Family presence during trauma activations and medical resuscitations in a pediatric emergency department: an evidence-based practice project

Trauma-informed and family-centered paediatric resuscitation: Defining domains and practices

Aim

For paediatric patients and families, resuscitation can be an extremely stressful experience with significant medical and psychological consequences. Psychological sequelae may be reduced when healthcare teams apply patient- and family-centered care and trauma-informed care, yet there are few specific instructions for effective family-centered or trauma-informed behaviours that are observable and teachable. We aimed to develop a framework and tools to address this gap.

Methods

We reviewed relevant policy statements, guidelines, and research to define core domains of family-centered and trauma-informed care, and identified observable evidence-based practices in each domain. We refined this list of practices via review of provider/team behaviours in simulated paediatric resuscitation scenarios, then developed and piloted an observational checklist.

Results

Six domains were identified: (1) Sharing information with patient and family; (2) Promoting family involvement in care and decisions; (3) Addressing family needs and distress; (4) Addressing child distress; (5) Promoting effective emotional support for child; (6) Practicing developmental and cultural competence. A 71-item observational checklist assessing these domains was feasible for use during video review of paediatric resuscitation.

Conclusion

This framework can guide future research and provide tools for training and implementation efforts to improve patient outcomes through patient- and family-centered and trauma-informed care.

Coronavirus disease 2019 in the pediatric emergency department: unique considerations in preparation and response

PURPOSE OF REVIEW

Pediatric Emergency Departments (PEDs) have experienced unique considerations throughout the coronavirus disease 2019 (COVID-19) pandemic. We review the adaptations and challenges surrounding the preparation and response for pediatric emergency patients, with a specific focus on operational modifications, evolving personal protected equipment (PPE) needs, protected resuscitation responses, clinical characteristics in children, and the unintended effects on children and youth.

RECENT FINDINGS

COVID-19 has thus far proven to have a milder course in children, with manifestations ranging from asymptomatic carriage or typical viral symptoms, to novel clinical entities such as 'COVID toes' and multisystem inflammatory syndrome in children (MIS-C), the latter associated with potentially significant morbidity. It has had an important effect on primary prevention, injury rates, reduced presentations for emergency care, and increased mental health, abuse and neglect rates in children and youth. PEDs have prepared successfully. The most significant adjustments have occurred with screening, testing, and consistent and effective use of PPE, along with protected responses to resuscitation, adaptations to maintain family-centered care, and technological advances in communication and virtual care. Simulation has been key to the successful implementation of many of these strategies.

SUMMARY

COVID-19 has pushed PEDs to rapidly adapt to evolving clinical and societal needs, with both resultant challenges and positive advances. Further experience and research will guide how in the face of a global pandemic we can further optimize the clinical and operational care of children and youth, ensure robust educational training programs, and maintain provider safety and wellness.

The effects of family-witnessed resuscitation on health professionals

Aim:

To gain an understanding of the effects of family-witnessed resuscitation (FWR) on health professionals.

Background:

FWR has been the subject of an ongoing debate for almost 30 years. Historically, emergency departments (EDs) have excluded family members of a critically ill or injured patient from the treatment area during resuscitation.

Methodology:

A systematic literature search of six nursing-focused databases was undertaken using pertinent keywords. Only studies published in English, focused on ED staff and undertaken after 2007 (published up to 2017) were included.

Findings:

FWR is not commonly practised by health professionals. The four themes identified were: fear of adverse litigation; the importance of the role of the facilitator; lack of FWR policies in the workplace; and staff lack of knowledge and education regarding FWR, resulting in fear and stress.

Conclusion:

By implementing policies in the workplace, and having a facilitator to provide support and guidance to families, stress and anxiety can be greatly reduced. The implementation of educational programmes can increase staff awareness and knowledge surrounding the benefits of FWR

Parental Presence in Pediatric Interfacility Critical Care Transport: A Descriptive Study of Children, Parents, and Health Care Professionals' Opinions

OBJECTIVE

Parental accompaniment during transport is considered a core quality metrics in pediatric transport and a key measure of family-centered care in this setting. However, children's opinions on this topic have never been sought. The aim of this study was to evaluate the opinion of different actors of a specialized pediatric transport system on parental presence during transport.

METHODS

This was a questionnaire-based descriptive study. Health care professionals qualified to be part of our pediatric transport team, and parents of hospitalized children completed self-administered surveys. Hospitalized children from 5 to 17 years of age were interviewed with a short verbal semistructured questionnaire using sentence completion.

RESULTS

Ninety-three professionals, 65 parents, and 25 children completed the questionnaires between February and August 2018. The majority of children (84%) thought that it would be important to be accompanied by their parent if they needed interfacility transport. All of the parents and 79% of health care professionals thought that parents should have the possibility to be present with their children during interfacility transport.

