Family presence during cardiopulmonary resuscitation

Formal Academic Training on Ethics May Address Junior Physicians' Needs

BACKGROUND

Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists' perceptions of triage and of the quality of the dying process before and after formal academic training.

METHODS

Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods.

RESULTS

More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician's age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members' reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process.

CONCLUSIONS

Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.

Health care professionals' concerns regarding in-hospital family-witnessed cardiopulmonary resuscitation implementation into clinical practice

BACKGROUND

In-hospital, family-witnessed cardiopulmonary resuscitation of adults has been found to help patients' family members deal with the short- and long-term emotional consequences of resuscitation. Because of its benefits, many national and international nursing and medical organizations officially recommend this practice. Research, however, shows that family-witnessed resuscitation is not widely implemented in clinical practice, and health care professionals generally do not favour this recommendation.

AIM

To describe and provide an initial basis for understanding health care professionals' views and perspectives regarding the implementation of an in-hospital, family-witnessed adult resuscitation practice in two European countries.

STUDY DESIGN

An inductive qualitative approach was used in this study.

METHODS

Finnish (n = 93) and Polish (n = 75) emergency and intensive care nurses and physicians provided written responses to queries regarding their personal observations, concerns and comments about in-hospital, family-witnessed resuscitation of an adult. Data were analysed using inductive thematic analysis.

FINDINGS

The study analysis yielded five themes characterizing health care professionals' main concerns regarding family-witnessed resuscitation: (1) family's horror, (2) disturbed workflow (3) no support for the family, (4) staff preparation and (5) situation-based decision.

CONCLUSION

Despite existing evidence revealing the positive influence of family-witnessed resuscitation on patients, relatives and cardiopulmonary resuscitation process, Finnish and Polish health care providers cited a number of personal and organizational barriers against this practice. The results of this study begin to examine reasons why family-witnessed resuscitation has not been widely implemented in practice. In order to successfully apply current evidence-based resuscitation guidelines, provider concerns need to be addressed through educational and organizational changes.

RELEVANCE TO CLINICAL PRACTICE

This study identified important implementation barriers for allowing families in critical care settings to be present during resuscitation efforts. These results can be further used in developing and adjusting clinical practice policies, protocols and guidelines related to family-witnessed resuscitation.

A randomised controlled trial of student nurse performance of cardiopulmonary resuscitation in a simulated family-witnessed resuscitation scenario

This randomized controlled trial, conducted in a UK University nursing department, compared student nurses' performance during a simulated cardiac arrest. Eighteen teams of four students were randomly assigned to one of three scenarios: 1) no family witness; 2) a "quiet" family witness; and 3) a family witness displaying overt anxiety and distress. Each group was assessed by observers for a range of performance outcomes (e.g. calling for help, timing to starting cardiopulmonary resuscitation), and simulation manikin data on the depth and timing of three cycles of compressions. Groups without a distressed family member present performed better in the early part of the basic life support algorithm. Approximately a third of compressions assessed were of appropriate pressure. Groups with a distressed family member present were more likely to perform compressions with low pressure. Groups with no family member present were more likely to perform compressions with too much pressure. Timing of compressions was better when there was no family member present. Family presence appears to have an effect on subjectively and objectively measured performance. Further study is required to see how these findings translate into the registered nurse population, and how experience and education modify the impact of family member presence.

The ABCDEF Bundle: Science and Philosophy of How ICU Liberation Serves Patients and Families

Over the past 20 years, critical care has matured in a myriad of ways resulting in dramatically higher survival rates for our sickest patients. For millions of new survivors comes de novo suffering and disability called "the postintensive care syndrome." Patients with postintensive care syndrome are robbed of their normal cognitive, emotional, and physical capacity and cannot resume their previous life. The ICU Liberation Collaborative is a real-world quality improvement initiative being implemented across 76 ICUs designed to engage strategically the ABCDEF bundle through team- and evidence-based care. This article explains the science and philosophy of liberating ICU patients and families from harm that is both inherent to critical illness and iatrogenic. ICU liberation is an extensive program designed to facilitate the implementation of the pain, agitation, and delirium guidelines using the evidence-based ABCDEF bundle. Participating ICU teams adapt data from hundreds of peer-reviewed studies to operationalize a systematic and reliable methodology that shifts ICU culture from the harmful inertia of sedation and restraints to an animated ICU filled with patients who are awake, cognitively engaged, and mobile with family members engaged as partners with the ICU team at the bedside. In doing so, patients are "liberated" from iatrogenic aspects of care that threaten his or her sense of self-worth and human dignity. The goal of this 2017 plenary lecture at the 47th Society of Critical Care Medicine Congress is to provide clinical ICU teams a synthesis of the literature that led to the creation of ICU liberation philosophy and to explain how this patient- and family-centered, quality improvement program is novel, generalizable, and practice changing.

