Healthcare provider-child-parent communication in the preoperative surgical setting

A Mobile Application for Child-Focused Tonsillectomy Education: Development and User-Testing

OBJECTIVE

Patient education is central to Enhanced Recovery After Surgery protocols, but child-focused materials are lacking. We developed and piloted a mobile application to support accessible, interactive patient and caregiver education about pediatric tonsillectomy.

METHODS

Thirty children ages 5-12 who were preparing for tonsillectomy, their caregivers, and six attending otolaryngologists participated in a user-testing trial of a web-based prototype. The trial measured feasibility, fidelity, and patient-centered outcomes. Patients and caregivers rated usability/likeability on the mHealth App Usability Questionnaire. Otolaryngologists rated quality on the Mobile App Rating Scale. The full mobile application, "Ready for Tonsillectomy," was then developed for iOS and Android.

RESULTS

Enrollment was 88.2%, retention was 90.0%, and use was 96.3%. Mean (SD) patient ratings for usability/likeability were 6.3 (1.1) out of 7; caregiver ratings were 6.5 (1.1). In common themes from open-ended feedback, patients described the application as helpful and appealing, and caregivers described it as informative, easy to understand, calming, and easy to use. Among caregivers who used the application during recovery, 92.3% reported that it helped them manage their child's pain. Providers would recommend the application to many or all of their patients (mean [SD]: 4.7 [0.5] out of 5). Mean provider ratings for domains of engagement, functionality, aesthetics, information quality, subjective quality, and app-specific value ranged from 4.1 to 4.8 out of 5.

CONCLUSION

Feasibility and fidelity were high. Families and otolaryngologists endorsed the resource as an engaging, informative tool that supports positive coping. Our mobile application offers a patient-centered solution readily scalable to other surgeries.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2455-2463, 2024.

Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate

OBJECTIVE

Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families.

DESIGN

Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure.

SETTING

Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital.

PARTICIPANTS

Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care.

RESULTS

ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety.

CONCLUSIONS

Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Family risk communication preferences in pediatric surgery: A scoping review

BACKGROUND

Effective patient-surgeon communication is vital in pediatric surgical practice. However, family (including child) preferences for the format and content of risk communication information are largely unknown. In order to optimize the shared-decision making process, this scoping review explored the family-preferred methods for risk communication in pediatric surgery.

METHODS

A search was conducted in 7 databases from inception until June 2020 to identify family risk communication preferences in pediatric surgical patients, with language restricted to English and French. Two independent reviewers completed the screening in Rayyan software following PRISMA protocol. Included publications were reviewed for data extraction, analyzed, and assessed for risk of bias using standardized instruments.

RESULTS

A total of 6370 publications were retrieved, out of which 70 were included. Studies were predominantly from ENT (30.0%), general surgery (15.7%), and urology (11.4%). Family-preferred risk communication methods were classified as visual, verbal, technology-based, written, decision aids or other. Technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods. Written tools were frequently used in general surgery and urology, while technology-based tools were widely used in ENT. Most studies were cross-sectional and had a significant risk of bias.

CONCLUSION

Eliciting families' preferences for risk communication methods is critical for the implementation of shared decision-making. Different risk communication media appear to be preferred within specific surgical domains. To further improve shared-decision making in pediatric surgery, the development and usage of robust, validated risk communication tools are necessary.

LEVEL OF EVIDENCE

Level IV (Scoping Review).

Role of information and preparation for improvement of pediatric perioperative care

The perioperative period is a significant and stressful experience that may cause negative consequences in children, both in a short-term and long-term perspective. Despite a wide base of evidence stating the importance of adequate preparation to reduce anxiety, improve coping, cooperation and enhance recovery, many children continue to report that they feel unprepared for their perioperative experience. To secure children's right to request and need for preparation, the content, format, and availability of existing programs need to be scrutinized. Preparation programs in perioperative care must change from simply providing information to embracing the importance of children's need to process the information provided in order to learn and understand. Interactive web-based technology can function as a significant resource for preparation of children for perioperative procedures. By changing perspective from children's need for information to their need for learning and by developing preparation programs including adequate educational principles, web-based technology can be used to its fullest advantage as a healthcare learning and preparation resource.

Parental Expression of Emotions and Surgeon Responses During Consultations for Obstructive Sleep-Disordered Breathing in Children

Importance

Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations.

Objective

To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types.

Design, Setting, and Participants

This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019.

Main Outcomes and Measures

Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences.

Results

A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98).

Conclusions and Relevance

This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.