CONCLUSION

All of the parents and the majority of health care providers and children interviewed think that parents should be able to be present with their child during interfacility transport.

Adolescent Access to Patient-Centered Medical Homes

OBJECTIVES

To analyze the distribution of patient-centered medical homes (PCMHs) among US adolescents, and to examine whether disparities exist among subgroups.

STUDY DESIGN

Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007.

RESULTS

Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007.

CONCLUSIONS

PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.

Parents’ Experience When Present During a Child’s Resuscitation: An Integrative Review

Understanding perceptions of parents is necessary to meet parents’ needs during a child’s resuscitation. Parent presence at pediatric resuscitations has been slow to become consistent practice in all hospital settings and remains controversial. The purpose of this integrative review was to synthesize research on parents’ experience while present during a child’s resuscitation to improve understanding for health care providers and to facilitate application in practice. Nine studies met inclusion criteria, identifying four major themes. Parents experienced conflicting emotions, articulated a need for communication and support, reported that being physically present was comforting, and described their reactions to the experience. The available research on parents’ experience during presence at their child’s resuscitation offers a foundation for further detailed study. Further study is needed about parents’ perspective of support needed while present during a child’s resuscitation, as well as about any long-term effects of presence on parent stress and coping.

Parent experience in the resuscitation room: how do they feel?

The aim of this study is to describe the experience of parents present in the resuscitation room during the attention given to their children in the pediatric emergency department, and to identify areas for improvement in this regard. This was a prospective study carried out in a third-level pediatric hospital. Children with life-threatening pathologies are treated in the resuscitation room of the pediatric emergency department. A survey was carried out among parents present in the resuscitation room during the period September 2016-August 2017. Excluded were the parents of children that died and those with a language barrier. The parents were interviewed in person or over the phone within 72 h of the care provided in the resuscitation room. Fifty surveys were completed (15 in person and 35 by phone). Forty mothers and 10 fathers responded, with an average age of 41. In the resuscitation room, 39 parents were accompanied by a health professional and 22 were given information about how the resuscitation room operated. The feelings most frequently reported by the parents were nervousness (39) and trust in the healthcare provided (20). All of the parents wished to be present. They felt that their presence was beneficial for the child (46), for themselves (50), and for the healthcare personnel (28).Conclusion: The experience of the parents in our resuscitation room is a positive one. Nevertheless, some aspects need to be improved, such as accompaniment of the parents and the information that they are provided. What is Known: • There is an international recommendation for parental presence during invasive procedures and cardiopulmonary resuscitation. • Few studies have been carried out on how parents in the resuscitation room feel and how they encounter the experience. What is New: • Even though most of the parents feel nervous in the resuscitation room, they expressed confidence in the medical team and they would wish to be present under similar circumstances.

Management of Pediatric Trauma

Injury is still the number 1 killer of children ages 1 to 18 years in the United States (http://www.cdc.gov/nchs/fastats/children.htm). Children who sustain injuries with resulting disabilities incur significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden. The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children.

Family presence during resuscitation in a paediatric hospital: health professionals' confidence and perceptions

AIMS AND OBJECTIVES

To investigate medical and nursing staff's perceptions of and self-confidence in facilitating family presence during resuscitation in a paediatric hospital setting.

BACKGROUND

Family presence during resuscitation is the attendance of family members in a location that affords visual or physical contact with the patient during resuscitation. Providing the opportunity for families to be present during resuscitation embraces the family-centred care philosophy which underpins paediatric care. Having families present continues to spark much debate amongst health care professionals.

DESIGN

A descriptive cross-sectional randomised survey using the 'Family Presence Risk/Benefit Scale' and the 'Family Presence Self-Confidence Scale 'to assess health care professionals' (doctors and nurses) perceptions and self-confidence in facilitating family presence during resuscitation of a child in a paediatric hospital.

METHODS

Surveys were distributed to 300 randomly selected medical and nursing staff. Descriptive and inferential statistics were used to compare medical and nursing, and critical and noncritical care perceptions and self-confidence.

RESULTS

Critical care staff had statistically significant higher risk/benefit scores and higher self-confidence scores than those working in noncritical care areas. Having experience in paediatric resuscitation, having invited families to be present previously and a greater number of years working in paediatrics significantly affected participants' perceptions and self-confidence. There was no difference between medical and nursing mean scores for either scale.

CONCLUSION

Both medical and nursing staff working in the paediatric setting understood the needs of families and the philosophy of family-centred care is a model of care practised across disciplines.

RELEVANCE TO CLINICAL PRACTICE

This has implications both for implementing guidelines to support family presence during resuscitation and for education strategies to shift the attitudes of staff who have limited or no experience.

[Family's presence in the pediatric emergency room: opinion of health's professionals]

OBJECTIVE

To learn the opinion of health professionals regarding the presence of family during pediatric emergency care.

