Family presence during invasive procedures and resuscitations in the emergency department: a critical review and suggestions for future research

Family caregivers as essential partners in care: examining the impacts of restrictive acute care visiting policies during the COVID-19 pandemic in Canada

INTRODUCTION

During the pandemic many Canadian hospitals made significant changes to their 'open family presence' and 'visitor policies' to reduce the spread of COVID-19 by instituting restrictive or 'zero visiting' policies in healthcare facilities. These policies have the potential to create great hardship, anxiety and stress for patients, families, caregivers and frontline healthcare providers (HCPs); along with concerns about the quality and safety of patient care. The presence of family members and other caregivers as essential partners in care is an explicit expression of the philosophy of patient- and family-centred care (PFCC) in action. The purpose of this study is to increase our understanding of how changes to family presence and visiting policies and practices during the COVID-19 pandemic have impacted patients, family caregivers and frontline healthcare providers (HCPs) in acute care hospitals.

METHODS

A total of 38 in-depth semi-structured interviews were conducted with patients, family caregivers and HCPs in Canadian provinces who had experience with visiting policies in acute care settings during the pandemic. COVID patients, and the caregivers of COVID patients, were excluded from this study. A maximum variation sampling strategy was used to guide the selection and recruitment of patients, family caregivers and HCPs, based on our interest in gaining a diversity of perspectives and experiences.

RESULTS

Many patients, family caregivers, and HCPs view family caregiver presence as integral to PFCC, describing the essential roles played by family caregivers prior to the pandemic. There were commonalities across all three groups with respect to their perspectives on the impacts of restrictive visiting policies on patients, family caregivers and HCPs. They fell into four broad integrated categories: (1) emotional and mental health; (2) communication and advocacy; (3) safety and quality of care; and (4) PFCC, trust in the healthcare system, and future decisions regarding accessing needed healthcare. Recommendations for pandemic visiting policies were also identified.

CONCLUSIONS

The findings from this study highlighted several impacts of restrictive family caregiver presence or visiting policies implemented during COVID-19 on patients, family caregivers and HCPs in acute healthcare settings across Canada. Participants emphasized that there is no "one-size-fits-all" caregiver presence policy that will address all patient needs. To be consistent with the practice of PFCC, patients and family caregivers are welcomed as part of the healthcare team in ways that work for them, demonstrating that flexibility in family presence and visiting policies is essential.

A Scoping Review of the Impact of Family Presence on Pediatric Resuscitation Team Members

OBJECTIVES

The purpose of this scoping review was to identify the extent, range, and nature of information currently available on family presence during pediatric resuscitation on resuscitation team members and their performance.

DATA SOURCES

A comprehensive search strategy was created and executed by identifying primary keywords in central articles, pretesting key words and combinations of them in databases to confirm articles returned fell within the search parameters, and checking that key articles were returned which confirmed the search strategy was not too narrow.

STUDY SELECTION

Two members of the research team independently conducted relevance screening using predetermined inclusion and exclusion parameters. Titles and abstracts of retrieved articles were reviewed using the set criteria involving. From the refined list of selected articles, full texts of each article were considered for final determination of inclusion.

DATA EXTRACTION

Key items of information were gathered from each article selected using a predefined extraction list. The extracted information was then sorted into themes and relevant issues.

DATA SYNTHESIS

Of the 3,012 studies initially identified, 48 met the inclusion criteria. Themes identified included as follows: 1) attitudes and opinions on family presence during pediatric resuscitation; 2) reasons in support of or against family presence during pediatric resuscitation; 3) education, training, and support; and 4) resuscitation performance and outcomes. Our review of the available information highlighted that the majority of work done to this point has focused heavily on healthcare provider opinions and relied mainly on survey method.

CONCLUSIONS

We propose that future research employ more rigorous research techniques, such as randomized control trials, place greater emphasis on healthcare provider behaviors and clinical outcomes during family presence during pediatric resuscitation, and increase exploration into the education and training needs of healthcare providers who already currently manage family presence during pediatric resuscitation.

