PEDIATRICS Vol. 120 No. 4 October 2007, pp. e777-e782 (doi:10.1542/peds.2006-3442)
ARTICLE |
Lumbar Puncture Success Rate Is Not Influenced by Family-Member Presence
Division of Emergency Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OVERVIEW. The presence of a family member during invasive pediatric procedures such as lumbar puncture has been shown to reduce patient anxiety. However, family presence might also affect clinicians’ stress and anxiety, with uncertain consequences for procedural success.
OBJECTIVE. Our goal was to evaluate the association between family-member presence and lumbar puncture success rates.
DESIGN/METHODS. We performed a prospective cohort study of all children who underwent a lumbar puncture in a single pediatric emergency department between July 2003 and January 2005. The presence of a family member was documented by the physician who performed the lumbar puncture. Success rates were assessed by using 2 main outcomes: (1) the rate of traumatic (cerebrospinal fluid red blood cells 
10000 cells per µL) or unsuccessful lumbar puncture (no cerebrospinal fluid sent for cell counts) and (2) the number of lumbar puncture attempts. Multivariate analyses were adjusted for patient age, race, time of day, physician experience, use of local anesthetic, catheter stylet removal, and patient movement during the procedure.
RESULTS. Of the 1474 eligible lumbar punctures, 1459 (99%) were included in the analysis. A family member was present for 1178 (81%) of the procedures studied. A total of 1267 (87%) lumbar punctures were nontraumatic, and 192 (13%) were traumatic or unsuccessful. Neither the rate of traumatic or unobtainable lumbar punctures nor the number of lumbar puncture attempts differed based on whether a family member was present for the procedure.
CONCLUSIONS. The presence of a family member was not associated with an increased risk of traumatic or unobtainable lumbar puncture, nor was it associated with more attempts at the procedure. The benefits of having a family member present during the procedure were not counterbalanced by adverse effects on procedural success.
Key Words: family members • parental presence • lumbar puncture • traumatic • children
Abbreviations: CSF—cereobrospinal fluid • LP—lumbar puncture • RBC—red blood cell • IQR—interquartile range • OR—odd ratio • CI—confidence interval
Family-member presence for invasive procedures in children is increasingly encouraged.1 Studies have consistently shown that family members prefer to remain with their children during painful procedures.2–7 The presence of a family member seems to decrease anxiety for both the child and the parent.4,8,9
Physicians have traditionally been more ambivalent about family-member presence during invasive pediatric procedures. Recent surveys have identified an increase in staff willingness to consider having a family member present for invasive pediatric procedures.10,11 However, many physicians have concerns regarding decreased procedural success, increased anxiety for the parent, the potential for family-member interference, and increased risk of litigation.4,10 The impact of family-member presence on procedural success rates has not been widely studied.
We prospectively studied >1400 children who underwent a lumbar puncture (LP) in a pediatric emergency department to directly observe current practices around family-member presence and to investigate the relationship between family-member presence and LP success rates.
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METHODS |
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Study Design
We prospectively evaluated all LPs performed during a 19-month period (July 2003 through January 2005) in the emergency department of Children's Hospital Boston. Physicians were asked to complete a questionnaire immediately after performing an LP. To facilitate data collection, study forms were attached to LP kits used in the emergency department. Receipt of study forms was compared with a daily log of cerebrospinal fluid (CSF) specimens received by the laboratory for quality assurance. Children who presented to the emergency department more than once during the study period were included separately for each visit in which an LP was performed. Details of study methodology have been described previously.12
All physicians who were working in the emergency department during the study period were asked to participate in the study. Of the 340 physician participants, there were 71 (21%) pediatric emergency medicine fellows or staff physicians, 19 (5%) general pediatricians, 148 (44%) pediatric residents, and 102 (30%) emergency medicine residents. Written informed consent was obtained from all physicians who participated in the study. LPs performed by consultants (neurologists or neurosurgeons) were not included (n = 16; 1% of all LPs).