Reducing Children's Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial

OBJECTIVE

Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies.

STUDY DESIGN

Prospective randomized controlled trial.

SETTING

Pediatric outpatient surgery center.

METHODS

Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction.

RESULTS

In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's d effect size = 0.94; P < .001). Intervention patients also expected less pain than control patients from the anesthesia mask and during surgery (d = 0.60-0.80; P < .001). The book encouraged more positive views of the procedure and preoperative explanations (P < .005). Furthermore, the book prepared patients to cope adaptively: intervention patients were significantly more likely to generate positive active coping strategies, distraction strategies, and support-seeking strategies (P < .001). Observer-rated behavioral anxiety at anesthesia induction did not differ between groups (P = .75). Caregivers in the intervention group were significantly more satisfied with each aspect of the surgical experience (P≤ .02).

CONCLUSION

The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at ClinicalTrials.gov (NCT04796077).

The interplay between children, their parents and anaesthesia staff during the child's anaesthesia - An observational study

AIMS AND OBJECTIVES

To interpret and understand the interplay between children, their parents, and anaesthetic staff to gain a greater understanding of children being anaesthetised.

BACKGROUND

Anaesthesia induction is a stressful procedure for the child and parents in the technologically advanced environment in the operating room (OR). Anaesthesia staff are a key resource for ensuring safety and interplays, but the meeting is often short, intensive, and can affect the child and the parent.

DESIGN

A qualitative observational design with a hermeneutic approach.

METHODS

Twenty-seven non-participant observations were conducted and videotaped when children were being anaesthetised. The SRQR checklist was used.

RESULTS

The result is presented as a theatre play with three headings; the scene, the actors, and the plot. The scene was not designed for the child or the parent's comfort and could lead to anxiety and insecurity. Four themes described the interplays: The need to be inviting and to be invited, The need for varying compliance, The need for mutual dependence, and The need to give and to receive emotional support. The plot could lead to uncertainty, and the interplay could change between being caring and uncaring depending on the actors.

CONCLUSIONS

The technologically advanced environment in the OR constituted an emotional obstacle, but the anaesthesia staff themselves can be a powerful resource creating a caring environment. The outcome of the plot may depend on the anaesthesia staff's bearing.

RELEVANCE TO CLINICAL PRACTICE

A caring approach in the OR requires a willingness from the anaesthesia staff to invite the child to participate and find a balance between helping the parents to find their place in the OR and support them in supporting their child. The findings can start reflections in the unit on how to create a more caring environment.

Factors impacting parental and child satisfaction in the perioperative setting

Understanding the different modifiable and non-modifiable factors and their positive or negative influence on parental and child satisfaction is essential to providing high-quality perioperative care. The purpose of this review is to focus on the perioperative environment and to report the various modifiable and non-modifiable factors that are associated with satisfaction. We found that factors such as quality of clinician-patient communication, clinician attitudes, teamwork, shared decision-making, and improved perioperative information were associated with increased parent and child satisfaction. Interventions such as preparation programs integrating role-play, teaching of coping skills, and family-centered programs were highly rated by parents and children. Healthcare providers and institutions should consider the above variables when treating children and their parents in the perioperative setting.

Nurse anesthetist attitudes towards parental presence during anesthesia induction- a nationwide survey

AIMS

To describe nurse anesthetists' attitudes towards the importance of parental presence during their child's anaesthesia induction and to explore associating factors.

DESIGN

A cross-sectional design.

METHODS

Nurse anesthetists from 55 Swedish hospitals were asked to participate (n = 1,285). A total of 809 completed the questionnaire, Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) during 2018. Data were analysed by descriptive statistics and multiple linear regression analysis.

RESULTS

Nurse anesthetists generally had a positive attitude towards the importance of parental presence. They reported a more positive attitude in family as a resource in nursing care (median = 40) followed by family as a conversational partner (median = 25), family not as a burden (median = 17) and family as its own resource (median = 13). Multiple linear regression analyses showed that working in a district hospital, working only with children, having routines/memorandum about parental presence, being a woman, allowing both parents to be present in their child's anaesthesia and greater experience of children's anesthesia, were associated with a more positive attitude.

CONCLUSION

This nationwide survey contributes important knowledge for understanding nurse anesthetists' attitudes and the result shows that nurse anesthetists generally have a positive attitude towards the importance of parents. Areas of improvement were, however, identified; the nurses tend to not value family as its own resource and family as a conversational partner highly.