Update for Anaesthetists on Clinical Features of COVID-19 Patients and Relevant Management

When preparing for the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the coronavirus infection disease (COVID-19) questions arose regarding various aspects concerning the anaesthetist. When reviewing the literature it became obvious that keeping up-to-date with all relevant publications is almost impossible. We searched for and summarised clinically relevant topics that could help making clinical decisions. This is a subjective analysis of literature concerning specific topics raised in our daily practice (e.g., clinical features of COVID-19 patients; ventilation of the critically ill COVID-19 patient; diagnostic of infection with SARS-CoV-2; stability of the virus; Covid-19 in specific patient populations, e.g., paediatrics, immunosuppressed patients, patients with hypertension, diabetes mellitus, kidney or liver disease; co-medication with non-steroidal anti-inflammatory drugs (NSAIDs); antiviral treatment) and we believe that these answers help colleagues in clinical decision-making. With ongoing treatment of severely ill COVID-19 patients other questions will come up. While respective guidelines on these topics will serve clinicians in clinical practice, regularly updating all guidelines concerning COVID-19 will be a necessary, although challenging task in the upcoming weeks and months. All recommendations during the current extremely rapid development of knowledge must be evaluated on a daily basis, as suggestions made today may be out-dated with the new evidence available tomorrow.

Comparison the effect of trained and untrained family presence on their anxiety during invasive procedures in an emergency department: A randomized controlled trial

Objective

The present study was aimed to compare the effect of the trained and untrained family presence on their anxiety during invasive procedures in an emergency department.

Methods

In this randomized controlled clinical trial, 90 patients who were candidates for receiving invasive nursing procedures were selected in an emergency department based on the inclusion criteria, and then were equally assigned into 3 groups by the random minimization method: A ("presence of the trained family member group "), B ("presence of the untrained family member group "), and C ("absence and untrained family member group"). The anxiety level was measured before and after implementation of the procedure using the Spielberger State-Trait Anxiety Inventory (STAI). The data were analyzed by SPSS software using the Kolmogorov-Smirnov test, Chi-Square test, Kruskal Wallis Independent-Samples test, Paired Samples T-test, and ANOVA at the significance level of 0.05.

Results

The three groups were similar in terms of demographic variables. In all three groups, the SATI score significantly decreased after intervention phase (p = 0.001). The mean changes of the SATI score were not statistically different between the groups. However, The STAI score decreased significantly after intervention in the group B compared to the group A (p = 0.011) and C (p = 0.042). However, there was no significant difference between the SATI score in the group A and C (p = 0.867).

Conclusion

The results of the study revealed that, the “presence of the untrained" family members caused them to experience significantly less anxiety than the other two groups. However, changes in the anxiety score were not significant between the groups.

Pain Assessment in Children Younger Than 8 Years in Out-of-Hospital Emergency Medicine: Reliability and Validity of EVENDOL Score

OBJECTIVE

Pain in children is underestimated and undertreated in out-of-hospital emergency medicine. In this setting, caregivers need a reliable pain scale, but none has been validated. A single observational pain scale for all children younger than 8 years, EVENDOL, has been validated in emergency pediatric units. We study the feasibility of EVENDOL score in an out-of-hospital emergency setting.

METHODS

This prospective multicenter study included all conscious children younger than 8 years transported by a mobile intensive care unit between October 2008 and May 2010. The emergency physician and nurse independently assessed the child's pain using first a numeric rating scale (score 0-10), then the 5-item EVENDOL scale (verbal/vocal expression, facial expression, movements, postures, and relationship with entourage) (score 0-3/item) at 3 time points (at rest, during examination, and after analgesia). We studied the scale's internal validity, interrater reliability, discriminant ability (influence of fever and anxiety), and face validity.

RESULTS

Of the 422 included children, 82 and 62 (29%-39%) were in pain according to the emergency physician and nurses (numeric rating scale >3/10). All EVENDOL scale attributes were satisfied at all 3 time points, for all population subsets. Values for the first assessment (entire study population) were as follows: internal validity (0.78-0.89), interrater reliability (r = 0.63-0.76, weighted κ = 0.49-0.65), construct validity, and discriminant ability (r = 0.6-0.7). Fever did not impact on EVENDOL score. Anxiety level and pain were correlated. Completion time was fast (mean, 2.3-3.4 minutes). Face validity was good.

CONCLUSION

EVENDOL is a quick, easy-to-use, discriminant instrument to assess pain in young children in out-of-hospital emergency settings.

Attitudes of Spine Surgeons Regarding Management of Preoperative Anxiety: A Cross-sectional Study

STUDY DESIGN

This is a cross-sectional study.

OBJECTIVE

To investigate spine surgeons' attitudes regarding preoperative anxiety measurement, management, and responsibility.