Exploring the Relationship Among Moral Distress, Coping, and the Practice Environment in Emergency Department Nurses

Emergency department (ED) nurses practice in environments that are highly charged and unpredictable in nature and can precipitate conflict between the necessary prescribed actions and the individual's sense of what is morally the right thing to do. As a consequence of multiple moral dilemmas, ED staff nurses are at risk for experiencing distress and how they cope with these challenges may impact their practice. To examine moral distress in ED nurses and its relationship to coping in that specialty group. Using survey methods approach. One hundred ninety-eight ED nurses completed a moral distress, coping, and demographic collection instruments. Advanced statistical analysis was completed to look at relationships between the variables. Data analysis did show that moral distress is present in ED nurses (M = 80.19, SD = 53.27), and when separated into age groups, the greater the age, the less the experience of moral distress. A positive relationship between moral distress and some coping mechanisms and the ED environment was also noted. This study's findings suggest that ED nurses experience moral distress and could receive some benefit from utilization of appropriate coping skills. This study also suggests that the environment in which ED nurses practice has a significant impact on the experience of moral distress. Because health care is continuing to evolve, it is critical that issues such as moral distress and coping be studied in ED nurses to help eliminate human suffering.

A qualitative study about experiences and emotions of emergency medical technicians and out-of-hospital emergency nurses after performing cardiopulmonary resuscitation resulting in death

OBJECTIVE

To explore the experiences, emotions and coping skills among emergency medical technicians and emergency nurses after performing out-of-hospital cardiopulmonary resuscitation manoeuvres resulting in death.

METHOD

An exploratory qualitative research was performed. Seven emergency medical technicians and six emergency nurses were selected by non-probability sampling among emergency medical system workers. The meetings took place up to information saturation, achieved after six individual interviews and a focal group. The meetings were then transcribed and a manual and inductive analysis of the contents performed.

MAIN RESULTS

After a failed resuscitation several short and long-term reactions appear. They can be negatives, such as sadness or uncertainty, or positives, such as the feeling of having done everything possible to save the patient's life. Emotional stress increases when ambulance staff have to talk with the deceased's family or when the patient is a child. The workers don't know of a coping strategy other than talking about their emotions with their colleagues.

CONCLUSIONS

Death after a failed resuscitation can be viewed as a traumatic experience for rescuers. Being in contact with the suffering of others is an emotional, stress-generating factor with direct repercussions on the working and personal lives of emergency staff. Nevertheless, structured coping techniques are not common among those professionals.

A literature review examining the barriers to the implementation of family witnessed resuscitation in the Emergency Department

BACKGROUND

Caring for people near death in the Emergency Department (ED) is challenging for professionals, duty bound to respond to the needs of the dying. Family witnessed resuscitation (FWR) is practiced internationally, allowing relatives to be present at the time of a patient's death, offering comfort to the dying and aiding the bereaved along a healthy grief trajectory.

AIM

The literature review elicits barriers to the implementation of FWR in the ED, examining why practice is sporadic despite numerous professional bodies calling for implementation. FWR is often met with opposition from staff, subsequently largely dependent upon who is on duty as opposed to adherence with best practice guidelines, risking inconsistent idiosyncratic practice.

FINDINGS

Barriers include; a lack of organisational support; shortage of manpower for provision of a family support person; absence of champions for the concept; willful non-adherence due to personal beliefs; restriction on coping strategies reliant upon the ability to emotionally detach, enhancing staff resilience facing repeated exposure to emotionally labile events.

CONCLUSION

All resuscitation efforts can be successful, whether the patient lives or dies, if practice supports healthy grieving. The challenge remains with such divided, entrenched and passionate views, how FWR can be adopted as accepted practice.

[Refractory cardiac arrest patients in prehospital care, potential organ donors]

Under the authority of the French Biomedicine Agency, a new care pathway integrates refractory cardiac arrest patients into a process of organ donation. It is a medical, logistical and ethical challenge for the staff of the mobile emergency services.

Reappraisal of visiting policies and procedures of patient's family information in 188 French ICUs: a report of the Outcomerea Research Group

Background

The relatives of intensive care unit (ICU) patients must cope with both the severity of illness of their loved one and the unfamiliar and stressful ICU environment. This hardship may lead to post-intensive care syndrome. French guidelines provide recommendations on welcoming and informing families of ICU patients. We questioned whether and how they are applied 5 years after their publication.

Methods

We conducted a large survey among French ICUs to evaluate their visiting policies and how information was provided to patient’s family. A questionnaire was built up by intensivists and nurses. French ICUs were solicited, and the questionnaire was sent to all participating ICUs, for being filled in by the unit medical and/or nursing head. Data regarding the hospital and ICU characteristics, the visiting policy and procedures, and the management of family information were collected.

Results

Among the 289 French ICUs, 188 (65 %) participated. Most ICUs have a waiting room 118/188 (62.8 %) and a dedicated room for meeting the family 152/188 (80.8 %). Of the 188 ICUs, 45 (23.9 %) were opened on a 24-h-a-day basis. In the remaining ICUs, the time period allowed for visits was 4.75 ± 1.83 h (median 5 h). In ICUs where visiting restrictions were reported, open visiting was allowed for end-of-life situations in 107/143 (74.8 %). Children are allowed to visit a patient in 164/188 (87.2 %) regardless of their age in 97/164 (59.1 %) of ICUs. Families received an information leaflet in 168/188 (89.3 %). Information was provided to families through structured meetings in 149/188 (79.2 %) of ICUs at patient admission with participation of nurses and nursing assistants in 133/188 (70.4 %) and 55/188 (29.2 %), respectively. Information delivered to the family was reported in the patient chart by only 111/188 ICUs (59 %). Participation in care was infrequent.