IMPACT

Nurse anesthetists have a crucial role in children's anesthesia care since the quality of parental presence experience depends on a positive attitude from the nurses. Parental involvement is important to establish a child-centered anaesthesia care, which should be highlighted in the education of nurse anesthetists. Parental involvement should also be addressed in healthcare policies and routines should be established.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Practice horizons in pediatric nonoperating room anesthesia

PURPOSE OF REVIEW

Anesthesia outside the operating room is rapidly expanding for adult and pediatric patients. Anesthesia clinicians practicing in this area need a good understanding of the challenges of the NORA environment and the anesthetic risks and perioperative implications of practice so that they can deliver safe care to their patients.

RECENT FINDINGS

Recent reports from large patient databases have afforded anesthesiologists a greater understanding of the risk of NORA when compared to anesthesia in the operating room. Descriptions of advances in team training with the use of simulation have allowed the development of organized procedural teams. With an emphasis on clear communication, an understanding of individual roles, and a patient-centered focus, these teams can reliably develop emergency response procedures, so that critical moments are not delayed in an environment remote from usual assistance.

SUMMARY

With appropriate attention to organizational concerns (i.e. team environment, safety protocols) and unrelenting focus on patient safety, anesthesiologists can assist in safely providing the benefit of cutting-edge technical advancements to pediatric patients in these challenging environments.

Gaze-Height and Speech-Timing Effects on Feeling Robot-Initiated Touches

This paper reports the effects of communication cues on robot-initiated touch interactions at close distance by focusing on two factors: gaze-height for making eye contact and speech timing before and after touches. Although both factors are essential to achieve acceptable touches in human-human touch interaction, their effectiveness remains unknown in human-robot touch interaction contexts. To investigate the effects of these factors, we conducted an experiment whose results showed that being touched with before-touch timing is preferred to being touched with after-touch timing, although gaze-height did not significantly improve the feelings of robot-initiated touch.

Survey of Social Touch Interaction Between Humans and Robots

In human-human interaction, social touch provides several merits, from both physical and mental perspectives. The physical existence of robots helps them reproduce human-like social touch, during their interaction with people. Such social touch shows positive effects, similar to those observed in human-human interaction. Therefore, social touch is a growing research topic in the field of human-robot interaction. This survey provides an overview of the work conducted so far on this topic.

Informed Consent in Pediatric Anesthesia: A Narrative Review

Informed consent for pediatric anesthesia challenges practitioners to navigate complex ethical, medical, and legal ambiguities. A patient's status as a minor does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced evaluation of age and development to involve the patient to an appropriate extent. Given the complexities involved with pediatric informed consent in anesthesia practice and research, it is important to understand the experience of key stakeholders involved. For this review, we searched Medline, the Cochrane database, PROSPERO, and Clinicaltrials.gov for studies involving pediatric anesthesia informed consent. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data were extracted from included studies: title, authors, date of publication, study type, intervention, data collection method, participant type (ie, parent, pediatric patient, anesthesia provider), number of participants, pediatric patient age range, and primary outcome measures. Twenty-two articles were included for final review: studies of informed consent in pediatric anesthesia span many aspects of informed consent. Parental understanding has been studied most often (7/22 studies), followed by parental preferences (5/22 studies) and provider-related outcomes (5/22 studies) such as time spent interacting with patients, subjective reporting on amount of training related to informed consent, and provider satisfaction with the informed consent process. Outcomes pertaining to pediatric patients themselves constitute the smallest number of studies, including child anxiety (1/22), child understanding (1/22), and child refusal (1/22). Among the parties involved, parents have been most frequently identified as the subjects of these studies (2719/3805 subjects across all included studies, or 71% of all subjects). Pediatric patients are the least frequently involved subjects of studies that investigate informed consent in pediatric anesthesia (493/3805, or 13% of all subjects). Anesthesia providers and investigators have been study subjects (593/3805, or 16% of all subjects) for a range of topics including time spent interacting with patient, nature of informed consent conversation in relation to trainee status, satisfaction with informed consent process, and priorities for informed consent content. The aim of the present narrative review is to summarize the work that has been done on informed consent for pediatric anesthesia.

Analyzing communication skills of Pediatric Postgraduate Residents in Clinical Encounter by using video recordings

Objective

To analyze communication skills of pediatric postgraduate residents in clinical encounter by using video recordings.

Methods

This qualitative exploratory research was conducted through video recording at The Children's Hospital Lahore, Pakistan. Residents who had attended the mandatory communication skills workshop offered by CPSP were included. The video recording of clinical encounter was done by a trained audiovisual person while the resident was interacting with the patient in the clinical encounter. Data was analyzed by thematic analysis.