SUMMARY OF BACKGROUND DATA

The vast majority of patients scheduled for spine surgery experience preoperative anxiety. However, there are currently no consensus guidelines for measure or management of preoperative anxiety in spinal operations.

MATERIALS AND METHODS

An anonymous questionnaire was sent online to spine surgeons of AO Spine North America to capture their views regarding preoperative anxiety.

RESULTS

Of 69 complete responses, most respondents were male (n=66, 95.7%), orthopedic surgeons (n=52, 75.4%), and practicing at an academic setting (n=39, 56.5%). Most spine surgeons practiced for at least 20 years (n=52, 75.4%), operated on 100-300 patients per year (n=48, 69.6%), and were attending physicians (n=61, 88.4%). Most did not measure preoperative anxiety (n=46, 66.7%) and would not use a rating scale to measure it (n=38, 55.1%). However, most would discuss it if mentioned by the patient (n=40, 58.0%). Other spine surgeons measured anxiety verbally (n=22, 31.9%) or with a rating scale or survey (n=6, 8.7%). Although preferences for preoperative anxiety management varied, most respondents used patient education (n=54, 78.3%) and permitting family members' presence (n=36, 52.2%) to reduce patient anxieties. Spine surgeons held themselves, anesthesiologists, and patients most responsible to manage preoperative anxiety.

CONCLUSIONS

The majority of spine surgeons surveyed did not regularly measure preoperative anxiety, but would discuss its management if the subject was broached by the patient. Spine surgeons relied on a variety of methods to manage a patient's anxiety, but most preferred preoperative education and permitting the presence of family members. Responsibility for controlling preoperative anxiety was chiefly allocated to surgeons, anesthesiologists, and patients. Future avenues for research may include developing a preoperative anxiety measurement scale and management protocol specific to spine surgery.

LEVEL OF EVIDENCE

Level IV.

Effect of an audience on trainee stress and performance during simulated neonatal intubation: a randomized crossover trial

BACKGROUND

Neonatal intubation is a stressful procedure taught to trainees. This procedure can attract additional observers. The impact of observers on neonatal intubation performance by trainees has not been studied. Our objective was to evaluate if additional observers present during neonatal mannequin endotracheal intubation (NMEI) by junior trainees, affects their performance and their stress levels.

METHODS

A randomized cross over trial was conducted. First year residents with no experience in neonatal intubation were assigned to NMEI condition A or B randomly on day 1. Subjects were crossed over to the other condition on day 2. Condition A: Only one audience member was present Condition B: Presence of an audience of 5 health care providers. Differences in the time to successful NMEI was recorded and compared between conditions. A portable heart rate monitor was used to measure peak heart rate above baseline during NMEI under both conditions.

RESULTS

Forty nine residents were recruited. 72% were female with a median age of 25 years (IQR: 24-27). Time to successful intubation was comparable under both conditions with a mean difference of - 3.94 s (95% CI: -8.2,0.4). Peak heart rate was significantly lower under condition A (mean difference - 11.9 beats/min, 95% CI -15.98 to - 7.78).

CONCLUSION

Although the time required to NMEI did not increase, our results suggest that presence of observers significantly increases trainee stress. The addition of extraneous observers during simulation training may better equip residents to deal with such stressors.

TRIAL REGISTRATION

Date of registration: March 2016, NCT 02726724 .

Consequences of Needle-Related Medical Procedures: A Hermeneutic Study With Young Children (3-7 Years)

Needle-related medical procedures (NRMPs) are often frightening and cause children anxiety and pain. Only a few studies have examined the perspectives of younger children. More knowledge is needed about younger children's experiences in caring situations such as NRMPs.

AIM

The aim of this study was to explain and understand the consequences related to NRMPs from younger children's perspectives.

METHODS

Participant observations and interviews with younger children who had experienced NRMPs were analysed using a lifeworld hermeneutic approach.

RESULTS

Experiencing fear is central for younger children during an NRMP and interpretation of its consequences formed the basis for the following themes: seeking security, realizing the adult's power, struggling for control, feeling ashamed, and surrendering. A comprehensive understanding is presented wherein younger children's experiences of NRMPs vary across time and space related to weakening and strengthening their feelings of fear.

CONCLUSIONS

Awareness is needed that adults' power becomes more obvious for children during an NRMP. Children's surrender does not necessarily imply acceptance of the procedure. Providing children with opportunities to control elements of the procedure creates a foundation for active participation, and vice versa.

