PEDIATRICS Vol. 120 No. 3 September 2007, pp. e565-e574 (doi:10.1542/peds.2006-2914)
ARTICLE |
Family Presence During Pediatric Trauma Team Activation: An Assessment of a Structured Program
Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. When a child presents to a trauma center with a serious injury, family members are often excluded from the initial trauma team evaluation. The objective of this study was to evaluate the outcomes of a structured program of family presence during pediatric trauma team activations by measuring (1) the need for termination of family presence, (2) times to completion of key parts of the trauma evaluation, and (3) the opinions of staff surveyed immediately after conclusion of family presence.
METHODS. This was a cross-sectional study that combined prospectively obtained data and surveys from trauma team evaluations in which family presence occurred, with retrospective chart review of all trauma activations during an 18-month study period. The study was conducted at a level 1 pediatric trauma center with a preestablished family presence program that assigns a staff member to screen family members for family presence, provide support, and record events. Times to completion of key components of the trauma evaluation were calculated and compared for cases with and without family presence. Cross-sectional surveys were performed immediately after each trauma team evaluation.
RESULTS. A total of 197 family members participated in family presence. There were no cases of interference with medical care by family members. Seven family members were asked to leave the trauma area by staff after initiation of family presence for various reasons. Times to completion of key components of the trauma evaluation did not differ significantly between enrolled patients with family presence and those without family presence. Surveys were completed for 136 cases, and the majority of providers reported that family presence either had no effect on or improved medical decision-making (97%), institution of patient care (94%), communication among providers (92%), and communication with family members (98%).
CONCLUSIONS. This prospective study suggests that there is an overall low prevalence of negative outcomes associated with family presence during pediatric trauma team evaluation after implementation of a structured family presence program. Excluding family members as a routine because of provider concerns about negative impact on clinical care does not seem to be indicated.
Key Words: family presence • trauma evaluation • pediatric trauma • family member presence • trauma team activation
Abbreviations: FP—family presence • ED—emergency department • PEM—pediatric emergency medicine • GCS—Glasgow Coma Scale • TS—trauma score • CI—confidence interval • CPR—cardiopulmonary resuscitation
Traumatic injury has a profound and sustained impact on the lives of children and their family members. Trauma is the leading cause of childhood mortality, accounts for 20% of pediatric hospitalizations, and annually leaves >30000 children with permanent disabilities.1,2 Families play an integral role in the ongoing care of pediatric trauma patients, but traditionally they have been separated from their children during the initial phase of trauma care, the trauma team evaluation.
In previous studies, trauma providers, including trauma surgeons and emergency physicians, have expressed concern about potential adverse effects of allowing family presence (FP) during trauma evaluations.3–6 Trauma providers have suggested that witnessing a trauma resuscitation may be psychologically damaging for family members, that family members may directly interfere with patient care, and that family member presence may increase staff stress and decrease procedure performance. Physicians have been the most hesitant of health care providers in their support of FP.3,4 In 1 survey, 98% of trauma surgeons believed that some phases of the trauma evaluation were not appropriate for FP, and almost one third believed that FP was never appropriate; however, only half reported ever having had an experience with FP.3 Previous research in adult and pediatric medical patients suggests that FP may in fact help both patients and family members cope with the stress of the experience and that negative effects on care are unfounded.7–22 However, no previous studies have specifically assessed the effects of FP in the pediatric trauma setting.
The objective of this study was to evaluate the outcomes of a structured FP program during pediatric trauma team activations. We hypothesized that a structured program to promote FP during pediatric trauma evaluations would be associated with a low prevalence of negative FP outcomes as measured by the need for termination of FP, time to completion of key parts of the trauma evaluation, and opinions of staff surveyed immediately after patient evaluation.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Design
This was a cross-sectional study that combined prospectively obtained data and surveys from trauma team evaluations when FP occurred, with retrospective chart review of all trauma team activations during the study period.