METHODS

Cross-sectional study, performed with 46 health professionals, members of the medical and nursing team of a pediatric emergency service. The data were collected via the application of a questionnaire composed by variables related to the opinion of professionals about the studied subject, in line with the professional category and the vocational training time, as well as invasive procedures during which the presence of family is authorized by the professionals.

RESULTS

The medical staff and the professionals with shorter time after graduation (<10 years) were more favorable to the presence of family during emergency procedures. Regarding the complexity of the procedures, the nursing staff proved more favorable to the presence of family during less complex procedures-peripheral venous puncture and fluid sample-whereas the consent of the medical staff was similar, regardless the performed procedure-peripheral venous puncture, fluid sample, intraosseous puncture, tracheal intubation and cardiopulmonary resuscitation.

CONCLUSIONS

In order to allow the presence of family in the emergency room, it is necessary to sensitize health professionals, especially the nursing staff and the longer-term acting professionals, which are more resistant to allow the family to stay with the child during the emergency care.

Patient- and family-centered care of children in the emergency department

Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This revised technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care.

[Has the presence of parents during invasive procedures in the emergency department increased in the last few years?]

INTRODUCTION

In the recent years, parents are playing an important role in Pediatric Emergency Department (PED), and wish to be present when invasive procedures (IP) are performed.

OBJECTIVES

1) To compare the presence of parents during IP in PED in Spain between 2008 and 2012. 2) To compare the arguments to restrict the presence and problems arising from this, and 3) To determine whether the views of health personnel have changed on this subject.

METHODOLOGY

A descriptive multicenter comparative study was conducted in 2008 and 2012. A total of 42 questionaires were sent by email to PED managers, with the responding hospitals being included in the 2 periods of the study.

RESULTS

A total of 22 hospitals participated in the study. The presence of parents in the PED increased between 2008 and 2012 for all IP, significantly in the blood test and urine catheterization. In 2012, managers state that children are not so nervous, and anxiety of the parents and staff fear of a poorer performance, as an argument to restrict family presence. There were few problems during the 2 periods, with the poor behavior of the children decreasing. According to managers, the opinion of health personnel has not changed in the last four years.

CONCLUSIONS

The presence of parents during the IP in the PED has increased in the last four years, although the presence is low for more invasive procedures. Managers argue the presence of fewer behavior problems to restrict family presence. The opinion of the staff has not changed in the last four years, although more studies are required on this issue.

Facilitated family presence at resuscitation: effectiveness of a nursing student toolkit

BACKGROUND

Facilitated family presence at resuscitation is endorsed by multiple nursing and specialty practice organizations. Implementation of this practice is not universal so there is a need to increase familiarity and competence with facilitated family presence at resuscitation during this significant life event. One strategy to promote this practice is to use a nursing student toolkit for pre-licensure and graduate nursing students. The toolkit includes short video simulations of facilitated family presence at resuscitation, a PowerPoint presentation of evidence-based practice, and questions to facilitate guided discussion.

METHODS

This study tested the effectiveness of this toolkit in increasing nursing students' knowledge, perceptions, and confidence in facilitated family presence at resuscitation. Nursing students from five universities in the United States completed the Family Presence Risk-Benefit Scale, Family Presence Self-Confidence Scale, and a knowledge test before and after the intervention.

RESULTS

Implementing the facilitated family presence at resuscitation toolkit significantly increased nursing students' knowledge, perceptions, and confidence related to facilitated family presence at resuscitation (p<.001). The effect size was large for knowledge (d=.90) and perceptions (d=1.04) and moderate for confidence (d=.51).

CONCLUSIONS

The facilitated family presence at resuscitation toolkit used in this study had a positive impact on students' knowledge, perception of benefits and risks, and self-confidence in facilitated family presence at resuscitation. The toolkit provides students a structured opportunity to consider the presence of family members at resuscitation prior to encountering this situation in clinical practice.

Ask the right question: a critical step for practicing evidence-based laboratory medicine

The purpose of laboratory medicine is to facilitate better decision making in clinical practice and healthcare delivery. Decision making implies an unresolved issue, problem or unmet need. The most important criterion for any investigation to be of value in clinical practice is that it addresses an unmet need. The different ways in which laboratory investigations are utilized in patient care can be represented in the form of questions. It is important that these questions are articulated to highlight the variables that will impact on the effectiveness of the investigation in the scenario being considered. These variables include the characteristics of the patient (or population) and clinical setting, the nature of the decision and action taken on receipt of the test result and the expected outcome. Asking a question is the first step of the evidence-based laboratory medicine (EBLM) cycle, the other steps being acquiring the evidence, critically appraising the evidence, applying the evidence and auditing use of the evidence. Getting the question right determines the quality of the whole process, thus, defines the quality in practice of laboratory medicine. Whilst the main focus of the EBLM cycle is to provide a strong evidence base for use in clinical practice, it is clear that the five steps are equally applicable in commissioning, delivery and audit (performance management) of services. Asking the right question is crucial to improving the quality of evidence, and practice, in laboratory medicine, and should be used in routine laboratory medicine practice and management throughout healthcare.

