Pediatrics/original research
The Effect of Family Presence on the Efficiency of Pediatric Trauma Resuscitations

Presented at the Pediatric Academic Societies' 2007 annual meeting, May 2007, Toronto, Ontario, Canada.
https://doi.org/10.1016/j.annemergmed.2008.10.002Get rights and content

Study objective

Family presence has broad professional organizational support and is gaining acceptance. We seek to determine whether family presence prolonged pediatric trauma team resuscitations as measured by time from emergency department arrival to computed tomographic (CT) scan, and to resuscitation completion.

Methods

A prospective trial offered families of pediatric trauma patients family presence on even days and no family presence on odd days. Primary outcome measures were time from arrival to CT scan and to resuscitation completion (laboratory tests, emergency procedures, portable radiographs, and secondary survey). We evaluated the effect of family presence in an adjusted Cox proportional hazards model. Staff and family experiencing a resuscitation with family presence were asked their opinions of that experience.

Results

Of 1,229 pediatric trauma activations, 705 patients were included in the study protocol, 283 with family presence on even days, 422 without family presence on odd days. Median times to CT scan (21 minutes; IQR 16 to 29 minutes) and median resuscitation times (15 minutes; IQR 10 to 20 minutes) were similar with and without family presence. There was no clinically relevant difference in CT time (hazard ratio 1.04; 95% confidence interval [CI] 0.83 to 1.30) or resuscitation time (hazard ratio 0.98; 95% CI 0.83 to 1.15). Families believed that family presence was helpful both to their child and themselves.

Conclusion

This prospective trial shows that family presence does not prolong time to CT imaging or to resuscitation completion for pediatric trauma patients. Family presence does not negatively affect the time efficiency of the pediatric trauma resuscitation.

Introduction

Family presence, introduced in the medical literature in 1987,1 is defined as “the attendance of family members in a location that affords visual or physical contact with the patient during invasive procedures or resuscitation.”2 Structured family presence programs provide written guidelines, education of staff, training for family support persons, and opportunity for feedback and evaluation. Family support for family presence is well documented.3, 4, 5, 6, 7 Organizational support includes the Emergency Nurses Association, American College of Emergency Physicians (ACEP), American Academy of Pediatrics (AAP), National Association of Emergency Medical Technicians, and the American Heart Association.8, 9, 10, 11, 12 A statement supported by ACEP and the AAP recommends the option of family presence for all aspects of emergency care.13

Support for family presence is not universal. A survey of trauma surgeons concluded that family presence during all aspects of the trauma resuscitation was inappropriate.14 One concern raised is that family will distract the trauma team, increasing stress, resulting in performance problems that affect care or prolong a resuscitation.14 A survey of health care providers found that 15% believed that family presence was associated with longer resuscitation efforts.3 Most pediatric trauma does not require immediate operative intervention, and many patients have computed tomographic (CT) imaging performed after the initial resuscitation. Prolonged resuscitation may delay patient movement to CT scan, and we believed the time from arrival to CT scanning (CT time) would be a good measure of the efficiency of the resuscitation. Because not all patients require CT, we used resuscitation time (time to completion of all laboratory testing, emergency procedures, portable radiographs and secondary survey) as another measure of resuscitation efficiency. Resuscitation delays could affect patient outcomes and need to be studied before family presence policies are implemented. Studying pediatric patients is important because families are increasingly allowed to witness procedures in the emergency department (ED) and accompany children during transport. Extending family presence into the trauma area may be indicated if it does not affect patient care.

We sought to focus our investigation on trauma care provided during the initial evaluation in the ED. We hypothesized that family presence does not prolong the resuscitation for pediatric trauma patients. Our study objective was to compare pediatric trauma resuscitations with and without family presence and evaluate the effect of family presence on CT time and resuscitation time.

Section snippets

Study Design and Setting

This was a single-center, prospective trial in the ED at a freestanding American College of Surgeons Level 1 pediatric trauma center with an annual ED census of 45,000 pediatric patients. The institutional review board at the University of Utah approved the study protocol, and written informed consent was obtained from staff before study initiation. Informed consent was waived for trauma registry data. Family members offered family presence gave verbal consent before entering the trauma room,

Results

A total of 1,229 pediatric trauma activations occurred during the study period, 623 on even days and 606 on odd days for the intention-to-treat analysis (light grey shading, Figure 1). On even days, 8 children had family available but family presence was either not offered or declined, and many patients did not have available family. On odd days, family presence status could not be verified on some charts (99), and 68 families were offered family presence at parent request. Twenty-seven records

Limitations

Our study was not randomized or blinded, introducing bias in patient enrollment. Prestudy education and agreement by all services involved attempted to eliminate caregiver bias. Children with family presence in our protocol were, however, less severely injured than those without family presence. We believe this is largely due to their mode of transport. Unstable patients and those with more severe injuries are transported quickly; usually by helicopter.17 Parents may not accompany their child

Discussion

We designed our study to evaluate the effect of a new family presence program on the efficiency of pediatric trauma resuscitations. Our results demonstrate that resuscitation time and CT time for patients with and without family presence are similar, concluding that when family presence is offered in a structured program, there is no significant effect on the efficiency of the trauma resuscitation. A previously published study, by O'Connell et al,19 did not identify any differences in time to

References (22)

  • National Association of EMTs. Guidelines for providing family-centered prehospital care (2001). Available at:...
  • Cited by (85)

    • Physician well-being: Special considerations in pediatrics

      2019, Current Problems in Pediatric and Adolescent Health Care
      Citation Excerpt :

      Strong partnership between parents and the health care team facilitate conditions that aid in healing and recovery of both the ill child and her entire family unit. There has been growing recognition of the importance of including parents in the health care team during advanced procedures, ranging from daily rounds to CPR.13-15 Increasingly, families of sick or injured children are viewed as an integral part of the care team, and interacting with family members can multiply the sense of satisfaction in the doctor-patient relationship.

    • Clinical Practice Guideline: Family Presence

      2019, Journal of Emergency Nursing
    • Family presence during resuscitation: A concise narrative review

      2017, Trends in Anaesthesia and Critical Care
    View all citing articles on Scopus

    Provide feedback on this article at the journal's Web site, www.annemergmed.com.

    Supervising editors: Michael W. Shannon, MD; Steven M. Green, MD

    Author contributions: NCD conceived the study. KLVW provided her knowledge of family presence and the literature to the creation of the family presence program. NCD, KWH, RAF, and ERS solicited the cooperation of staff and the hospital in this endeavor. NCD, KWH, and RAF designed the trial. NCD obtained research funding. KLVW created the education program for staff and educated family support persons and staff about family presence. NCD, KWH, and ERS supervised the conduct of the trial and data collection. KWH managed the data and provided quality control for the trauma registry. RAF provided statistical advice and provided his knowledge of trauma scoring systems to the analysis and article. NCD and AED analyzed the data. AED reviewed the data analysis and performed the regression analysis. NCD drafted the article, and all authors contributed substantially to its revision. NCD takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by a grant from the Primary Children's Medical Center Foundation.

    Reprints not available from the authors.

    Publication date: Available online November 14, 2008.

    View full text