Setting and Program Organization
This study was conducted in the emergency department (ED) of an urban, university-affiliated children's hospital and level I pediatric trauma center that sees 
75000 annual ED visits. On the basis of information reported by prehospital providers over radiotelephones, trauma patients are triaged by the pediatric emergency medicine (PEM) physician. Patients who meet criteria for a trauma team activation are assigned to 1 of 2 tiers: level 1 or level 2. Criteria for triage are based on mechanism and vital sign information similar to previously published systems for use of trauma team resources.23,24 Physiologic and anatomic criteria for a level 1 trauma activation include intubated patients or those with an unstable or compromised airway; unstable vital signs; cardiac arrest; Glasgow Coma Scale (GCS) score <8; lateralizing or worsening neurologic examination; any age-appropriate signs of shock; major proximal vascular injuries or amputations; significant penetrating injury to the chest, abdomen, head, neck, or groin; 
25% total body surface area burns; and unstable spinal cord injuries. A level 2 trauma activation is designated for patients who have potentially life-threatening injuries but stable vital signs. This includes patients with a GCS score 9, hypotension before transport that has resolved, blunt abdominal or chest trauma with abnormal examination, significant penetrating trauma to extremities, significant distal crush injury or amputation, or any injury or mechanism with a high index of suspicion for a significant injury. Responders to all trauma activations include the ED attending and fellow, trauma surgeon, surgical resident, ED resident, ED nursing staff, and social worker; a pediatric intensive care physician and additional staff attend level 1 activations.
The FP program for trauma activations began 6 months before data collection for this study. A key component of the program is the designated family support person. At our institution, this person is usually a social worker but can be a nurse, clergy, or anyone who is trained and qualified to support the family. This individual is responsible for prescreening family members, clearing FP as an option with the medical staff, and providing explanations and support for family members while in the trauma area. They are also trained to recognize and act on situational changes that involve family members. The prescreening process is used to identify family members who display worrisome behaviors that might interfere with the patient's care. Acceptable behaviors that would allow them to be a participant in FP include being distressed, distracted, anxious, quiet, or angry, as long as they are consolable, cooperative, and able to follow instructions. Family members who are physically aggressive, uncooperative, threatening or argumentative, hysterical, or intoxicated or have an altered mental status are not given the option of FP. The social worker documents all events involving FP, which include the results of the behavioral prescreening, whether FP was an option, who declined FP if the option was not given, whether family members opted to participate, the events surrounding their participation, and whether family members were asked to leave or were removed from the trauma area. Because the resuscitation area can accommodate several patients simultaneously, trauma evaluations that occur when >1 patient is in the resuscitation area are excluded from FP to protect patient confidentiality.
Health care providers and those who would serve as the family support person were educated on FP by participating in conferences, workshops, lectures, confidential surveys, and mock codes involving FP. During these sessions, the benefits of FP, concerns regarding FP, and plans for addressing potential complications were discussed. Lectures were given to non–health care providers on how a typical resuscitation should proceed. Feedback was given to family support persons and health care providers on how FP events should be managed on the basis of video review and continuous quality improvement data.
For assessment of outcomes of the program, a cross-sectional survey was performed immediately after each trauma evaluation when FP occurred. Study staff were present to administer the survey from 8:00 AM to midnight daily. Members of the trauma team who were surveyed included the PEM attending, PEM fellow, trauma surgeon, resident, and nurse. Using a 3-point scale (1 = easier, 2 = same, and 3 = harder), team members were asked to rate the impact that FP had on their ability to make medical decisions, institute patient care, communicate with other medical providers, and communicate with the family. They were also asked to give the number of years they have been practicing medicine at their current position and the number of previous FP experiences. Last, they were asked whether they would support FP in the future using a 5-point Likert scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree).
Data Collection
Approval of the institutional review board was obtained for access to surveys, FP evaluation forms, and medical charts. Hospital information systems were used to identify all trauma evaluations for patients who were 18 years or younger during the 18-month study period. Demographic characteristics, times of arrival and procedures, and standard clinical data that are part of the routine history and physical examination involved in trauma team evaluations including a standardized trauma score (TS)24 were collected retrospectively from the medical chart.