Cynicism and other attitudes towards patients in an emergency department in a middle eastern tertiary care center

BACKGROUND

A caring, compassionate practitioner of the medical arts is the idealized version of what makes a good doctor. If asked to think of a painting of a doctor we most likely conjure an image of a physician sitting at a patient's bedside checking the pulse with a concerned look on his face. The reality is however that cynicism, among other negative attitudes, is becoming more prominent among physicians and medical staff. The causes and extent of cynicism likely vary among medical departments and different cultures. In this study, we aimed to assess attitudes of medical students and physicians in an Emergency Department (ED) in Lebanon that accommodates both local patients and is also known to attract patients from around the Middle East.

METHODS

A total of 30 students, residents and attending physicians at the American University of Beirut Medical Center were invited to participate. All participants underwent semi-structured interviews that were recorded, transcribed and then analyzed for common themes.

RESULTS

More negative emotions were expressed among participants than positive ones. Negative emotions were more frequently expressed among medical students, interns and residents than attending physicians. Cynicism in the ED was commonly reported however, maintenance of professionalism and adequate patient care were underscored. While empathy was recurrently found among participants, a trend towards a decrease in empathy with career progression was noted among attending physicians. Further, negative feelings towards patient families were prominent. Participants tended to categorize patients based on willingness to cooperate, gender, age, case acuity, ethnic origins and social status.

CONCLUSIONS

Cynicism emerged as a prominent theme among medical students and staff in our study. However, participants were also empathetic. These attitudes were generally attributed to the peculiar stressors associated with the Lebanese culture, low acuity cases and "VIP" patients. It is crucial to explore methods in order to decrease cynicism and improve patient care. Also, the implications of these attitudes on patient care remain to be discovered.

Improving Pediatric Radiography Patient Stress, Mood, and Parental Satisfaction Through Positive Environmental Distractions: A Randomized Control Trial

To evaluate how a positive environmental distraction intervention impacted pediatric radiography patient behavioral stress-responses, mood states, and parental satisfaction.

METHODS

Behavioral observation, rating scales, surveys on 182 pediatric patients and their parents randomly assigned to three positive distraction levels (minimum, light, light and animation).

RESULTS

Under interventional conditions, patients exhibited less low-stress coping behaviors (ps<0.001-0.007) and more verbal behaviors indicating positive affect (p=0.003); parents more favorably rated environmental pleasantness (ps<0.001), sense of environmental control (ps=0.002), and willingness to return and recommend the facility (ps=0.001-0.005).

CONCLUSION

The intervention improved pediatric radiography experience but needs further investigation in more stressful settings.

Effect of family presence on pain and anxiety during invasive nursing procedures in an emergency department: A randomized controlled experimental study

BACKGROUND

Patients generally prefer to have their family present during medical or nursing interventions. Family presence is assumed to reduce anxiety, especially during painful interventions.

AIM

This study employed a randomized controlled experimental design to determine the effects of family presence on pain and anxiety during invasive nursing procedures.

METHOD

The study population consisted of patients hospitalized in the observation unit of the internal medicine section in the emergency department of a university hospital. The sample comprised 138 patients assigned into the experimental and control groups by drawing lots. The invasive nursing procedure was carried out in the presence of family members, for members of the experimental group, and without family members, for members of the control group. Thus, the effects of family presence on pain and anxiety during the administration of an invasive nursing procedure to patients were analyzed.

RESULTS

The results showed that members of the experimental and control groups did not differ with respect to the pain and state anxiety scores during the intervention.

CONCLUSION

Family presence does not influence the participants' pain and anxiety during an invasive nursing procedure. Thus, the decision regarding family presence during such procedures should be based on patient preference.

Parents' perspectives on supporting children during needle-related medical procedures

When children endure needle-related medical procedures (NRMPs), different emotions arise for the child and his/her parents. Despite the parents’ own feelings, they have a key role in supporting their child through these procedures. The aim of this study is to describe the meanings of supporting children during NRMPs from the perspective of the parents. Twenty-one parents participated in this study. A reflective lifeworld research (RLR) approach was used and phenomenological analysis was applied. The essential meaning of the phenomenon—supporting children during an NRMP—is characterized as “keeping the child under the protection of one’s wings,” sometimes very close and sometimes a little further out under the wingtips. The essential meaning is additionally described through its constituents: paying attention to the child’s way of expressing itself, striving to maintain control, facilitating the child’s understanding, focusing the child’s attention, seeking additional support, and rewarding the child. The conclusion is that parents’ ability to be supportive can be affected when seeing their child undergo an NRMP. To regain the role as the child’s protector and to be able to keep the child “under the protection of one’s wings,” parents need support from the staff.