Results

Initially on open coding 36 codes emerged and then through axial and selective coding these were condensed to 17 subthemes. Out of these four main themes emerged: (1) Courteous and polite attitude, (2) Marginal nonverbal communication skills, (3) Power game/Ignoring child participation and (4) Patient as medical object/Instrumental behaviour. All residents treated the patient as a medical object to reach a right diagnosis and ignored them as a human being. There was dominant role of doctors and marginal nonverbal communication skills were displayed by the residents in the form of lack of social touch, and appropriate eye contact due to documenting notes. A brief non-medical interaction for rapport building at the beginning of interaction was missing and there was lack of child involvement.

Conclusion

Paediatric postgraduate residents were polite while communicating with parents and child but lacking in good nonverbal communication skills. Communication pattern in our study was mostly one-way showing doctor's instrumental behaviour and ignoring the child participation.

The perspective of children on factors influencing their participation in perioperative care

AIMS AND OBJECTIVES

To describe the experiences of participation in perioperative care of 8- to 11-year-old children.

BACKGROUND

All children have the right to participate in decisions that affect them and have the right to express their views in all matters that concern them. Allowing children to be involved in their perioperative care can make a major difference in terms of their well-being by decreasing fear and anxiety and having more positive experiences. Taking the views of children into account and facilitating their participation could thus increase the quality of care.

DESIGN

Descriptive qualitative design.

METHODS

The study was conducted in 2013 and data were collected by narrative interviews with 10 children with experience from perioperative care in Sweden. Qualitative content analysis was chosen to describe the variations, differences and similarities in children's experiences of participation in perioperative care.

RESULTS

The result showed that receiving preparatory information, lack of information regarding postoperative care and wanting to have detailed information are important factors for influencing children's participation. Interaction with healthcare professionals, in terms of being listened to, being a part of the decision-making and feeling trust, is important for children's participation in the decision-making process. Poor adaptation of the care environment to the children's needs, feeling uncomfortable while waiting and needs for distraction are examples of how the environment and the care in the operating theatre influence the children's experiences of participation.

CONCLUSIONS

Efforts should be made to improve children's opportunities for participation in the context of perioperative care and further research is needed to establish international standards for information strategies and care environment that promotes children's participation in perioperative care.

RELEVANCE TO CLINICAL PRACTICE

Nurse anaesthetists need to acquire knowledge and develop strategies for providing preparatory visits and information to children prior to surgery as well as reducing waiting times and creating environments with meaningful and tailored opportunities for distraction in perioperative care.

Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): development

BACKGROUND

As a result of cost-containment efforts, preparation programs for outpatient surgery are currently not available to the majority of children and parents. The recent dramatic growth in the Internet presents a unique opportunity to transform how children and their parents are prepared for surgery. In this article, we describe the development of a Web-based Tailored Intervention for Preparation of parents and children undergoing Surgery (WebTIPS).

DEVELOPMENT OF PROGRAM

A multidisciplinary taskforce agreed that a Web-based tailored intervention consisting of intake, matrix, and output modules was the preferred approach. Next, the content of the various intake variables, the matrix logic, and the output content was developed. The output product has a parent component and a child component and is described in http://surgerywebtips.com/about.php. The child component makes use of preparation strategies such as information provision, modeling, play, and coping skills training. The parent component of WebTIPS includes strategies such as information provision, coping skills training, and relaxation and distraction techniques. A reputable animation and Web design company developed a secured Web-based product based on the above description.

CONCLUSIONS

In this article, we describe the development of a Web-based tailored preoperative preparation program that can be accessed by children and parents multiple times before and after surgery. A follow-up article in this issue of Anesthesia & Analgesia describes formative evaluation and preliminary efficacy testing of this Web-based tailored preoperative preparation program.

Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): formative evaluation and randomized controlled trial

BACKGROUND

The purpose of this 2-phase project was to conduct a formative evaluation and to test the preliminary efficacy of a newly developed Web-based Tailored Intervention for Preparation of parents and children undergoing Surgery (WebTIPS).

METHODS

Phase 1 enrolled 13 children 2 to 7 years of age undergoing outpatient elective surgery and their parents for formative evaluation of WebTIPS. Parent participation focus groups are common in qualitative research and are a method of asking research participants about their perceptions and attitudes regarding a product or concept. In phase 2, children 2 to 7 years of age in 2 medical centers were assigned randomly to receive the WebTIPS program (n = 38) compared with children receiving the standard of care (n = 44). The primary outcome of phase II was child and parent preoperative anxiety.