Three groups (patients with FP, those without FP [referred to as the "no FP" group], and those who were missed from prospective data collection) were compared for differences in demographics and patient severity. The no FP group included patients for whom family members were known not to be present during their trauma evaluations for the following reasons: a family member did not arrive while the patient was being evaluated, the option of FP was denied by the trauma team for provider preference or issues of patient confidentiality, or family members opted not to participate in FP. FP status was not known in the "missed" group, which consisted of patients who presented during overnight hours or other times when research assistants were not present (although FP may have occurred). Patients in the FP group were compared with the no FP group for differences in times to completion of key medical interventions.
Data Analysis
Statistical analyses were performed using SPSS 12.0 (SPSS Inc, Chicago, IL). Continuous variables were summarized using mean, median, and range. Discrete variables were described using proportions and reported with 95% confidence intervals (CIs). Comparisons were made using 
2 or Fisher's exact tests for categorical variables and t test or analysis of variance for continuous variables. All statistical tests were 2-tailed. Statistical significance was designated at P 
.05.
Sample Size
We hypothesized an acceptable rate of termination of FP to be 5% and a rate of negative survey responses to be 10%. A sample size of 300 would provide an estimate of the frequency of termination of FP with a 95% CI width of 5%. A sample of 200 completed surveys would allow an estimate of negative responses with a 95% CI of 10%. A total sample size of 400 trauma patients was calculated on the basis of an estimated FP data completion rate of 75% (300 patients) and a survey completion rate of 50% (200 patients). This sample size would also allow us to detect a one-third SD difference (with 80% power) between completion times for key resuscitation interventions of patients with and without FP. On the basis of pilot data from our institution, a study period of 18 months was necessary to obtain this sample size.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Participants
Between September 1, 2003, and March 31, 2005, a total of 595 pediatric patients presented to our ED in need of trauma team activations and were evaluated in our trauma area. Of these, 572 (96.1%) had a trauma team activation level recorded and 291 (48.9%) were designated level 1 trauma activations. For all trauma patients, the most common mechanisms of injury were falls (25.7%), pedestrian injuries (18%), and motor vehicle crashes (14.8%). A total of 294 trauma patients were enrolled and had FP data collected; 301 were missed for data collection and FP outcomes were unknown, 249 of these arrived during daytime hours, and 52 arrived between midnight and 8:00 AM (Fig 1). Missed patients did not differ significantly from all other enrolled patients (FP and no FP combined) with respect to race, gender, age, or TS (Table 1). Patients who were missed did have a lower GCS score (12.7 vs 13.3; P = .04) and a trend toward a lower hospitalization rate (73.8% vs 80.3%; P = .06) by statistical testing, although the differences were of small clinical magnitude. Among the 294 patients with data collection, 90 were not eligible for FP: 86 because no family member was present and 4 because there was >1 patient being evaluated in the trauma area.
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Family member prescreening forms were completed on 175 (86%) of the 204 eligible traumas before participation in FP. Family members who missed prescreening arrived with the patient and were in the trauma area before the family support person arrived. Screening defined no family members as inappropriate for FP. Two patients were denied the option of FP by the medical team: 1 because the team was concerned for child abuse and the child arrived with the suspected perpetrator and 1 for provider preference in a mildly injured child. Six family members declined the option of FP for emotional reasons and personal comfort level. A total of 197 patients (96% of those eligible) participated in FP during the trauma evaluation. When compared with the 98 patients who had data collected but did not have FP (Table 1), patients with FP tended to be younger (mean age: 7.8 vs 9.7; P = .002) but did not differ significantly by gender, race, GCS score, TS, or disposition. Mothers alone participated in 55% of FP evaluations, fathers alone in 11%, both mother and father in 5%, siblings in 2%, and other family members in 20%.