Data Collection
The physician who first attempted the LP completed the data form. The physician recorded whether 1 or more family members were present for the procedure (yes or no). Although family-member presence during invasive procedures was generally encouraged, the decision whether to have the family member present or absent for the procedure was left to the discretion of the treating clinician, the family member, and the patient (when applicable).
The physician who performed the LP recorded his or her level of training (resident, fellow, or attending). The following factors were recorded on a structured data sheet: clinical indication for the LP; use of local anesthetic (injected lidocaine and/or eutectic mixture of local anesthetics; stylet placement as the catheter advanced into the subarachnoid space ("stylet-in" versus "stylet-out"); patient movement during the procedure (least to most movement on a 5-point scale); and number of LP attempts. Medical charts were reviewed to determine patient age, gender, time of procedure, and patient disposition. Time of day recorded was dichotomized into day (8 AM to 8 PM) and night (8 PM to 8 AM). Emergency department registration records were reviewed to determine race, which was categorized as white, black, or other. Results of CSF studies were obtained from a computerized laboratory database.
Outcome Measures
We studied the association between the presence of a family member and LP success rates. We defined 2 primary outcomes to assess procedural success: (1) rate of traumatic or unsuccessful LPs and (2) number of LP attempts.
We considered an LP to be successful if CSF was obtained and the fluid obtained was nontraumatic (CSF red blood cells [RBCs] < 10000 cells per µL). Conversely, we considered an LP to be unsuccessful if no CSF was obtained or if the fluid that was obtained was traumatic (CSF RBCs 10000 cells per µL).12,13 We used the results of the CSF, which was sent to the laboratory for analysis, regardless of the number of attempts required to obtain the fluid.
We also defined LP success by the number of procedural attempts required, because multiple LP attempts subject the patient to additional discomfort. The physician who performed the procedure recorded the number of attempts. Each time the spinal needle penetrated the skin was considered a separate attempt, whereas redirecting the spinal needle without exiting the skin was considered a single attempt.
Statistical Methods
The relationship between patient and physician factors and family-member presence during the LP was assessed by using univariate 
2 testing. Multiple logistic regression was used to examine the association of family-member presence and risk of traumatic or unsuccessful LP, adjusting for other important covariates that were felt to be clinically related to LP success: patient age (dichotomized as <1 vs 1 year), patient race, time of day, level of physician training, use of local anesthetic, catheter stylet position, and patient movement (dichotomized as least movement [1, 2, or 3 on 5-point scale] versus most movement [4 or 5]. Given the distribution of LP attempts observed in our sample (discrete right skew), Poisson regression was used to examine the relationship between family-member presence and the number of LP attempts, adjusted for the same covariates. Because of the potential association of patient age with both family-member presence and LP success rates, we performed multivariate analysis stratified by age (<1 vs 1 year).
Statistical analysis was performed by using both SPSS14 and the SAS system for Windows.15
The study was approved by the institutional review board of Children's Hospital Boston.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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A total of 1459 (99%) of the 1474 eligible LPs were included in the study (Fig 1). Forty-three patients (3%) had multiple LPs during the study period. The median patient age was 3 months (interquartile range [IQR]: 1–7 years). Fifty-five percent of the patients were male. Sixty-two percent of the patients were admitted to the hospital. Most children had an LP performed to evaluate for the possibility of meningitis (n = 1100 [75% of all LPs performed]). Other clinical indications included seizure (172 [12%]), evaluation for increased intracranial pressure (85 [6%]), mental status change (54 [4%]), acute life-threatening events (16 [1%]), ataxia (14 [1%]), demyelinating disorder (9 [0.7%]), subarachnoid hemorrhage (6 [0.4%]), and other (3 [0.2%]).
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A family member was present for 1178 (81%) of the LPs performed. The presence or absence of a family member did not differ by patient race (white, black, or other), time of day (day or night), level of physician training (resident, fellow, or attending), or patient movement (still or moving) (Table 1). In addition, family-member presence was not associated with catheter stylet removal. Family members were more likely to be present for LPs performed on children 1 year of age or older and for LPs in which local anesthetic was used.
