A Randomized, Controlled Trial of Bedside Versus Conference-Room Case Presentation in a Pediatric Intensive Care Unit

Design

Every child admitted to the PICU after October 2004 was eligible for the study. The 7-bed unit of general pediatric tertiary care center, without transplant or cardiac surgery, admits between 400 and 600 patients a year. The study began with the first case presentation after the patient's admission to the PICU. To be eligible, the patient had to be hospitalized for a minimum of 48 hours in the PICU so that he could have 2 different case presentations on 2 consecutive mornings. Both case presentations had to be performed in the presence of the same resident, pediatrician, and parent. Every child admitted in a medicolegal context (eg, shaken infant) and those with a diagnosis or a suspicion of brain death or an imminent death within 48 hours after the beginning of the research project were excluded. Every child was subject to both types of case presentation. A computer-generated randomization was made on the first round: BCP or CRCP (Fig 1). Randomization was made by block for every pediatrician participating in the study. Only the parents were blinded to the types of case presentation.

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FIGURE 1

Randomization flowchart.

Case Presentation

BCP was a clinical case presentation performed by the resident to the attending pediatrician in the child's and parents' presence. This presentation usually included the history, physical examination, and test results, as well as the treatment plan proposed by the resident. Any information asked by the parents about the illness or the prognosis could be answered by the resident or the attending pediatrician. The attending physician was allowed to ask additional questions to the family or the resident on any part of the presentation and to do some teaching.

CRCP was the same type of presentation performed in the absence of the child and of the child's parents. The parents were not aware that the presentation was under way. It was performed at the doctors' desk at a reasonable distance from the beds. After the presentation, the pediatrician was allowed to reassess parts of history or physical examination. All patients and parents had a wrap-up session after CRCP.

After every presentation, parents and residents had to fill out a questionnaire. Parental consent was obtained (and child's assent if possible). Consent of all the residents was obtained at the beginning of the research project. The institutional review board of the Centre Hospitalier Universitaire de Sherbrooke approved this research project.

Questionnaires

Both questionnaires (parent and resident) were constructed from patients, parents, and physicians satisfaction questionnaire,^9,11–27 and from research on patient-physician communication,^28–30 bedside teaching,^3,31,32 and parents' experience in the PICU.^33,34 The parent questionnaire was validated with 2 pediatricians working in the PICU and 2 parents of a child who was recently hospitalized in PICU. The resident questionnaire was validated with 2 pediatricians and 2 residents in training in the PICU. Both questionnaires were self-administered.

The day-1 parent questionnaire included demographic questions and 28 questions to answer on a 100-mm linear scale not graduated and without intermediary descriptor (0 = completely disagree and 100 = completely agree). The questionnaire was divided into 5 subjects: satisfaction (2 questions), understanding (5 questions), elements related to the case presentation (13 questions), staff (4 questions), and bedside versus conference-room preference (4 questions). A 29th multiple-choice question asked parents to identify the type of case presentation that they thought they had that morning. The day-2 questionnaire repeated all 29 questions from the day-1 questionnaire, and 2 questions with multiple choices were added. The first one asked parents whether they noticed a difference between case presentations on each day. A second one asked their preference between bedside and conference room (both were briefly described).

The day-1 resident questionnaire included demographic questions and 25 questions on the same scale. The questionnaire was divided into 4 subjects: satisfaction and comfort of the resident (4 questions), elements of case presentation (12 questions), performance (2 questions), and satisfaction or comfort for the patient (7 questions). The day-2 questionnaire repeated all 25 questions from the questionnaire on the first day. A multiple-choice question on their preference between bedside and conference room was added.

For the nominal variables with normal distribution, we opted for the paired Student's t test. We used Statview 5.0 for Windows (SAS Institute, Inc, Cary, NC).

Demography

Twenty-two patients (17 boys) were recruited. Twenty-one mothers and 10 fathers answered the day-1 questionnaire. Nineteen mothers and 8 fathers answered the day-2 questionnaire. Thus, only the 27 parents that answered the 2 questionnaires were analyzed; 13 in the group that began with BCP and 14 in the group that began with CRCP. A total of 21 questionnaires were answered by 10 different residents (9 women) on both days. Ten were in the group that began with BCP, and 11 were in the other group.