FP Outcomes
Time to family member entry into the trauma area was recorded for 163 of the FP resuscitations. The mean time to family member entry was 8.6 minutes (SD: 9.3), with a range of 0 to 47 minutes after the patient arrived. Thirty-one (19%) family members arrived with the patient and went immediately into the trauma area; 49 (30.4%) entered the patient care area between 1 and 5 minutes after the patient's arrival, 54 (33.1%) between 6 and 15 minutes, and 29 (17.5%) between 16 and 47 minutes. Most (78%) patients who had FP were awake and alert on arrival, 11% had altered mental status, 9% arrived intubated but not receiving cardiopulmonary resuscitation (CPR), and 2% (4 patients) arrived with CPR in progress. Of the 4 patients who received CPR, 2 families chose to leave the resuscitation area for emotional and comfort reasons, and the remaining 2 stayed with the patient throughout the entire resuscitation. There were a total of 7 trauma-associated deaths that occurred while in the trauma area: 1 with FP, 2 without FP, and 4 among missed cases.
Of the 197 patients whose family member entered the trauma area, there were no cases of interference with medical care by these family members (95% CI: 0%–1.9%; Fig 1). Seven family members were asked to leave the trauma area by hospital staff at some time after the initiation of FP: 2 were for the provider's comfort during patient intubation, 1 was asked to leave so that the team could better communicate their concerns for child abuse, 2 became emotionally overwhelmed but remained appropriate in the resuscitation area and were asked by the social worker to step out of the area briefly, and 2 became emotionally overwhelmed and inconsolable. One of these family members missed the prescreening process because she entered the room with the patient before the social worker arrived. When compared with all patients with FP, those whose family members were asked to leave were overall significantly more injured (mean GCS score: 9.1 ± 5.4 vs 13.5 ± 3.5; TS: 12.9 ± 3.0 vs 14.7 ± 2.8). Fourteen (7%) family members chose to leave the trauma area for emotional and personal comfort reasons. Patients whose family members left for emotional reasons were also more severely injured (GCS score: 10.3 ± 5.8 vs 13.5 ± 3.5; TS: 11.9 ± 4.2 vs 14.7 ± 2.8).
On evaluation of severely injured patients, 22 who had both a GCS 8 and a TS 12 had a family member participate in FP. Ten of the 22 FP events were not completed: 4 were terminated by hospital staff (1 for inappropriate family member behavior, 1 for overwhelmed but appropriate family member behavior, 1 for team comfort and communication, and 1 for provider comfort with an invasive procedure), and 6 were terminated by the family members themselves (5 for emotional/comfort reasons and 1 for telephone support). Two additional children who had only a TS 12 had a family member participate in FP. These 2 FP events were terminated by the family members (1 for emotional/comfort reasons and 1 for telephone support.)
Time to Completion of Trauma Interventions
Enrolled patients with FP were compared with those without FP for times to completion of key components of the trauma evaluation: time to patient log-roll (occurs at the end of the primary survey), time to first radiograph while in the trauma area, and times of clinical interventions (intravenous access, central line access, intubation, and tube thoracostomy). No significant time differences were noted between those with FP and those without FP (Table 2).
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Survey Results
Overall, 136 (69%) patients had posttrauma evaluation surveys completed: 72% (n = 142) were completed by PEM attendings, 60% (n = 118) by trauma surgeons, 62% (n = 121) by PEM fellows, 81% (n = 159) by residents, and 72% (n = 142) by nurses. To evaluate whether patient severity played a role in survey completion, we compared FP resuscitations with and without surveys, and these groups were similar with respect to TS, GCS score, and final disposition.
There were 33 individual PEM attendings, 40 trauma surgeons, 14 PEM fellows, 139 residents, and 88 nurses who completed postresuscitation surveys. PEM attendings had the most years of clinical experience at their current position (range: 1.0–30.0 years; mean: 8.8 years), followed by nurses (range: 0.08–29.0 years; mean: 5.70 years), trauma surgeons (range: 0.2–8.0 years; mean: 2.8 years), residents (range: 0.02–9.0 years; mean: 2.6 years), and fellows (range: 0.0–4.0 years; mean: 1.5 years). Almost all of the providers had at least some previous experience with FP; among all surveys, 1% of fellows, 2% of nurses, 9% of residents, and 3% of trauma surgeons reported no previous FP exposures.