Conclusions

Although French ICUs do not follow the consensus recommendations, slow progress exists compared to previous reports. Implementation of these recommendations is largely needed to offer better welcome and information improvement. Further studies on that topic would enable evaluating remaining obstacles and increasing caregivers’ awareness, both critical for further progresses on that topic.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0185-x) contains supplementary material, which is available to authorized users.

Assessment of cardiopulmonary resuscitation practices in emergency departments for out-of-hospital cardiac arrest victims in Lebanon

BACKGROUND

The survival rate of out-of-hospital cardiac arrest (OHCA) victims in Lebanon is low. A national policy on resuscitation practice is lacking. This survey explored the practices of emergency physicians related to the resuscitation of OHCA victims in Lebanon.

METHODS

A sample of 705 physicians working in emergency departments (EDs) was recruited and surveyed using the LimeSurvey software (Carsten Schmitz, Germany). Seventy-five participants responded, yielding 10.64% response rate.

RESULTS

The most important factors in the participants' decision to initiate or continue resuscitation were presence of pulse on arrival (93.2%), underlying cardiac rhythm (93.1%), the physician's ethical duty to resuscitate (93.2%), transport time to the ED (89%), and down time (84.9%). The participants were optimistic regarding the survival of OHCA victims (58.1% reporting > 10% survival) and reported frequent resuscitation attempts in medically futile situations. The most frequently reported challenges during resuscitation decisions were related to pressure or presence of victim's family (38.8%) and lack of policy (30%).

CONCLUSION

In our setting, physicians often rely on well-established criteria for initiating/continuing resuscitation; however, their decisions are also influenced by cultural factors such as victim's family wishes. The findings support the need for a national policy on resuscitation of OHCA victims.

Should Sabbath Prohibitions Be Overridden to Provide Emotional Support to a Sick Relative?

BACKGROUND

There is a consensus among the halachic authorities that life-saving actions override Sabbath prohibitions. They are painstaking in securing that the sanctity of the Sabbath is maintained but that not a single life be lost.

OBJECTIVE

This manuscript examines if and when a relative's presence at the bedside of a seriously ill individual is potentially life-saving against the backdrop of the scientific literature. It specifically addresses the permissibility of traveling in a motorized vehicle, generally prohibited on the Sabbath, to be with one's relative in hospital for the provision of emotional support.

METHODS

Discourse of the halachic issues in the context of the scientific literature.

RESULTS

Stress, mental or physical, has been determined as a potentially life-threatening condition in many disease entities. The literature attests to both the patient's and the professionals' perception of the curative potential of the presence of loved ones by advocating for the patient and relieving stress in the hospital experience. Emotional support from a loved one is perceived by some patients as vital to survival. There is halachic consensus that a patient's perception of the emotional need for a relative's presence is sufficient to permit overriding rabbinic prohibitions. Torah prohibitions, which may be overridden for medical needs, may be overridden for emotional support, providing a health professional or family member attests to the fulfilment of this specific need as diminishing the danger to the patient's life. In certain cases, the latter contingency is unnecessary.

CONCLUSIONS

Emotional support has an impact on the patient's health status; the degree to which its impact is strong enough to save life is still being studied. As more data from scientific studies emerge, they may be relevant to sharpening the halachic rulings with respect to the issue at hand.

Family Presence During Resuscitation: Impact of Online Learning on Nurses' Perception and Self-confidence

BACKGROUND

Family presence during resuscitation (FPDR) is supported by patients and their family members. Nurses, however, including critical care nurses who frequently implement resuscitative care, have mixed views.

OBJECTIVES

To determine the impact of online learning on critical care nurses' perception of and self-confidence with FPDR.

METHODS

A 2-group, random assignment, pretest and posttest quasi-experimental study was conducted with critical care nurses recruited nationally. An online learning module on FPDR was developed and administered to the intervention group. Perceptions and self-confidence for FPDR were measured by using the Family Presence Risk- Benefit Scale (FPR-BS) and the Family Presence Self-confidence Scale (FPS-CS). Two-factor, mixed-model factorial analysis of variance was used to compare mean scores.

RESULTS

A total of 74 critical care nurses participated in the study. Mean FPR-BS and FPS-CS scores were significantly greater in the intervention group than in the control group. For the intervention group, mean scores on the FPR-BS increased from 3.63 to 4.07 (P < .001) and on the FPS-CS increased from 4.24 to 4.57 (P < .001), signifying improved perception and self-confidence. Scores did not change significantly in the control group: mean FPR-BS score increased from 3.82 to 3.88 (P = .23) and the mean FPS-CS score of 4.40 did not change (P > .99).

CONCLUSIONS

Online learning is a feasible and effective method for educating large numbers of critical care nurses about FPDR. Online learning can improve perceptions and self-confidence related to FPDR, which may promote more widespread adoption of FPDR into practice.

Family-witnessed resuscitation: focus group inquiry into UK student nurse experiences of simulated resuscitation scenarios

Aims

To describe the impact of family members’ presence on student nurse performance in a witnessed resuscitation scenario. To explore student nurses’ attitudes to simulated family-witnessed resuscitation and their views about its place in clinical practice.