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Of the 1459 included LPs, 1267 (87%) were nontraumatic, 106 (7%) were traumatic (CSF RBCs
10000 cells per µL), and 86 (6%) yielded no CSF for cell counts. Eighty-seven percent of the LPs performed with a family member present were successful (nontraumatic CSF obtained) compared with 84% of LPs performed without a family member present. After adjusting for clinically significant covariates, LP success rates did not differ on the basis of the presence of a family member (adjusted odds ratio [OR] for family member present versus not present: 0.9 [95% confidence interval (CI): 0.6–1.4]; P = .69) (Table 2).
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The number of attempts for each child who underwent an LP ranged from 1 to 6. The majority of patients had 1 LP attempt: 981 (67%) procedures required a single attempt, 241 (17%) 2 attempts, 122 (8%) 3 attempts, 60 (4%) 4 attempts, 40 (3%) 5 attempts, and 15 (1%) 6 attempts (Fig 2). The mean number of LP attempts was 1.6 (±1.1 SD) for procedures performed with a family member present and 1.7 (±1.2) with a family member absent. The number of attempts did not differ by family-member presence after multivariate adjustment (adjusted OR of means for family member present to not present: 0.95 [95% CI: 0.87–1.04]; P = .26).
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A higher proportion of LPs performed on infants <1 year old were unsuccessful compared with older children (18% <1 year vs 6% in children
1 year). After adjusting for clinically relevant covariates, LP success rate did not differ on the basis of family-member presence for either children <1 year (adjusted OR: 0.9 [95% CI: 0.6–1.4] or 1 year of age (adjusted OR: 1.0 [95% CI: 0.4–2.7]). The proportion of patients who required >1 LP attempt did not differ based on family-member presence for either children <1 year (34% for family member present vs 34% for family member absent; P = .97) or 1 year (30% for family member present vs 37% for family member absent; P = .17). |
DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Despite increasing evidence that parents wish to be present for invasive procedures performed on their children,5,7 acceptance of family presence is highly variable among providers.10,11,16–18 Interference with procedure success is a frequently cited concern among emergency staff members who argue against routine family-member presence for pediatric procedures.3,4,11,16–18 Few studies, however, have examined actual procedure outcomes with respect to family presence.4,8,19 In our large cohort of children who underwent LP in a pediatric emergency department, we found that the presence of a family member did not adversely affect procedural success rates. The rate of traumatic or unsuccessful LP, as well as the number of LP attempts, did not differ on the basis of family-member presence or absence for the procedure.
Several survey-based studies have demonstrated that a "hierarchy of invasiveness" exists with respect to both parents’ desire to be present and providers’ acceptance of family-member presence for procedures. In 1 survey of 645 pediatric physicians and nurses, the overwhelming majority (nearly 90%) supported family presence for minimally invasive procedures such as intravenous catheter placement and laceration repair, whereas far fewer (30%–40%) supported the practice for resuscitations.16 Another survey of 104 pediatric emergency physicians and nurses found a similar trend, with >90% of clinicians supporting family presence for intravenous catheter placement, bladder catheterization, and laceration repair. Support for family presence for more-invasive procedures decreased to 64% for LP and decreased even further for the most invasive procedures such as endotracheal intubation (28%) and resuscitation (32%).11 Other surveys of pediatric providers have confirmed this hierarchy, and LP resides somewhere between minimally invasive procedures such as venipuncture and laceration repair, and maximally invasive procedures such as intubation, chest tube placement, and cardiopulmonary resuscitation.3,11,18,20
Despite this widespread clinician reluctance to support routine family presence for increasingly invasive procedures, surveys of parents have indicated that even for the most invasive of procedures, parents wish to be present. One survey of 400 parents in an emergency department presented 5 hypothetical scenarios including venipuncture, laceration repair, LP, intubation, and resuscitation, and asked parents whether they would wish to be present for these procedures for their children. The overwhelming majority of parents wished to be present. Even for the most invasive procedures, including resuscitation, the majority of parents wished to be present (70% if the child was unconscious, 80% if the child was conscious, and 83% if the child was likely to die).5 Another survey of 553 parents in an emergency department waiting room in Australia reported similar findings, in which 94% of parents wished to stay for venipuncture, 83% wished to stay for LP, and 85% wished to stay for resuscitation.7 Although these studies were limited by the hypothetical nature of the scenarios, other observational studies that assessed family member opinions after actually having been present for a procedure reported similar findings. In 1 observational study of family-member presence for procedures including more-invasive procedures such as LP, rapid sequence induction, and resuscitation, the majority of physicians (93%) and family members (91%) thought that family-member presence for the procedure was a "good idea" when surveyed after the completion of the procedure.6