Survey responses are displayed in Fig 2. For the survey question of FP impact on medical decision-making, the majority (82.7%) of trauma providers reported that medical decision-making was not affected by FP. Overall, only 2.6% (95% CI: 1.5%–4.1%) believed that medical decision-making was harder in the presence of family members. For how FP affected the providers’ ability to institute patient care, again, most (81.4%) believed that FP did not interfere and only 3.9% reported it to have been harder (95% CI: 2.6%–5.7%). For how FP had an impact on team communication during the resuscitation, the majority (85.2%) of providers believed that their ability to communicate with other team members was the same or easier in the presence of family members, and only 7.4% believed that it was harder (95% CI: 5.5%–9.6%). For the question of how FP affected communication with the family during the resuscitation, overall, the majority of providers believed that having family members present made communication easier (39.5%) or the same (58.0%), and only 2.4% believed that it was harder (95% CI: 1.3%–3.9%).
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Overall, 86% of providers reported support for FP in the future: 99% of PEM attendings, 91% of PEM fellows, 86% of nurses, 81% of residents, and 74% of trauma surgeons responded positively. Trauma surgeons were less likely than other health care providers to report positive support for FP in the future (P < .01).
We evaluated the influence that patient and provider characteristics had on survey responses. We combined all surveys for this analysis because provider responses were overall similar across types of providers. When we examined the relationship between patient severity and survey responses, the only significant finding was the patient's GCS score and its influence on team communication. Cases in which providers reported communication between staff to have been harder with FP tended to have lower GCS scores (mean GCS score of 12.4 for harder with FP versus 13.7 for same with FP versus 14.1 for easier with FP; P = .02 by analysis of variance). TSs did not differ significantly across these groups. Neither the patient's GCS score nor TS was associated with different responses to the survey questions on medical decision-making, institution of patient care, communication with family members, or future support for FP. For provider characteristics, there was some association with previous experience with FP and survey responses on medical decision-making, institution of the care plan, and future support for FP; 13% of providers with no previous FP experience reported strong support for FP in the future compared with 22% with 1 to 5 previous experiences and 46% among those with >5 previous FP experiences (P < .01 by 2). In addition, support for FP in the future was associated with an increasing number of years of provider experience (mean: 5.3 years for those with strong support compared with 3.1 years for those who were neutral and 2.3 years for those with strong disagreement with FP; P < .01).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Overall, during the 18-month study period, we observed a low prevalence of negative outcomes related to a structured program for including family members in trauma team evaluations. Of 197 pediatric trauma evaluations with FP, there were no cases of medical interference by family members. Almost half of all family members were with the patient in the trauma area within the first 5 minutes of arrival, a time when the initial patient evaluation and stabilizing medical interventions are performed. The majority (82.4%) of family members were present within the first 15 minutes, a time frame when most trauma evaluations are still active and procedures are ongoing. In our study, FP did not prolong the time that it took providers to perform key components of the trauma evaluation and emergency procedures. For the few cases in which family members were asked to leave or family members chose to terminate FP for personal reasons, the patients tended to be more severely injured as measured by GCS score and TS (mean GCS score: 9.1 ± 5.5, TS: 12.9 ± 3.0 SD for patients whose family members were asked to leave the resuscitation area; mean GCS score: 10.3 ± 5.8, TS: 11.9 ± 4.2 for patients whose family members chose to leave for personal reasons).
Surveys that were completed by providers immediately after each trauma team activation revealed that FP rarely was believed to have a negative impact on the ability to make medical decisions, institute patient care, or communicate with other medical providers. In addition, a substantial proportion of providers reported that FP improved communication with family members. Previous FP experience and a greater number of years of provider clinical experience were associated with future support for FP.