Observational study of family member presence for pediatric emergency department procedures

OBJECTIVE

The aim of this study was to observe the proportion of family members who choose to remain present during children's pediatric emergency department procedures in actual clinical situations.

METHODS

Family members of a convenience sample of children undergoing invasive procedures in a pediatric emergency department were observed. Data were collected on whether family members chose to remain present or leave during the procedure and family member and health care worker behaviors. Consent to participate in the study was obtained after the observation, and family members were surveyed regarding demographics, anxiety, and previous experiences.

RESULTS

Fifty-nine children undergoing 66 procedures and accompanied by 83 family members were enrolled. The median age of the children was 69 months; 47% were female and 73% were Hispanic. The family members consisted of 64% mothers and 24% fathers, with a median age of 33 years. The most common procedures were vascular access (25), laceration repair (11), and urethral catheterization (9). Overall, 73% of the family members stayed during the child's procedure, 18% left, and 9% showed some mixture of staying and leaving. Health care workers asked the family members to leave twice, encouraged them to leave once, and used nonverbal cues to exclude the family members twice. Caregivers helped to restrain the child 35% of the time.

CONCLUSIONS

Family members remain present during actual children's emergency department procedures less often than they indicate they would in hypothetical scenario surveys.

The relationship between parental catastrophizing about child pain and distress in response to medical procedures in the context of childhood cancer treatment: a longitudinal analysis

OBJECTIVE

Children with leukemia frequently undergo invasive medical procedures, such as lumbar punctures (LPs) and bone marrow aspirations (BMAs). To date, cross-sectional evidence indicates that LP/BMA procedures continue to elicit distress over the course of treatment in children and parents.

METHOD

The current study used prospective analyses investigating in 28 children diagnosed with leukemia, the course of parental and child distress when confronted with consecutive LP/BMA procedures and potential moderation by catastrophic thinking. Parents' level of catastrophic thoughts was assessed before the first treatment-related LP/BMA, while child and parent distress was reported on after each LP/BMA procedure.

RESULTS

Whereas parental distress decreased over time among low catastrophizing parents, LP/BMA procedures remained highly distressing for high catastrophizing parents. Child distress during LP/BMA procedures increased over time and was positively related with parental distress.

CONCLUSION

These findings stress the importance of targeting child and parent distress as early as possible in treatment.

The impact of parental accompaniment in paediatric trauma: a helicopter emergency medical service (HEMS) perspective

Major trauma remains a significant cause of mortality and morbidity in young people and adolescents throughout the western world. Both the physical and psychological consequences of trauma are well documented and it is shown that peri-traumatic factors play a large part in the emotional recovery of children involved in trauma. Indeed, parental anxiety levels may play one of the biggest roles. There are no publically available guidelines on pre-hospital accompaniment, and where research has been done on parental presence it often focuses primarily on the parents or staff, rather than the child themselves. Whilst acknowledging the impact on parents and staff, the importance of the emotional wellbeing of the child should be reinforced, to reduce the likelihood of developing symptoms in keeping with post-traumatic stress disorder. This non-systematic literature review, aims to examine the impact of parental accompaniment to hospital, following paediatric trauma, and to help pre-hospital clinicians decide whether accompaniment would be of benefit to their patient population. The lack of published data does not enable a formal recommendation of parental accompaniment in the helicopter to be mandated, though it should be the preference in land based conveyance. Future research is needed into the emotional recovery of children after trauma, as well as the experiences of patient, parent and staff during conveyance.

Family presence during brain death evaluation: a randomized controlled trial*

OBJECTIVE

To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress.

DESIGN

Randomized controlled trial.

SETTING

Four ICUs at an academic tertiary care center.

SUBJECTS

Immediate family members of patients suspected to have suffered brain death.

INTERVENTIONS

Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated "understanding brain death" survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention.

MEASUREMENTS AND MAIN RESULTS

Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1-2) if present versus 0 (interquartile range, 0-0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention "understanding" scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250).

CONCLUSIONS

Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

Parental presence during cardiopulmonary resuscitation of children: the experience, opinions and moral positions of emergency teams in France

OBJECTIVE

To evaluate the experience, opinions and moral positions of French emergency physicians (EP) who had taken a paediatric university course on parental presence during child cardiopulmonary resuscitation (CPR), and to compare it with the responses of nurses on their teams.