Background

Family-witnessed resuscitation remains controversial worldwide. Hospital implementation remains inconsistent despite professional organisation support. Systematic reviews of international literature indicate family members wish to be involved and consulted; healthcare professionals express concerns about being observed while resuscitating. Student nurse perspectives have not been addressed.

Design

Qualitative, focus groups.

Methods

Participants: UK university second-year student nurses (n=48) who participated in simulated resuscitation scenarios (family member absent, family member present but quiet or family member present but distressed). Data generation 2014: focus group interview schedule—five open-ended questions and probing techniques. Audio recordings transcribed, analysed thematically. Research ethics approval via University Research Ethics committee.

Findings

Overarching theme=students’ sense making—making sense of situation (practically/professionally), of themselves (their skills/values) and of others (patients/family members). Students identify as important team leader allocating tasks, continuity of carer and number of nurses needed. Three orientations to practice are identified and explored—includes rule following, guidance from personal/proto-professional values and paternalistic protectionism.

Discussion

We explore issues of students’ fluency of response and skills repertoire to support family-witnessed resuscitation; explanatory potential to account for the inconsistent uptake of family-witnessed resuscitation. Possible future lines of inquiry include family members’ gaze as a motivational trigger, and management of guilt.

Relatives' Presence During Cardiopulmonary Resuscitation

BACKGROUND

The question of whether or not to allow family to be present during resuscitation is relevant to everyday professional health care assistance, but it remains largely unexplored in the medical literature.

OBJECTIVES

We conducted an online survey with the aim of increasing our knowledge and understanding of this issue.

METHODS

This is a cross-sectional, multicenter, descriptive, national, and international study using a web-based, voluntary survey. The survey was designed and distributed through a medical website in Spanish, targeting physicians who frequently deal with critical patients.

RESULTS

A total of 1,286 Argentine physicians and 1,848 physicians from other countries responded to this voluntary survey. Of Argentine respondents, 15.8% (203) treat only children, 68.2% (877) treat adults, and 16% (206) treat patients of any age. The survey found that 23% (296) of Argentine and 20% of other respondents favor the presence of family members during cardiopulmonary resuscitation (p = 0.03). This practice was more common among physicians treating pediatric and neonatal patients than among those who treat adults. The most commonly reported reason (21.8%) for avoiding the presence of relatives was concerns that physicians, communications, and medical practices might be misunderstood or misinterpreted.

CONCLUSIONS

Avoiding relatives' presence while performing cardiopulmonary resuscitation is the most frequent choice made by the surveyed physicians who treat critical Argentine patients. The main causes for discouraging family presence during cardiopulmonary resuscitation or other critical procedures include the following: risk of misinterpretation of the physician's actions and/or words; risk of a relative's decompensation; uncertainty about possible reactions; and interpretation of the relative's presence as negative.

Family Presence during Resuscitation: A Qualitative Analysis from a National Multicenter Randomized Clinical Trial

BACKGROUND

The themes of qualitative assessments that characterize the experience of family members offered the choice of observing cardiopulmonary resuscitation (CPR) of a loved one have not been formally identified.

METHODS AND FINDINGS

In the context of a multicenter randomized clinical trial offering family members the choice of observing CPR of a patient with sudden cardiac arrest, a qualitative analysis, with a sequential explanatory design, was conducted. The aim of the study was to understand family members' experience during CPR. All participants were interviewed by phone at home three months after cardiac arrest. Saturation was reached after analysis of 30 interviews of a randomly selected sample of 75 family members included in the trial. Four themes were identified: 1- choosing to be actively involved in the resuscitation; 2- communication between the relative and the emergency care team; 3- perception of the reality of the death, promoting acceptance of the loss; 4- experience and reactions of the relatives who did or did not witness the CPR, describing their feelings. Twelve sub-themes further defining these four themes were identified. Transferability of our findings should take into account the country-specific medical system.

CONCLUSIONS

Family presence can help to ameliorate the pain of the death, through the feeling of having helped to support the patient during the passage from life to death and of having participated in this important moment. Our results showed the central role of communication between the family and the emergency care team in facilitating the acceptance of the reality of death.

Family Centered Practice During Pediatric Death in an Out of Hospital Setting

OBJECTIVE

To understand effective ways for EMS providers to interact with distressed family members during a field intervention involving a recent or impending out-of-hospital (OOH) pediatric death.

METHODS

Eight focus groups with 98 EMS providers were conducted in urban and rural settings between November 2013 and March 2014. Sixty-eight providers also completed a short questionnaire about a specific event including demographics. Seventy-eight percent of providers were males, 13% were either African American or Hispanic, and the average number of years in EMS was 16 years. They were asked how team members managed the family during the response to a dying child, what was most helpful for families whose child suddenly and unexpectedly was dead in the OOH setting, and what follow up efforts with the family were effective.

RESULTS

The professional response by the EMS team was critical to family coping and getting necessary support. There were several critical competencies identified to help the family cope including: (1) that EMS provide excellent and expeditious care with seamless coordination, (2) allowing family to witness the resuscitation including the attempts to save the child's life, and (3) providing ongoing communication. Whether the child is removed from the scene or not, keeping the family appraised of what is happening and why is critical. Exclusion of families from the process in cases of suspected child abuse is not warranted. Giving tangible forms of support by calling friends, family, and clergy, along with allowing the family time with the child after death, giving emotional support, and follow-up gestures all help families cope.