The concept of FP during resuscitation was first introduced in the mid-1980s, when the ED staff at Foote Hospital in Michigan began systematically to encourage family members to attend resuscitations of loved ones.5 Historically, trauma providers have been hesitant to allow family members to witness trauma resuscitations, although family members have often been with the child from the moment the injury occurred. Although few studies have assessed the impact of FP on pediatric trauma resuscitation, data from medical resuscitation and adult trauma resuscitation have documented substantial potential benefits without medical interference.5,7–17
In this study we also evaluated a number of specific perceived barriers to FP to assess their validity in pediatric trauma evaluations. A common perceived barrier to FP for health care providers is the fear of physical interference and obstruction of medical care by family members.3–10,19–22 During the 18-month period of observation at our hospital, there were no cases of direct or physical interference with patient care by family members. Our observations were consistent with previous studies. In the literature, the majority of physicians who have had experience with FP have witnessed appropriate family member behaviors. During a 9-year period of observation, Foote Hospital reported no occurrences of interference.18 Another hospital that monitored its FP experiences reported only 1 incidence of family member interference of 61 FP resuscitations (a case in which a spouse was too upset).14 More recently, of 54 family members who were observed during invasive pediatric procedures, only 2 demonstrated minor interferences.19 Another recent study that evaluated the effectiveness of an FP protocol reported no cases of interruption of patient care during their 64 FP events involving 66 family members.20
Another concern is that FP may increase staff stress, decrease procedure performance, and adversely affect the resuscitative efforts.5,10 Our study results showed that most providers did not believe that FP interfered with their ability to make medical decisions or institute patient care. Having a family member present did not prolong the times to critical procedural interventions or the completion of the trauma survey. In 1 adult study that involved medical resuscitations, 30% of providers reported an increased level of stress with FP.5 However, on formal video review of the resuscitations, FP did not affect CPR or procedural performance. Trauma providers may find it harder to work with family members looking on, but with increasing confidence in one's skills and experience with dealing with distressed family members, this anxiety decreases.13,21,22
In the literature, health care providers have expressed concerns about the effect that FP may have on team discussion of critical patient care issues3–10,19,21,22 Communication among trauma providers is critical in the coordination of resuscitation efforts. Active discussion of medical events is also needed for the educational purposes of junior staff, who have expressed concerns about FP hindering their ability to ask questions and seek guidance. The results of our surveys showed that the majority of health care providers did not believe that FP had an adverse impact on their ability to communicate with other members of the team; some correlation between the assessment of communication was observed in patients with lower GCS scores, which may indicate an impact of severity on communication. In a few select cases in which child abuse was a concern, the providers either denied FP from the onset or asked the family member to leave so that critical information could be discussed without hesitation. Only 2 family members exhibited behavior that interfered with team communication. Each was escorted from the trauma area because they had become emotionally overwhelmed and inconsolable.
Good communication and inclusion of family members in the care plan promotes collaboration and fosters trust. A large percentage of our providers believed that their communication with the family was made easier when family members were witness to the evaluations. Parents who believe that they are included in the decision-making process are less likely to have feelings of doubt about the adequacy of care.25–27 FP may serve to decrease litigation risks to health care providers when family members believe that their situation has been met with compassion and concern and they have seen with their own eyes the efforts that have been made.28–30
In applying our results to other settings, a key factor to consider was the structured nature of our program, which we consider instrumental to the success of FP. The program included training, a formalized prescreening process, and a dedicated staff member without any primary patient care responsibilities to support and monitor family members The American Academy of Pediatrics and the American College of Emergency Physicians policy statement on FP in the emergency setting encourages physicians to consider FP during all phases of ED care.31 Although we support and encourage FP for trauma team evaluations and resuscitations, the care of the pediatric patient remains the highest priority. FP is a decision that involves the health care providers, families, and patients. Our experience suggests that with a structured FP program, family members can safely be involved without having a negative impact on patient care.
There were a number of limitations in this study. First, this was a convenience sample of pediatric traumas. We had incomplete enrollment, with 42% of eligible pediatric traumas being missed for FP data collection. Eligible patients were missed for several reasons, including incomplete study staff coverage during normal study hours and occasional lack of advance notification about the presence of a trauma patient. The missed cases were overall similar to those enrolled except that those missed had a lower mean GCS score that did not seem to be clinically significant. Missed patients were discharged from the hospital more often than those who were enrolled, perhaps suggesting that enrolled patients may have been somewhat more ill overall. Therefore, it seems unlikely that convenience sampling underrepresented situations that would be considered higher risk for FP.