RESULTS

In phase 2, parents reported WebTIPS to be both helpful (P < 0.001) and easy to use (P < 0.001). In phase 2, children in the WebTIPS group (36.2 ± 14.1) were less anxious than children in the standard of care group (46.0 ± 19.0) at entrance to the operating room (P = 0.02; Cohen d = 0.59) and introduction of the anesthesia mask (43.5 ± 21.7 vs 57.0 ± 21.2, respectively, P = 0.01; Cohen d = 0.63). Parents in the WebTIPS group (32.1 ± 7.4) also experienced less anxiety compared with parents in the control group (36.8 ± 7.1) in the preoperative holding area (P = 0.004; Cohen d = 0.65).

CONCLUSIONS

WebTIPS was well received by parents and children and led to reductions in preoperative anxiety.

Treating perioperative anxiety and pain in children: a tailored and innovative approach

Millions of children undergo outpatient surgery in the United States each year; the overwhelming majority will experience significant perioperative anxiety and pain. Behavioral preparation programs focused on skills acquisition and modeling, considered essential for effective preparation, are no longer offered to most children and families in the outpatient surgery setting. Moreover, what little preparation does occur is typically generic in nature, rather than tailored to unique characteristics of the child and family. Untreated anxiety and pain have significant implications for children's short- and long-term recovery and future interactions in the medical environment. The rapid growth of the World Wide Web and increasing access to Internet by families across the country provide an opportunity to develop tailored, Web-based behavioral preparation programs that can be accessed repeatedly at times convenient to the child and family, that include coping skills training and modeling, and that can provide unique output based upon child and parent characteristics known to impact perioperative pain and anxiety. In this review article, we present a conceptual framework for a computer-based intervention that may transform the way we manage children and parents before and after surgery.

Development of a short version of the modified Yale Preoperative Anxiety Scale

BACKGROUND

The modified Yale Preoperative Anxiety Scale (mYPAS) is the current "criterion standard" for assessing child anxiety during induction of anesthesia and has been used in >100 studies. This observational instrument covers 5 items and is typically administered at 4 perioperative time points. Application of this complex instrument in busy operating room (OR) settings, however, presents a challenge. In this investigation, we examined whether the instrument could be modified and made easier to use in OR settings.

METHODS

This study used qualitative methods, principal component analyses, Cronbach αs, and effect sizes to create the mYPAS-Short Form (mYPAS-SF) and reduce time points of assessment. Data were obtained from multiple patients (N = 3798; Mage = 5.63) who were recruited in previous investigations using the mYPAS over the past 15 years.

RESULTS

After qualitative analysis, the "use of parent" item was eliminated due to content overlap with other items. The reduced item set accounted for 82% or more of the variance in child anxiety and produced the Cronbach α of at least 0.92. To reduce the number of time points of assessment, a minimum Cohen d effect size criterion of 0.48 change in mYPAS score across time points was used. This led to eliminating the walk to the OR and entrance to the OR time points.

CONCLUSIONS

Reducing the mYPAS to 4 items, creating the mYPAS-SF that can be administered at 2 time points, retained the accuracy of the measure while allowing the instrument to be more easily used in clinical research settings.

Patient Satisfaction in Pediatric Surgical Care

Objective

This study seeks to synthesize evidence-based findings related to patient satisfaction as a process measure in pediatric surgical care.

Data Sources

PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials.

Review Methods

We queried 4 standard search engines (1992-2013) for studies specific to pediatric surgical fields in which patient or parent satisfaction or experience of care was a primary outcome measure. Data were systematically analyzed to determine study characteristics, setting, parent or patient focus, measure of experience, and bias. Two independent investigators independently reviewed all articles.

Results

The initial search yielded 4748 publications (1503 duplicates), of which 170 underwent full-text review. Thirty-five were included for analysis; the majority (24/35,77%) were published in the last 5 years. Studies examined experience of the child (3/35), parent (23/35), or both (9/35). Experience and satisfaction were evaluated either by validated self-assessment instruments (8), by satisfaction tools (8), or by nonstandard institutional or author-developed tools (19). Experience was measured in the outpatient (7), preoperative (11), operative (14), and postoperative (3) care settings. Specific findings were unique to setting; however, in many studies higher satisfaction correlated with education/information giving, health care provider interpersonal behaviors, and facile/efficient care processes.