CONCLUSION

The study revealed effective ways for EMS providers to interact with distressed family members during an OOH pediatric death.

Factors associated with initiation of medical advanced cardiac life support after out-of-hospital cardiac arrest

Background

Termination of resuscitation rule permits to stop futile resuscitative efforts by paramedics. In a different setting, the decision to withhold resuscitation by emergency physician could be based on different factors. We aimed to identify the factors associated with the initiation of a medical ACLS in out-of-hospital cardiac arrest patients.

Methods

We prospectively collected the characteristics of all out-of hospital cardiac arrest patients occurring in a French district between March 2010 and December 2013 and managed by the emergency medical system. We analyzed the factors associated with the initiation of medical ACLS.

Results

Medical ACLS was initiated in 69 % of the 2690 patients included in the register. ACLS patients were younger (69 years [55–80] vs. 84 years [77–90]) and more frequently men. A higher percentage of witnessed cardiac arrest and BLS were observed. Duration of no-flow was shorter in the ACLS patients, whereas BLS duration was longer. A higher proportion of shockable rhythm and application of AED were found in this group. Mains factors associated with the initiation of medical ACLS were a suspected cardiac cause (1.73 [1.30–2.30]) and use of an automated external defibrillator (1.59 [1.18–2.16]), whereas factors associated with no medical ACLS were higher age (0.93 [0.92–0.94]), absence of BLS (0.62 [0.52–0.73]), asystole (0.31 [0.18–0.51]) and location in nursing home (0.23 [0.11–0.51]).

Conclusions

The medical decision to not initiate ACLS in out-of-hospital cardiac arrest patients seems to rely on a complex combination of validated criteria used for termination of resuscitation and factors resulting from an intuitive perception of the outcome.

FAMILY PERCEPTION ABOUT THEIR PRESENCE OR NOT IN A PEDIATRIC EMERGENCY SITUATION

ABSTRACT The objective was to understand the perception of family members who experienced an emergency situation in relation to their presence or not during the child's treatment in the Pediatric Emergency Department. A qualitative study developed in a Pediatric Emergency Department. The study subjects consisted of ten relatives who had experienced an emergency situation. Data collection was through semi-structured interviews and data were submitted for thematic content analysis. The results showed that among the ten relatives interviewed only one said that they preferred not to remain with the child during the emergency situation. Regarding the clinical condition of the children, five of them had special health care needs. Previous negative situations had influenced the family member's choice of staying during the assistance. Considering the benefits of family presence, it is recommended that nursing teams develop strategies which can facilitate the inclusion of the family in child care in any situation, while respecting the uniqueness of each person.

Update in hospital medicine: Evidence you should know

BACKGROUND

The practice of hospital medicine is complex, and the number of clinical publications each year continues to grow. To maintain best practice it is necessary for hospitalists to stay abreast of the literature, but difficult to accomplish due to time. The annual Society of Hospital Medicine meeting offers a plenary session on Updates in Hospital Medicine. This article is a summary of those papers presented at the meeting.

METHODS

We reviewed articles published between January 2014 and January 2015 in the leading medical journals, searching for papers with good methodological quality, the potential to change practice, and papers that are thought provoking. The authors collectively agreed on 14 articles. The findings, cautions, and implications are discussed for each paper.

RESULTS

Key findings include: a novel neprilysin inhibitor and angiotensin receptor blocker combination drug reduces mortality in patients with heart failure; the concern for acute kidney injury after venous contrast may be overstated; the Confusion Assessment Method Severity score is an important tool for prognostication in delirious patients; ramelteon shows promise for lowering incident delirium among elderly medical patients; polyethylene glycol appears effective in rapidly resolving hepatic encephalopathy; cirrhotic patients on a nonselective β-blocker have increased mortality after they develop spontaneous bacterial peritonitis; current guidelines regarding prophylaxis against venous thromboembolism (VTE) in medical inpatients likely result in non-beneficial use of medications; from a safety and efficacy perspective, direct oral anticoagulants perform quite well against conventional therapies in patients with VTE and atrial fibrillation, including in elderly populations; 2 new once-weekly antibiotics, dalbavancin and oritivancin, approved for skin and soft tissue infections, appear noninferior to vancomycin; offering family members of a patient undergoing cardiopulmonary resuscitation the opportunity to observe has durable impact on long-term psychological outcomes.

CONCLUSIONS

This update reviews key clinical articles published in 2014, selected by the authors for their methodological quality and potential for changing the practice of inpatient physicians. All of these articles add to the body of inpatient medical knowledge and contribute to the debate on best practices.

Factors affecting the quality of cardiopulmonary resuscitation in inpatient units: perception of nurses

Abstract OBJECTIVE To identify, in the perception of nurses, the factors that affect the quality of cardiopulmonary resuscitation (CPR) in adult inpatient units, and investigate the influence of both work shifts and professional experience length of time in the perception of these factors. METHOD A descriptive, exploratory study conducted at a hospital specialized in cardiology and pneumology with the application of a questionnaire to 49 nurses working in inpatient units. RESULTS The majority of nurses reported that the high number of professionals in the scenario (75.5%), the lack of harmony (77.6%) or stress of any member of staff (67.3%), lack of material and/or equipment failure (57.1%), lack of familiarity with the emergency trolleys (98.0%) and presence of family members at the beginning of the cardiopulmonary arrest assistance (57.1%) are factors that adversely affect the quality of care provided during CPR. Professional experience length of time and the shift of nurses did not influence the perception of these factors. CONCLUSION The identification of factors that affect the quality of CPR in the perception of nurses serves as parameter to implement improvements and training of the staff working in inpatient units.