Relatively few seriously injured patients were included in our study population, and the times when family members witnessed highly invasive procedures were infrequent. Because of this, we have limited ability to describe experiences with FP during resuscitations of critically ill trauma patients. Patients whose family members were asked to leave were overall more severely injured. Family members were asked to leave for reasons of provider comfort and communication for 3 of the 7 cases and for family member behavior in 4 of the 7 cases. Although severely injured patients are an important subgroup and may be of most interest to trauma surgeons, the trauma literature clearly suggests that most children who meet widely used trauma team activation criteria do not in fact have serious injuries that require immediate procedures. For example, Sola et al,23 in describing the trauma response system at Johns Hopkins Hospital, found that only 17% of patients who met trauma activation criteria required transfer to the operating room or ICU. Our patients were a representative sample of our pediatric trauma population. That most children who meet standard trauma activation criteria do not require immediate intervention in the resuscitation room only speaks further to the appropriateness of including family members. The decision to involve family members in FP for severely injured patients should be made on an individual basis, with both the provider comfort and family member appropriateness fully evaluated.
Another limitation was the high rate of previous experience with FP among medical providers as a result of the initiation of the FP program for trauma evaluations 6 months before data collection for this study. Previous studies and data gathered here suggest that previous FP experience is related to positive acceptance of and support for FP.21 Surveys were completed multiple times by single providers during the study period. Because each survey focused on the specific resuscitation that had just occurred, we believed that analyzing each event separately was important. Comparing first and last evaluations by the same provider did not reveal any significant changes in response patterns, and limiting analysis to the first evaluation for each provider gave similar results. However, results might have differed if a higher proportion of providers with no previous FP experience had been included in the sample.
Finally, survey evaluations concentrated on the experiences of health care providers. We did not survey family members for their opinions on the impact of FP, although previous literature on FP suggests that it may be beneficial.5,12–18 Future studies should explore family member experiences during pediatric trauma resuscitations.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Overall, our results suggest that there is a low prevalence of negative outcomes during pediatric trauma team evaluations after implementation of a structured FP program. Excluding family members as a routine because of concerns about a negative impact on clinical care does not seem to be indicated. Future studies should further evaluate FP in the severely injured pediatric population, observe staff performance through objective techniques such as video assessment, assess family member and patient opinions regarding FP, and measure long-term outcomes that are associated with FP.
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ACKNOWLEDGMENTS |
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We thank Dr Mike Nance, Marla Vanore, and Monica Liebman from the Division of Surgery; Dr Kathy Shaw and Dr Dennis Durbin from the Division of Emergency Medicine; Cindy Thomas and the ED social workers; and the ED attendings, fellows, residents, and nurses for support of our FP program and for completing the surveys that were used for this study.
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FOOTNOTES |
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Accepted Feb 6, 2007.
Address correspondence to Karen J. O'Connell, MD, Children's National Medical Center, Emergency Medicine and Trauma Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: koconnel{at}cnmc.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr O'Connell's current affiliation is Emergency Medicine and Trauma Center, Children's National Medical Center, Washington, DC.
Dr Spandorfer's current affiliation is Pediatric Emergency Medicine Associates, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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- Ruddy RM, Fleisher GR. An approach to the injured child. In: Fleisher GM, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1249 –1258
- Ziegler MM, Gonzalez Del Ray JA. Major trauma. In: Fleisher GM, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:1259 –1269
- Helmer SD, Smith SR, Dort JM, Shapiro WM, Katan BS. Family presence during trauma resuscitation: a survey of AAST and ENA members. J Trauma. 2000;48 :1015 –1024[Web of Science][Medline]
- Mitchell MH, Lynch MB. Should relatives be allowed in the resuscitation room?
J Accid Emerg Med. 1997;14
:366
–369
[Abstract/Free Full Text] - Doyle CJ, Post H, Burney RE, Maino J, Keefe M, Rhee KJ. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16 :673 –675[CrossRef][Web of Science][Medline]
- Redley B, Hood K. Staff attitudes towards family presence during resuscitation. Accid Emerg Nurs. 1996;4 :145 –151[CrossRef][Medline]
- Wolfram RW, Turner ED, Philput C. Effects of parental presence during young children's venipuncture. Pediatr Emerg Care. 1997;13 :325 –358[CrossRef][Web of Science][Medline]
- Powers KS, Rubenstein JS. Family presence during invasive procedures in the pediatric intensive care unit.