Performance anxiety leading to an unsuccessful procedure is a frequently cited disadvantage for routine family-member presence.11,16,18,21 This is particularly so with respect to less-frequently performed and more-invasive procedures such as LP.17 However, data from the few studies that have examined the validity of this concern demonstrate no difference in the successful performance of a procedure. A randomized, controlled trial of 431 patients who underwent venipuncture, intravenous catheter placement, or bladder catheterization demonstrated no difference in number of procedure attempts or ultimate procedure success when a parent was present or absent.4 Even for highly invasive procedures, such as endotracheal intubation, chest tube placement, or central line placement performed in an ICU, no difference in procedure success was found between 2 groups in which a parent was either present or absent.11
We know of only 1 study that attempted to answer the question of whether parent presence impedes the successful performance of an LP.19 In this study, parents of 57 children that underwent LP were randomly assigned to be present or absent for the procedure. Although the primary outcome was family-member anxiety after the procedure was performed, it is notable that there was no statistical difference between the groups with respect to number of LP attempts required.19 Our study provides further evidence that the number of LP attempts does not differ on the basis of family-member presence or absence. In addition, our study demonstrates that the overall rate of traumatic or unsuccessful LP is not affected by family-member presence, which further supports the notion that family-member presence does not hinder LP success rates.
Our study has several limitations. First, our study was observational, and parents were not randomly assigned to be present or absent for the LP; this decision was left to the parent and the physician who performed the procedure. Therefore, we could only look for an association between family-member presence and procedural success and are unable to prove a cause-and-effect relationship. Second, we did not collect data on the number of family members present or their level of involvement during the procedure. In addition, although we asked the physician performing the procedure to indicate whether a family member was present, we did not specifically ask the parent whether they would have preferred to be present for the procedure. We also did not collect physician or parent information regarding their comfort or anxiety level with the procedure. Finally, we relied on the log of specimens received by the hospital laboratory to track LPs performed, but we could not ensure complete study-form completion for LPs when no CSF was obtained. However, an audit of 1 week of pediatric emergency department medical charts at the study institution demonstrated complete capture of LPs performed.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Overwhelming data suggest that family members wish to be present for invasive procedures performed on their children, which is supported by evidence that their presence is psychologically beneficial for both the parent and child. However, concerns that the procedure success will be hampered by family-member presence remain widely cited. This study suggests that even for an invasive and often-frightening procedure (an LP), the presence of a family member does not increase either the frequency of traumatic or unsuccessful LPs or the number of attempts at the procedure. Therefore, family-member presence should not be discouraged because of concerns that this presence would impede successful performance of the procedure. A recent Institute of Medicine report highlighted the importance of patient-centered care.22 Encouraging family-member presence during invasive procedures in children may help to achieve that goal.
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ACKNOWLEDGMENTS |
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We thank Richard Bachur, MD, for contributions to the study design and critical review of the manuscript and Patrick Johnston, MMath, for assistance with statistical analyses.
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FOOTNOTES |
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Accepted Mar 3, 2007.
Address correspondence to Lise E. Nigrovic, MD, MPH, Division of Emergency Medicine, 300 Longwood Ave, Children's Hospital Boston, Boston, MA 02115. E-mail: lise.nigrovic{at}childrens.harvard.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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