The offering of family presence during resuscitation: a systematic review and meta-analysis

BACKGROUND

Family members may wish to be present during resuscitation of loved ones, despite concerns that they may interfere with the resuscitation or experience psychological harm.

METHODS

We conducted a systematic review to determine whether offering family presence during resuscitation (FPDR) affected patient mortality, resuscitation quality, or family member psychological outcomes. We searched multiple databases up to January 2014 for studies comparing FPDR to usual care. Two reviewers independently assessed eligibility, risk of bias, and extracted data. Data from randomized controlled trial (RCTs) at low or uncertain risk of bias were eligible for pooling. Quality of evidence was assessed using GRADE.

RESULTS

Three RCTs evaluated the offering of FPDR in adults, finding no differences in resuscitation duration, prehospital/emergency room mortality (odds ratio [OR] 0.80, 95 % confidence interval [CI] 0.54-1.19), or 28-day mortality (OR 1.24, 95 % CI [0.50-3.03]). Hospital Anxiety and Depression Scale scores for anxiety (mean difference [MD] -0.99, 95 % CI [-1.77, -0.22]) and depression (MD -1.00, 95 % CI [-1.78, -0.23]), along with Impact of Events Scale intrusion score (MD -1.00, 95 % CI [-1.96, -0.03]), were better in family members offered FPDR. One RCT evaluated FPDR in pediatric patients, finding no mortality differences at 28 days (OR 0.30; 95 % CI [0.11-0.79]), but did not report psychological outcomes in family members.

CONCLUSIONS

Moderate-quality evidence suggests the offering of FPDR does not affect adult resuscitation outcomes and may improve family member psychological outcomes. Low-quality evidence suggests FPDR does not affect pediatric resuscitation outcomes. The generalizability of these findings outside the prehospital and emergency room setting is limited due to the absence of trials in other health care settings.

Providing immediate neonatal care and resuscitation at birth beside the mother: clinicians' views, a qualitative study

OBJECTIVES

The aims of this study were to assess clinicians' views and experiences of providing immediate neonatal care at birth beside the mother, and of using a mobile trolley designed to facilitate this bedside care.

DESIGN

Qualitative interview study with semistructured interviews.

RESULTS

The results were analysed using thematic analysis.

SETTING

A large UK maternity unit.

PARTICIPANTS

Clinicians (n=20) from a range of disciplines who were present when the trolley was used to provide neonatal care at birth at the bedside. Five clinicians provided/observed advanced resuscitation by the bedside.

RESULTS

Five themes were identified: (1) Parents' involvement, which included 'Contact and involvement', 'Positive emotions for parents' and 'Staff communication'; (2) Reservations about neonatal care at birth beside the mother, which included 'Impact on clinicians' and 'Impact on parents'; (3) Practical challenges in providing neonatal care at the bedside, which included 'Cord length' and 'Caesarean section'; (4) Comparison of the trolley with usual resuscitation equipment and (5) Training and integration of bedside care into clinical routine, which included 'Teething problems' and 'Training'.

CONCLUSIONS

Overall, most clinicians were positive about providing immediate neonatal care at the maternal bedside, particularly in terms of the clinicians' perceptions of the parents' experience. Clinicians also perceived that their close proximity to parents improved communication. However, there was some concern about performing more intensive interventions in front of parents. Providing immediate neonatal care and resuscitation at the bedside requires staff training and support.

Providing immediate neonatal care and resuscitation at birth beside the mother: parents' views, a qualitative study

OBJECTIVES

The aims of this study were to assess parents' views of immediate neonatal care and resuscitation at birth being provided beside the mother, and their experiences of a mobile trolley designed to facilitate this bedside care.

DESIGN

Qualitative study with semistructured interviews. Results were analysed using thematic analysis.

SETTING

Large UK maternity hospital.

PARTICIPANTS

Mothers whose baby received initial neonatal care in the first few minutes of life at the bedside, and their birth partners, were eligible. 30 participants were interviewed (19 mothers, 10 partners and 1 grandmother). 5 babies required advanced neonatal resuscitation.

RESULTS

5 themes were identified: (1) Reassurance, which included 'Baby is OK', 'Having baby close', 'Confidence in care', 'Knowing what's going on' and 'Dad as informant'; (2) Involvement of the family, which included 'Opportunity for contact', 'Family involvement' and 'Normality'; (3) Staff communication, which included 'Communication' and 'Experience'; (4) Reservations, which included 'Reservations about witnessing resuscitation', 'Negative emotions' and 'Worries about the impact on staff' and (5) Experiences of the trolley, which included 'Practical issues' and 'Comparisons with standard resuscitation equipment'.

CONCLUSIONS

Families were positive about neonatal care being provided at the bedside, and felt it gave reassurance about their baby's health and care. They also reported feeling involved as a family. Some parents reported experiencing negative emotions as a result of witnessing resuscitation of their baby. Parents were positive about the trolley.