Arch Pediatr Adolesc Med. 1999;153
:955
–958
[Abstract/Free Full Text] - Sacchetti A, Lichenstein R, Carraccio CA, Harris RH. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care. 1996;12 :268 –271[Web of Science][Medline]
- Fein JA, Ganesh J, Alpern ER. Medical staff attitudes toward family presence during pediatric procedures. Pediatr Emerg Care. 2004;20 :224 –227[CrossRef][Web of Science][Medline]
- Eichhorn DJ, Meyers TA, Guzzetta CE. Family presence during resuscitation: it is time to open the door. Capsule and comments. Crit Care Nurs. 1995;3 :8 –13
- Meyers TA, Eichhorn DJ, Guzzetta CE. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs. 1998;24 :400 –405[CrossRef][Medline]
- Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation. Am J Nurs. 2000;100 :32 –43[Web of Science][Medline]
- Belanger MA, Reed S. A rural community hospital's experience with family-witnessed resuscitation. J Emerg Nurs. 1997;23 :238 –239[CrossRef][Medline]
- Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, Egleston CV, Prevost AT. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352 :614 –617[CrossRef][Web of Science][Medline]
- Rattrie E. Witnessed resuscitation: good practice or not? Nurs Stand. 2000;14 :32 –35[Medline]
- Adams S, Whitlock M, Higgs R, Bloomfield P, Baskett PJ. Should relatives be allowed to watch resuscitation?
BMJ. 1994;308
:1687
–1692
[Free Full Text] - Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department's nine-year perspective. J Emerg Nurs. 1992;18 :104 –106[Medline]
- Sacchetti A, Paston C, Carraccio C. Family members do not disrupt care when present during invasive procedures. Acad Emerg Med. 2005;12 :477 –479[CrossRef][Web of Science][Medline]
- Mangurten J, Scott SH, Guzzetta CE, et al. Effects of family presence during resuscitation and invasive procedures in a pediatric emergency department. J Emerg Nurs. 2006;32 :225 –233[CrossRef][Web of Science][Medline]
- Sacchetti A, Carraccio C, Leva E, Harris RH, Lichenstein R. Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience. Pediatr Emerg Care. 2000;16 :85 –87[CrossRef][Web of Science][Medline]
- O'Brien MM, Creamer KM, Hill EE, Welham J. Tolerance of family presence during pediatric cardiopulmonary resuscitation: a snapshot of military and civilian pediatricians, nurses, and residents. Pediatr Emerg Care. 2002;18 :409 –413[CrossRef][Web of Science][Medline]
- Sola JE, Scherer LR, Haller JA Jr, Colombani PM, Papa PA, Paidas CN. Criteria for safe cost-effective pediatric trauma triage: prehospital evaluation and distribution of injured children. J Pediatr Surg. 1994;29 :738 –741[CrossRef][Web of Science][Medline]
- Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med. 1981;9 :672 –676[Web of Science][Medline]
- Rydman RJ, Roberts RR, Albrecht GL, Zalenski RJ, McDermott M. Patient satisfaction with an emergency department asthma observation unit. Acad Emerg Med. 1999;6 :178 –183[Web of Science][Medline]
- Tsai E. Should family members be present during cardiopulmonary resuscitation? N Engl J Med. 2002;13 :1019 –1021
- Trout A, Magnusson R, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say? Acad Emerg Med. 2000;7 :695 –709[Web of Science][Medline]
- Offord RJ. Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation? Intensive Crit Care Nurs. 1998;14 :288 –293[CrossRef][Medline]
- Brown JR. Letting the family in during a code. Legally, it makes good sense. Nursing. 1989;19 :46[Medline]
- Forster H, Schwartz J, Derenzo E. Reducing legal risk by practicing patient-centered medicine.
Arch Intern Med. 2002;162
:1217
–1219
[Free Full Text] - The American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, O'Malley P, Brown K, Mace SE. Patient- and family-centered care and the role of the emergency physician providing care to a child in the emergency department.
Pediatrics. 2006;118
:2242
–2244
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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