Conclusion

The patient experience of care is a valuable quality measure that is being more frequently evaluated as a mechanism to improve pediatric surgical care processes. Findings related to patient satisfaction and experience of care may be limited due to lack of measurement using validated tools. Findings from this review may bear significance as patient experience measures become routinely integrated with quality and reimbursement.

A systematic review of surgeon-patient communication: strengths and opportunities for improvement

OBJECTIVE

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon-patient communication.

METHODS

Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits.

RESULTS

2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy.

CONCLUSION

Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills.

PRACTICE IMPLICATIONS

These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care.

Illness uncertainty and quality of life in children with cancer

BACKGROUND

Illness uncertainty is prevalent in children with cancer and has been associated with increased psychological distress. The relationship between illness uncertainty and quality of life in pediatric cancer patients remains unclear. The aim of the present study was to examine illness uncertainty as a predictor of health-related quality of life in children diagnosed with cancer. It was hypothesized that child-reported illness uncertainty would be negatively associated with child health-related quality of life.

PROCEDURE

Children aged 8 to 18 years old and receiving treatment for cancer were recruited to participate in this study. One hundred twenty children and their parent(s) completed measures of illness uncertainty, pain, anxiety, and quality of life during a routine visit to the Cancer Center at Children's Hospital of Orange County.

RESULTS

Illness uncertainty was significantly associated with child age (P=0.02), overall health-related (P<0.001) and cancer-related (P<0.001) quality of life, but not with treatment status (on/off chemotherapy) or demographic variables including sex and household income. Regression analyses statistically controlling for age, anxiety, and pain revealed that illness uncertainty significantly predicted child-reported cancer-related and health-related quality of life (P<0.01) as well as parent-reported cancer-specific quality of life (P<0.01).

CONCLUSIONS

Illness uncertainty is prevalent and associated with lower quality of life in children diagnosed with cancer. Improved communication with children regarding disease state, treatment expectations, and prognosis may alleviate uncertainty and improve functioning in this vulnerable patient population.

Analysing a family-centred preoperative intervention programme: a dismantling approach

BACKGROUND

The goal of this project was to identify key effective components of ADVANCE, a family-centred preoperative intervention programme, through the use of a dismantling approach. ADVANCE was previously demonstrated to be more effective than parental presence and just as effective as midazolam in reducing children's preoperative anxiety. The total programme, however, may be difficult to implement in hospitals across the country.

METHODS

Subjects in this follow-up dismantling report were 96 children aged 2-10 who were part of the original study and who underwent anaesthesia and surgery. Baseline characteristics, parental adherence to the components of ADVANCE, and child and parent anxiety were assessed.

RESULTS

We found that greater parental adherence to the ADVANCE intervention was associated with lower child anxiety before surgery. The two components of ADVANCE that emerged as having a significant impact on children's anxiety were practising with the anaesthesia mask at home and parental planning and use of distraction in the preoperative holding area. In fact, not only did children experience significantly less preoperative anxiety when their parents were adherent to mask practise and use of distraction, their anxiety tended to remain stable and relatively low throughout the preoperative period.

CONCLUSIONS

Shaping and exposure (i.e. practise with the anaesthesia mask) and parental use of distraction in the surgical setting are two beneficial components that could be included in preoperative preparation programmes that will be designed in the future.

Children's desire for perioperative information

BACKGROUND

The purpose of this investigation was to identify what perioperative information children want to receive from the medical staff.

METHODS

As a first step, we developed an instrument based on a qualitative study conducted with children in Great Britain, input from a focus group, and input from school children. On the day of surgery, 143 children aged 7-17 yr completed a 40-item assessment of desired surgical information and a measure of anxiety (State-Trait Anxiety Inventory for Children). Parents completed a measure assessing their child's temperament (Emotionality, Activity, Sociability, and Impulsivity Survey) and a measure of their own anxiety (State-Trait Anxiety Inventory).

RESULTS

Results indicated that the vast majority of children had a desire for comprehensive information about their surgery, including information about pain and anesthesia, and procedural information and information about potential complications. The most highly endorsed items by children involved information about pain. Children who were more anxious endorsed a stronger desire for pain information and lesser tendency to avoid information. Younger children wanted to know what the perioperative environment would look like more than adolescent children.

CONCLUSIONS

We conclude that the majority of children aged 7-17 yr who undergo surgery want to be given comprehensive perioperative information and health care providers should ensure adequate information regarding postoperative pain is provided.