Pediatric trauma due to motor vehicle accidents on high traffic roadway

OBJECTIVE: To outline a profile of pediatric trauma victims and verify the likelihood of trauma in children on a high traffic roadway. METHODS: A descriptive cohort study of the records of emergency medical service activations on the Rio-Niterói Bridge, a high traffic roadway in Rio de Janeiro, Brazil. Descriptive statistics were expressed as absolute and relative frequencies. The estimated risk of trauma in children aged < 12 years was calculated by means of odds ratios, with a 95% confidence interval. RESULTS: Trauma accounted for 514 of 1,244 activations (41.31%) of the Rio-Niterói Bridge emergency medical service between March 2002 and March 2003. Response to incidents involving children aged < 12 years accounted for 52 of these (4.18%). Half of victims were between the ages of 6 and 12 years (n = 26), and 55.76% were male (n = 29). Of the 52 victims, 37 (71.15%) were involved in motor vehicle accidents (OR: 3.70; 95%CI: 1.94-7.13; p < 0.0001). Of these, 28 were vehicle-vehicle collisions (75.67%). The most common sites of injury were the extremities (n = 12; 32.43%), face (n = 10; 27.02%), and head (n = 9; 24.32%). Pre-hospital procedures were performed on 23 of the 37 patients (62.16%), and 44.23% (n = 23/52) required hospital transportation. There were no deaths during the study period. CONCLUSIONS: In this study, children were at significantly higher odds of being treated for trauma while on a highway with heavy traffic flow. The most common sites of injury in this sample were the lower extremities and the head, face, and neck complex.

"It's just what we do": a qualitative study of emergency nurses working with well-established family presence protocol

INTRODUCTION

ENA has supported family presence at the bedside during resuscitation of a loved one since 1993. Limited support from health care institutions has resulted in research that includes few data from hospitals with long-term family presence experience. The study objectives were to (1) describe the benefit and harm of being present during resuscitation to family members, using perceptions of nurses who work in an emergency department with a well-established family presence protocol; and (2) define family presence using perceptions of nurse participants.

METHODS

A descriptive qualitative study was conducted in an emergency department that has had a written family presence protocol since 1992. Fourteen emergency nurses described their experience with family presence in face-to-face interviews using an investigator-developed, open-ended tool. Transcribed interviews were evaluated using conceptual content analysis.

RESULTS

Nurses perceived benefits to family members in that 1) the family is able to see evolving events, described as a family member's ability to see a loved one's condition change over time, and 2) is able to validate efforts to save the life of their loved one. Nurses also indicated that family members' appreciation that everything possible was done increased nurses' confidence that they did everything they could during the resuscitation event. No nurses described observing actual harm to family members who were present during resuscitation.

DISCUSSION

Emergency nurses can embrace family presence and influence benefits for family members when the practice is well established. Behavior modeling rather than written protocol may affect acceptance of family presence during resuscitation efforts among emergency nurses.

Laboratory medicine best practices: systematic evidence review and evaluation methods for quality improvement

OBJECTIVE

To develop methods for systematically reviewing evidence for identifying effective laboratory medicine (LM) practices associated with improved healthcare quality outcomes.

RELEVANCE

Although many evidence-evaluation systems have been developed, none are designed to include and rate healthcare quality improvement studies to identify evidence-based practices that improve patient safety and LM quality.

METHODS

Validated evidence-based medicine methods established by governmental agencies, the Guide to Community Preventive Services, and others were adapted for the LM field. Key methods modifications included (a) inclusion of quality improvement study designs; (b) mechanisms for inclusion of unpublished evidence, (c) combining of individual ratings of study quality, effect size, and relevance of outcome measures to evaluate consistency of practice evidence; and (d) deriving an overall strength rating to support evidence-based best practice recommendations. The methods follow the process steps of: ask; acquire; appraise; analyze; apply; and assess. Expert panels used the systematic evidence review results on practice effectiveness for improving healthcare quality outcomes consistent with the Institute of Medicine's healthcare quality aims (safe, timely, effective, equitable, efficient, and patient-centered).

CONCLUSIONS

Adapting and developing methods from validated systems and applying them to systematically review and evaluate practices in LM by using published and unpublished studies is feasible. With these methods, evidence from quality improvement studies can be systematically synthesized and summarized to identify effective LM practices. Practical and scientifically validated demonstration of a positive impact on outcomes ensures that practitioners, policy makers, and decision makers at all levels have the evidence needed for improving healthcare quality and public health.