METHODS

A questionnaire was sent to 550 EPs who had taken the course during the previous 6 years; the EPs were also asked to give a copy of the questionnaire to nurses on their staff. Data were collected on experience of parental presence during child CPR, opinions on the practice, arguments for and against parental presence, and the moral positions of respondents regarding their perception of life and the sharing of medical/parental power in the decision-making process.

RESULTS

343 responses were analysed, 47% from EPs (29% response rate) and 53% from nurses. 52% of respondents had experienced parental presence during child CPR, but it had been the physician's wish on only 6% of these occasions. Only 17% of respondents favoured parental presence, with EPs (27%) being favourable more often than nurses (12%). The reasons against parental presence were psychological trauma for the parents, risk of interference with medical management, and care team stress. Respondents not in favour of parental presence expressed this view more for medical reasons than for parent-related reasons. The physicians not in favour of parental presence espoused a moral position predicated on medical power.

CONCLUSIONS

A majority of EPs and nurses were reluctant to have parents present during child CPR. Their attitude involved medical paternalism.

[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.

Nurses' perspectives on supporting children during needle-related medical procedures

Children state that among their worst fears during hospitalization are those related to various nursing procedures and to injections and needles. Nurses thus have a responsibility to help children cope with needle-related medical procedures (NRMP) and the potentially negative effects of these. The aim of the study is to describe the lived experience of supporting children during NRMP, from the perspective of nurses. Fourteen nurses took part in the study, six of whom participated on two occasions thus resulting in 20 interviews. A reflective lifeworld research approach was used, and phenomenological analysis was applied. The result shows that supporting children during NRMP is characterized by a desire to meet the child in his/her own world and by an effort to reach the child's horizon of understanding regarding these actions, based on the given conditions. The essential meaning of the phenomenon is founded on the following constituents: developing relationships through conversation, being sensitive to embodied responses, balancing between tact and use of restraint, being the child's advocate, adjusting time, and maintaining belief. The discussion focuses on how nurses can support children through various types of conversation and by receiving help from the parents' ability to be supportive, and on whether restraint can be supportive or not for children during NRMP. Our conclusion is that nurses have to see each individual child, meet him/her in their own world, and decide on supportive actions while at the same time balancing their responsibility for the completion of the NRMP. This work can be described as "balancing on a tightrope" in an unpredictable situation.

Look before you LEAPP™: An interprofessional approach to bedside pediatric inpatient procedures

The Golisano Children's Hospital at Upstate Medical University is a 71 bed children's hospital within a hospital, serving nearly two million people in Central New York. Minor procedures occur daily in all children's hospitals, yet team coordination when planning for these procedures is often overlooked. LEAPP™ is a mnemonic for: Listen, Evaluate, Anticipate, Plan, and Proceed. The "Look before You LEAPP™" program was developed by a group of nurses, child life specialists, faculty, a chief resident and a fellow. LEAPP™ is a team-based program providing consistent care to all children undergoing inpatient procedures. It improves patient satisfaction and reduces procedural distress. Through LEAPP™ steps, teams are created at point of care - at the bedside or treatment room of inpatient units. Educational goals are linked to the practical goal of cooperation for good health care. The approach uses an online educational module for residents, students and nurses to introduce an innovative protocol and a planning tool.1 Pocket cards, promotional pens, and logo door-clings, purchased through grant funds (The Foundation for Upstate Medical University) were initially used to encourage participation. Pre/post observations of procedural planning and performance of the nurse, caregiver, physician, child-life specialist and independent observer included patient and family preparation, pain and anxiety, staffing and supplies, and satisfaction. Fifty procedures were assessed pre-implementation and 28 post implementation. Although satisfaction with procedures improved between pre and post LEAPP™ implementation, there were overall differences in satisfaction with procedural management and pain/anxiety control by physicians, caregivers, and staff that remained statistically significant. Interdisciplinary bedside teamwork can be used to support interprofessional education and this education can similarly be used to support improved patient outcomes.

Family witnessed resuscitation: nationwide survey of 337 prehospital emergency teams in France

OBJECTIVE

To assess the practices and opinions of prehospital emergency medical services (EMS) with regard to family witnessed resuscitation (FWR) and to analyse the differences between physicians' and nurses' responses.

DESIGN

An anonymous questionnaire (30 yes/no questions on demographics and FWR) was sent to all prehospital emergency staff (physicians, nurses and support staff) working for the 377 Mobile Intensive Care Units in France.