Finding a Middle Ground: Exploring the Impact of Patient- and Family-Centered Design on Nurse-Family Interactions in the Neuro ICU

OBJECTIVE

This comparative study of two adult neuro critical care units examined the impact of patient- and family-centered design on nurse-family interactions in a unit designed to increase family involvement.

BACKGROUND

A growing evidence base suggests that the built environment can facilitate the delivery of patient- and family-centered care (PFCC). However, few studies examine how the PFCC model impacts the delivery of care, specifically the role of design in nurse-family interactions in the adult intensive care unit (ICU) from the perspective of the bedside nurse.

METHODS

Two neuro ICUs with the same patient population and staff, but with different layouts, were compared. Structured observations were conducted to assess changes in the frequency, location, and content of interactions between the two units. Discussions with staff provided additional insights into nurse attitudes, perceptions, and experiences caring for families.

RESULTS

Nurses reported challenges balancing the needs of many stakeholders in a complex clinical environment, regardless of unit layout. However, differences in communication patterns between the clinician- and family-centered units were observed. More interactions were observed in nurse workstations in the PFCC unit, with most initiated by family. While the new unit was seen as more conducive to the delivery of PFCC, some nurses reported a loss of workspace control.

CONCLUSIONS

Patient- and family-centered design created new spatial and temporal opportunities for nurse-family interactions in the adult ICU, thus supporting PFCC goals. However, greater exposure to unplanned family encounters may increase nurse stress without adequate spatial and organizational support.

Family presence during resuscitation: A Canadian Critical Care Society position paper

BACKGROUND

Recent evidence suggests that patient outcomes are not affected by the offering of family presence during resuscitation (FPDR), and that psychological outcomes are neutral or improved in family members of adult patients. The exclusion of family members from the resuscitation area should, therefore, be reassessed.

OBJECTIVE

The present Canadian Critical Care Society position paper is designed to help clinicians and institutions decide whether to incorporate FPDR as part of their routine clinical practice, and to offer strategies to implement FPDR successfully.

METHODS

The authors conducted a literature search of the perspectives of health care providers, patients and families on the topic of FPDR, and considered the relevant ethical values of beneficence, nonmaleficence, autonomy and justice in light of the clinical evidence for FPDR. They reviewed randomized controlled trials and observational studies of FPDR to determine strategies that have been used to screen family members, select appropriate chaperones and educate staff.

RESULTS

FPDR is an ethically sound practice in Canada, and may be considered for the families of adult and pediatric patients in the hospital setting. Hospitals that choose to implement FPDR should develop transparent policies regarding which family members are to be offered the opportunity to be present during the resuscitation. Experienced chaperones should accompany and support family members in the resuscitation area. Intensive educational interventions and increasing experience with FPDR are associated with increased support for the practice from health care providers.

CONCLUSIONS

FPDR should be considered to be an important component of patient and family-centred care.

Coming to a theatre near you soon a witnessed CPR event'

A current review of the last thirty years is indicative of improvement in outcome across surgical specialities with the implementation of safer working practices and initiatives in enhanced recovery, preparing patients to be 'fit' for surgery. The focus of training for nurses and operating department practitioners lies with assuring technical competence and the drive is to establish best practice based on evidence. Once qualified, training for professionals within the perioperative environment is developed to enable participation in areas of anaesthesia, surgery and recovery roles. Advanced, intermediate and basic life support as well as advanced scrub practitioner courses are available, further aspects for patient safety have been implemented and pathways developed.

Psychological impact on dispatched local lay rescuers performing bystander cardiopulmonary resuscitation

AIM

We studied the short-term psychological impact and post-traumatic stress disorder (PTSD)-related symptoms in lay rescuers performing cardiopulmonary resuscitation (CPR) after a text message (TM)-alert for out-of-hospital-cardiac arrest, and assessed which factors contribute to a higher level of PTSD-related symptoms.

METHODS

The lay rescuers received a TM-alert and simultaneously an email with a link to an online questionnaire. We analyzed all questionnaires from February 2013 until October 2014 measuring the short-term psychological impact. We interviewed by telephone all first arriving lay rescuers performing bystander CPR and assessed PTSD-related symptoms with the Impact of Event Scale (IES) 4-6 weeks after the resuscitation. IES-scores 0-8 reflected no stress, 9-25 mild, 26-43 moderate, and 44-75 severe stress. A score ≥ 26 indicated PTSD symptomatology.

RESULTS

Of all alerted lay rescuers, 6572 completed the online questionnaire. Of these, 1955 responded to the alert and 507 assisted in the resuscitation. We interviewed 203 first arriving rescuers of whom 189 completed the IES. Of these, 41% perceived no/mild short-term impact, 46% bearable impact and 13% severe impact. On the IES, 81% scored no stress and 19% scored mild stress. None scored moderate or severe stress. Using a multivariable logistic regression model we identified three factors with an independent impact on mild stress level: no automated external defibrillator connected by the lay rescuer, severe short-term impact, and no (very) positive experience.

CONCLUSION

Lay rescuers alerted by text messages, do not show PTSD-related symptoms 4-6 weeks after performing bystander CPR, even if they perceive severe short-term psychological impact.

