the ten busiest hospitals– they also do not allow one of the parents to enter the operating room as a general rule. However, both hospitals say they are studying improvement measures. Mutua de Terrassa is carrying out a clinical trial to assess the impact of this accompaniment on children. According to the coordinator of pediatric surgery at the hospital's pediatric service, Sara Fuentes, when it is completed "the entry protocol will be implemented for everyone."
Following Anna Gual's request, the Terrassa University Hospital organized a multidisciplinary meeting with several specialists and some families, as a result of which it committed to implementing a "short-medium term improvement action plan for pediatric surgery processes." They outlined these in a statement sent to Gual. One of these changes has already materialized: the center now allows one parent to enter the resuscitation room.
"Changes like these are the result of consensus among all the professionals involved in the process and the infrastructure and resources must be available to carry them out," explains Dámaris Amoraga, coordinator of the surgical block at the Terrassa University Hospital. However, at this centre, the possibility of parental accompaniment until the induction of anaesthesia is not yet a reality for all families. Nor are there plans to make this change in the short term and, according to Amoraga, it will continue to be managed as it has been until now: "Accompaniment until entering the operating room must be considered on a case-by-case basis; either at the request of the parents, or because the team considers it appropriate and necessary." However, within the same action plan, the hospital agreed to allow it in the future also "in those cases in which intranasal premedication has not been sufficiently effective."
Complaints received by the Ombudsman
According to what the Creatures, the Ombudsman has received around six complaints on this issue since 2021. However, the Ombudsman's 2016 report on children's rights already stated that "there are several complaints that have reached the institution from parents who express their discomfort at having accompanied them rather than not being able to be present." Following these complaints, the Communications department points out that the Ombudsman has sent several letters to the director of the Catalan Health Service.
According to one of the responses to the complaints, the Ombudsman admits the violation of the rights set out, among others, in the United Nations Convention on the Rights of the Child, which "requires States Parties to make efforts" to ensure their own.
In his response, the Ombudsman urges the affected family to question the hospital's refusal: "I suggest that you review the response provided to the family regarding the possibility of accompanying their daughter during the anesthetic induction process so that it can be guaranteed."
In all centers with pediatric surgery it should be mandatory for parents to be able to enter ”
Bernardo Núñez Vice President of the Catalan Society of Pediatrics
A matter of will
"In all hospitals with pediatric surgery, it should be mandatory for parents to be able to enter," says the pediatric surgeon and vice president of the Catalan Pediatric Society (SCP), Bernardo Núñez, for whom the impediment to unifying hospital protocols comes exclusively from "the operating room professionals themselves." He argues that to make it possible, only will is needed: "Even in Caesarean sections, parents are entering and that is more intrusive because they are in the operating room during the operation."
Núñez assures that, today, "it is proven and there are many articles" that prove the benefits of accompanying the patient to the operating room. "We have tried to humanize this process with electric cars, screens and virtual reality glasses"But the best thing for children is to be with their parents, without a doubt," he concludes.
In fact, a doctoral thesis The study, led by the head of Pediatric Anesthesiology and Resuscitation at La Paz, Madrid, demonstrated in 2019 that the presence of parents during anesthetic induction leads to a clear increase in patient safety because it multiplies the percentage of perfect inductions by more than 7.5. The quality of anesthetic induction is a determining factor since, according to the study, anxiety can lead to tachypnea and tachycardia during the operation, as well as acute and chronic post-traumatic stress after the operation and a delay in the patient's hospital discharge.
Change protocols
One of the hospitals that has recently modified the protocol to allow family accompaniment to the operating room in pediatric surgeries is the Olot Hospital. "It took six months of discussions, but in the end we managed it," explains Núñez, who heads the Pediatric Surgery service at the Parc Taulí Hospital and also performs operations at this and other Catalan centers.
Roser R. and Javier G.'s son was two years old when they learned that he would have to undergo surgery at the Olot Hospital. But two weeks before the operation, initially scheduled for May 2024, the anesthesiologist explained to them that they would not be able to accompany their son until he fell asleep. "That shook us up a lot, we knew he would have a terrible time," explains Roser. They wrote an email to the public services: accompaniment, for them too, was essential. They were told that it would not be possible, although they were considering reviewing the protocol, they were told. Roser and Javier decided to postpone the operation. They considered changing the center. But time was running out and the intervention was urgent. Luckily, on December 2nd they received a call from the hospital. They had done a pilot plan and it had gone well. They were told that their words had had something to do with it.
Mom looked into her son's eyes until he closed them: "It was exciting"
So, on January 15, Roser walked into the operating room lobby with her son in her arms. "With the midazolam - the premedication - he became more relaxed, but he was conscious and awake." She asked her mother to carry him on her shoulders. She also had a teddy bear in her hand. They entered the operating room. They put the baby in the operating room. Mic on TV. "Everyone was very kind. Inside the operating room I held him on my shoulders until I put him on the stretcher." The anesthesiologist put the mask on him so that he would fall asleep with the inhalation gas and sang him a song. She looked into his eyes until he closed them. "It was exciting," she remembers. The operation went smoothly. "We waited patiently at the doors of the operating room and, when it was over, the whole team greeted us," explains Roser, who only regrets not having been able to be in the recovery room before he woke up. When they found him again, the little boy was half awake and immediately wanted to go back to where it all began: in his mother's arms.
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