RESULTS

Of the 2689 responses received 2664 were analysed. Mean respondent age was 38 ± 8 years, the male to female ratio was 1:2. 87% of respondents had already performed FWR and 38% had offered relatives the option to be present during resuscitation. Most respondents (90%) felt that FWR might cause psychological trauma to the family; 70% thought that FWR might impact on the duration of resuscitation and 68% on EMS team concentration. In the 28% of cases when relatives had asked to be present, 59% of respondents had acquiesced but only 27% were willing to invite relatives to be routinely present.

CONCLUSIONS

Prehospital EMS teams in France seems to support FWR but are not yet ready to offer it systematically to relatives. Following our survey, written guidelines are currently in development in our department. These guidelines could be the first step of a national strategy for developing FWR in France. We await results from other studies of family members' opinions to compare prehospital practitioners' and family members' views to further develop our practice.

Relief of pain and anxiety in pediatric patients in emergency medical systems

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child's and family's reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction.

Initial management of bereaved relatives following trauma

Emergency department (ED) staff confront death more frequently than any other specialty except oncology. These deaths are often traumatic, sudden, unexpected and occur in a younger age group. As a consequence, bereaved survivors have a greater risk of an abnormal grief reaction. [ Walters DT, Tupin JP (1991) Family grief in the emergency department. Emergency Medicine Clinics of North America 9(1): 189–206.] Whilst the severity or timing of traumatic injuries may preclude medical attempts to influence patient survival, the approach of the same resuscitation team to the bereaved before death, during resuscitation and after death may have profound influences on subsequent grief in the bereaved. Despite this, it can be argued that Emergency Medicine within the UK has given little thought and time for reflection upon how we treat the bereaved. That the care of the dying and the bereaved within the ED matters is greatly reinforced by the Scottish Government’s 2010 Consultation document on bereavement that states: ‘There is … evidence that the way [the] bereaved experience events around the time of death will influence their grief. Where health services get it right … bereaved people are supported to accept the death … Conversely if the health services get it wrong, then bereaved people may experience additional distress, and that distress will interfere with their successful transition through the grieving process’.

Family presence during invasive procedures at the emergency department: what is the opinion of Spanish medical staff?

OBJECTIVES

Family presence (FP) during invasive procedures (IPs) in children remains controversial among pediatric emergency department (PED) staff. The authors aimed to determine health care providers' attitudes toward FP during IPs in Spain, to learn whether parents are given the option of being present during different IPs, and to study which factors influence the providers' opinions.

METHODS

Observational study. Physicians and nurses were asked to answer a questionnaire, which was sent to 43 PEDs and was available at the Spanish Pediatric Emergency Society Web site.

RESULTS

We obtained 222 questionnaires from 36 Spanish hospitals. A total of 65.8% of the surveys were answered by physicians (66.4% pediatricians) and 34.2% by nurses. The median age of the respondents was 32 years, and 69.2% were women. Parents were given the option of being present during blood sampling (36.4%), intravenous line placement (32.7%), urethral catheterization (32.1%), lumbar puncture (13.5%), and resuscitation (1%). More than 60% of providers approved of FP during blood sampling, sutures, intravenous line placement, and urethral catheterization; however, only 10.8% of providers encourages FP during resuscitation. Against FP, health care staff argue procedural invasiveness (75.6%), parents' anxiety (87.6%), and worsened performance of the procedure (66%). Commonly expressed advantages were reducing patient distress (72.9%) and parent anxiety (62.3%). Physicians, especially the older ones, are more likely to encourage FP than nurses for some IPs.

CONCLUSIONS

The PED staff tend to prefer parents not to be present during IPs as the level of invasiveness increases. Family presence is not common in Spanish PEDs. Older physicians are more likely to support FP than nurses.

Family presence during trauma resuscitation: ready for primetime?

BACKGROUND

The concept of family presence during trauma resuscitation (FPTR) remains controversial. Healthcare providers have expressed concern that resuscitation of severely injured trauma patients is inappropriate for family members as they may have psychologic distress, disrupt resuscitative efforts, or misinterpret provider actions, which can ultimately impact satisfaction with care. The minimal evidence that exists is descriptive or anecdotal.