An Analytical Comparison of the Opinions of Physicians Working in Emergency and Trauma Surgery Departments at Tabriz and Vienna Medical Universities Regarding Family Presence during Resuscitation

The present study evaluated the opinions of physicians working in the emergency and trauma surgery departments of Vienna Medical University, in Austria, and Tabriz Medical University, in Iran, regarding the presence of patients' relatives during resuscitation. In a descriptive-analytical study, the data obtained from questionnaires that had been distributed randomly to 40 specialists and residents at each of the participating universities were analyzed. The questionnaire consisted of two sections aimed at capturing the participants' demographic data, the participants' opinions regarding their support for the family's presence during resuscitation, and the multiple potential factors affecting the participants' attitudes, including health beliefs, triggers that could facilitate the procedure, self-efficacy, intellectual norms, and perceived behavioral control. The questionnaire also included a direct question (Question 16) on whether the participants approved of family presence. Each question could be answered using a Likert-type scale. The results showed that the mean scores for Question 16 were 4.31 ± 0.64 and 3.57 ± 1.31 for participants at Vienna and Tabriz universities, respectively. Moreover, physicians at Vienna University disapproved of the presence of patients' families during resuscitation to a higher extent than did those at Tabriz University (P = 0.018). Of the studied prognostic factors affecting the perspectives of Vienna Medical University's physicians, health beliefs (P = 0.000; B = 1.146), triggers (P = 0.000; B = 1.050), and norms (P = 0.000; B = 0.714) were found to be significant. Moreover, of the studied prognostic factors affecting the perspectives of Tabriz Medical University's physicians, health beliefs (P = 0.000; B = 0.875), triggers (P = 0.000; B = 1.11), self-efficacy (P = 0.001; B = 0.5), and perceived behavioral control (P = 0.03; B = 0.713) were significant. Most physicians at Vienna and Tabriz Medical universities were not open towards family members' presence during resuscitation.

The rise of multiple imputation: a review of the reporting and implementation of the method in medical research

Background

Missing data are common in medical research, which can lead to a loss in statistical power and potentially biased results if not handled appropriately. Multiple imputation (MI) is a statistical method, widely adopted in practice, for dealing with missing data. Many academic journals now emphasise the importance of reporting information regarding missing data and proposed guidelines for documenting the application of MI have been published. This review evaluated the reporting of missing data, the application of MI including the details provided regarding the imputation model, and the frequency of sensitivity analyses within the MI framework in medical research articles.

Methods

A systematic review of articles published in the Lancet and New England Journal of Medicine between January 2008 and December 2013 in which MI was implemented was carried out.

Results

We identified 103 papers that used MI, with the number of papers increasing from 11 in 2008 to 26 in 2013. Nearly half of the papers specified the proportion of complete cases or the proportion with missing data by each variable. In the majority of the articles (86%) the imputed variables were specified. Of the 38 papers (37%) that stated the method of imputation, 20 used chained equations, 8 used multivariate normal imputation, and 10 used alternative methods. Very few articles (9%) detailed how they handled non-normally distributed variables during imputation. Thirty-nine papers (38%) stated the variables included in the imputation model. Less than half of the papers (46%) reported the number of imputations, and only two papers compared the distribution of imputed and observed data. Sixty-six papers presented the results from MI as a secondary analysis. Only three articles carried out a sensitivity analysis following MI to assess departures from the missing at random assumption, with details of the sensitivity analyses only provided by one article.

Conclusions

This review outlined deficiencies in the documenting of missing data and the details provided about imputation. Furthermore, only a few articles performed sensitivity analyses following MI even though this is strongly recommended in guidelines. Authors are encouraged to follow the available guidelines and provide information on missing data and the imputation process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-015-0022-1) contains supplementary material, which is available to authorized users.

Policies allowing family presence during resuscitation and patterns of care during in-hospital cardiac arrest

BACKGROUND

A growing number of hospitals have begun to implement policies allowing for family presence during resuscitation (FPDR). However, the overall safety of these policies and their effect on resuscitation care is unknown.

METHODS AND RESULTS

We conducted an observational cohort study of 252 hospitals in the United States with 41,568 adults with cardiac arrest. Multivariable hierarchical regression models were used to evaluate patterns of care at hospitals with and without an FPDR policy. Primary outcomes included return of spontaneous circulation and survival to discharge. Secondary outcomes included resuscitation quality, interventions, and facility-reported potential resuscitation systems errors. There were no significant differences in facility characteristics between hospitals with and without an FPDR policy, nor were there significant differences in return of spontaneous circulation (adjusted risk ratio, 1.02; 95% confidence interval, 0.95-1.06) or survival to discharge (adjusted risk ratio, 1.05; 95% confidence interval, 0.95-1.15). There was a small, borderline significant decrease in the mean time to defibrillation at hospitals with an FPDR policy compared with hospitals without the policy (mean difference, 0.32 minutes; 95% confidence interval, -0.01 to 0.64). Resuscitation quality, interventions, and facility-reported potential resuscitation systems errors did not meaningfully differ between hospitals with and without an FPDR policy.

CONCLUSIONS

Hospitals with an FPDR policy generally have no statistically significant differences in outcomes and processes of care as hospitals without this policy, suggesting such policies may not negatively affect resuscitation care. Further study is warranted about the direct effect of FPDR attempts on adult patients with an in-hospital cardiac arrest and their families.