Three pediatricians participated in 3, 11, and 8 patient case presentations. Seven children were <1 year, 8 between 1 and 3 years, and 7 >3 years. Eight children had a previous hospitalization, and 7 were hospitalized twice or more. Six patients had previously been admitted in PICU.

Parents were 19 to 46 years old (median: 31 years). Eleven parents had a university diploma. Eight families earned more than $60000.

Residents were 22 to 31 years old (median: 24 years). Four were first-year pediatric residents, 4 were in the second year, 1 in the third year, and 1 in the fifth year.

Parents' Questionnaire

By comparing all BCP with all CRCP, parents' satisfaction was higher during BCP (96 vs 92; P = .0016; Table 1). Asking for the next case presentation, 81% of the parents desired that it be performed at the bedside. Table 1 lists some elements surveyed by the questionnaires.

To the question “I prefer when the doctors discuss my child in front of me and also give me the news of the day,” the mean parents' agreement was 95. To the question “I prefer when the doctors discuss my child at a distance (far from the bed, in my absence) and come to give me news afterward,” the mean parents' agreement was 15. Preference for bedside was statistically significant (P < .0001).

To the question “I am comfortable when the pediatrician does his teaching to the resident at the bedside (near my child and near me),” the mean parents' agreement was 89. To the question “I prefer that the pediatrician does his teaching to the resident at a distance (far from the bed, in my absence),” the mean parents' agreement was 19. Preference for bedside was statistically significant (P < .0001).

Several elements scored significantly higher for BCP when we compared both types of presentation on day 1. The parents better understood what the doctor said to them (96 vs 86; P = .016) and felt that confidentiality and intimacy were more respected (97 vs 86; P = .007) for BCP. The parents perceived that more of their questions were answered (97 vs 91; P = .013) and that the time spent with them was enough (96 vs 87; P = .016) for BCP. In addition, parents felt that their child was more respected (97 vs 93; P = .016) and that their problem was taken more seriously (98 vs 94; P = .026). They also felt that information about the tests performed was better (97 vs 89; P = .05) and was the same with treatment plan (97 vs 89; P = .04). To the question “The doctors told me all that I wanted to know about the current condition of my child” BCP scored 97 vs 92 for CRCP (P = .02). Parents found the resident to be more competent during BCP (98 vs 92; P = .04). On the other hand, residents felt more competent during CRCP (75 vs 56; P = .017) on the same day.

Parents who began with BCP were not more satisfied with CRCP the second day (96 vs 95). Those who began with CRCP scored significantly higher for BCP the next day (96 vs 90; P = .0005).

Residents' Questionnaire

By comparing all BCP with all CRCP, there was no difference in the residents' satisfaction (79 vs 76; Table 2) nor in their comfort giving the actual case presentation (80 vs 78; Table 2). Residents were, on the other hand, significantly more comfortable asking questions and being asked questions during CRCP (see Table 2). Asking for the next case presentation, 19% of resident answered that they would prefer BCP with the parents present, 14% preferred BCP without the parents, 10% preferred CRCP, and 57% did not have a preference. Table 2 lists some elements surveyed by the questionnaires.

Residents were afraid that BCP would be more disturbing for the patient (20 vs 9; P = .048; Table 2) or the patient's family (13 vs 7; P = .009; Table 2). By comparing all BCPs with CRCPs, there was no difference in the perception of disturbance to the patient (12 vs 10) or the patient's family (7 vs 7) after each case presentation. The residents found BCP more beneficial for the patient (68 vs 45; P = .0006; Table 2) and they perceived the parents more satisfied during BCP (83 vs 69; P = .017; Table 2).

There was no difference between BCP and CRCP for the residents' comfort in presenting the different parts of the clinical case (history, physical examination, plan) and for the perception of the teaching received on the physical examination, diagnosis, management, and fundamental sciences.