METHODS

Using a previously developed FPTR protocol, a prospective, comparative study assessing 50 adult family members, who were present (n = 25) or not present (n = 25) with their severely injured adult family member during resuscitation, was conducted. Family member anxiety was assessed using State-Trait Anxiety Inventory, satisfaction using a Revised-Critical Care Family Needs Inventory, and well-being using Family Member Well-being Index within 48 hours of intensive care unit admission. Mean total scores were compared for both groups with independent t tests. Significance was set at p < 0.05.

RESULTS

Age and Injury Severity Score were statistically equivalent in all patients. Anxiety, satisfaction, and well-being were not statistically different in family members present compared with those not present during resuscitation. There were no untoward events during resuscitation efforts. Family members present felt they benefited the patient and gained a better understanding of the situation. Conversely, family members not present commented that they would have preferred to have been present during resuscitation.

CONCLUSIONS

Family members present during trauma resuscitation suffered no ill psychologic effects and scored equivalent to those family members who were not present on anxiety, satisfaction, and well-being measures. Quality of care during trauma resuscitation was maintained. The fact that all the family members would repeat experience again supports the idea that FPTR was not too traumatic for those who chose to be present.

Patient-centered integrated networks of emergency care: consensus-based recommendations and future research priorities

Patient-centered care is defined by the Institute of Medicine (IOM) as care that is responsive to individual patient needs and values and that guides the treatment decisions. This article is a result of a breakout session of the 2010 Academic Emergency Medicine (AEM) consensus conference and describes the process of developing consensus-based recommendations for providing patient-centered emergency care. The objectives of the working group were to identify and describe the critical gaps in the provision of patient-centered care, develop a consensus-based research agenda, and create a list of future research priorities. Using e-mail and in-person meetings, knowledge gaps were identified in the areas of respect for patient preferences, coordination of clinical care, and communication among health care providers. Four consensus-based recommendations were developed on the following themes: enhancing communication and patient advocacy in emergency departments (EDs), facilitating care coordination after discharge, defining metrics for patient-centered care, and placing the locus of control of medical information into patients' hands. The set of research priorities based on these recommendations was created to promote research and advance knowledge in this dimension of clinical care.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.

A multi-center study on the attitudes of Malaysian emergency health care staff towards allowing family presence during resuscitation of adult patients

Background

The practice of allowing family members to witness on-going active resuscitation has been gaining ground in many developed countries since it was first introduced in the early 1990s. In many Asian countries, the acceptability of this practice has not been well studied.

Aim

We conducted a multi-center questionnaire study to determine the attitudes of health care professionals in Malaysia towards family presence to witness ongoing medical procedures during resuscitation.

Methods

Using a bilingual questionnaire (in Malay and English language), we asked our respondents about their attitudes towards allowing family presence (FP) as well as their actual experience of requests from families to be allowed to witness resuscitations. Multiple logistic regression was used to analyze the association between the many variables and a positive attitude towards FP.

Results

Out of 300 health care professionals who received forms, 270 responded (a 90% response rate). Generally only 15.8% of our respondents agreed to allow relatives to witness resuscitations, although more than twice the number (38.5%) agreed that relatives do have a right to be around during resuscitation. Health care providers are significantly more likely to allow FP if the procedures are perceived as likely to be successful (e.g., intravenous cannulation and blood taking as compared to chest tube insertion). Doctors were more than twice as likely as paramedics to agree to FP (p-value = 0.002). This is probably due to the Malaysian work culture in our health care systems in which paramedics usually adopt a ‘follow-the-leader’ attitude in their daily practice.

Conclusion

The concept of allowing FP is not well accepted among our Malaysian health care providers.

Putting patients first: Partnering with patients' families

This is the sixth in a series of articles from Planetree, an international nonprofit organization founded in 1978 that's "committed to improving medical care from the patient's perspective." For more information, go to www.planetree.org.

Using research to determine support for a policy on family presence during resuscitation

National guidelines and professional organizations have recommended allowing family presence during resuscitation and bedside invasive procedures. Studies found that only 5% of critical care units have written policies. Periodic requests by family members prompted the creation of a task force, including nurses, physicians, and respiratory therapists, to develop this controversial policy. Before development, a research study of healthcare personnel attitudes, concerns, and beliefs toward family presence during cardiopulmonary resuscitation and bedside invasive procedures was done. This descriptive and correlational study showed support for family presence by critical care and emergency department nurses. Findings revealed both support and non-support for families to be present during resuscitative efforts. Providing family presence as an option offers an opportunity for reluctant healthcare team members to refuse their presence and an opportunity for those who support family presence to welcome the family.