Jill Chorney

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.

Behavioral Analysis of Children's Response to Induction of Anesthesia

BACKGROUND: It is documented that children experience distress at anesthesia induction, but little is known about the prevalence of specific behaviors exhibited by children. METHOD: Digital audiovisual recordings of 293 children undergoing outpatient elective surgery were coded using Observer XT software and the validated Revised Perioperative Child-Adult Medical Procedure Interaction Scale. Multiple pass second-by-second data recording was used to capture children’s behaviors across phases of anesthesia induction. RESULTS: More than 40% of children aged 2–10 yr displayed some distress behavior during induction with 17% of these children displaying significant distress and more than 30% of children resisting anesthesiologists during induction. Children’s distress and nondistress behaviors displayed four profiles over the course of anesthesia induction: Acute Distress, Anticipatory Distress, Early Regulating Behaviors, and Engagement with Procedure. Older children had higher scores on early regulating and engagement profiles whereas younger children had higher scores on Acute Distress. There were no differences across age in children’s Anticipatory Distress. Construct validity of behavior profiles was supported via correlations of profile score (overall and on the walk to the operating room) with a validated assessment of children’s anxiety at induction. CONCLUSIONS: Children undergoing anesthesia display a range of distress and nondistress behaviors. A group of behaviors was identified that, when displayed on the walk to the operating room, is associated with less distress at anesthesia induction. These data provide the first examination of potentially regulating behaviors of children, but more detailed sequential analysis is required to validate specific functions of these behaviors.

Healthcare Provider and Parent Behavior and Children's Coping and Distress at Anesthesia Induction

Background:To date, no study has evaluated the impact of specific healthcare provider and parent behaviors on children’s distress and coping during anesthesia induction. Method:Extensive digital video data were collected on 293 two- to ten-yr-old children undergoing anesthesia induction with a parent present. Anesthesiologist, nurse, and parent behavior and children’s distress and coping were coded using the Revised Preoperative Child–Adult Medical Procedure Interaction Scale administered using specialized coding software. Results:Anesthesiologists and parents engaged in higher rates of most behaviors than nurses. Overall, adult emotion-focused behavior such as empathy and reassurance was significantly positively related to children’s distress and negatively related to children’s coping behaviors. Adult distracting behavior such as humor and distracting talk showed the opposite pattern. Medical reinterpretation by anesthesiologists was significantly positively related to children’s coping behaviors, but the same behavior by parents was significantly positively related to children’s distress. Conclusions:The data presented here provide evidence for a relation between adult behaviors and children’s distress and coping at anesthesia induction. These behaviors are trainable, and hence it is possible to test whether modifying physician behavior can influence child behavior in future studies.

Family-centered pediatric perioperative care.

FAMILY-CENTERED care is an approach to the planning and delivery of health care that is based on partnerships among patients, families, healthcare providers, and hospitals. Family-centered care encourages a collaborative, team approach that respects individual and family strengths, cultures, traditions, and expertise. Providing care in a family-centered way honors the involvement of the patient, family, and informal caregivers and improves outcomes by encouraging communication among all stakeholders, enhancing coordination and promoting integration of medical care. Despite the attention to family-centered care in specialties such as pediatrics, neonatology, and emergency medicine, there has been very little integrated literature on this unique approach to patient care in anesthesiology. Although there are studies within the field that may fall into the general rubric of family-centered care, guidelines and policy statements have not been developed. Thus, the purpose of this Clinical Concept and Commentary article is to promote the philosophy of family-centered care in anesthesiology by providing a practical and clinically relevant model of delivering pediatric perioperative care in a family-centered manner. The basic message is that families are an integral part of the perioperative care team and should be treated as such. Efforts should be made to establish collaborations by openly communicating, developing a shared vision for the care of the child, and building a cohesive care team that includes healthcare providers and family members throughout the perioperative period.

Streamed Video Clips to Reduce Anxiety in Children During Inhaled Induction of Anesthesia

BACKGROUND:Anesthesia induction in children is frequently achieved by inhalation of nitrous oxide and sevoflurane. Pediatric anesthesiologists commonly use distraction techniques such as humor or nonprocedural talk to reduce anxiety and facilitate a smooth transition at this critical phase. There is a large body of successful distraction research that explores the use of video and television distraction methods for minor medical and dental procedures, but little research on the use of this method for ambulatory surgery. In this randomized control trial study we examined whether video distraction is effective in reducing the anxiety of children undergoing inhaled induction before ambulatory surgery. METHODS:Children (control = 47, video = 42) between 2 and 10 years old undergoing ambulatory surgery were randomly assigned to a video distraction or control group. In the video distraction group a video clip of the child’s preference was played during induction, and the control group received traditional distraction methods during induction. The modified Yale Preoperative Anxiety Scale was used to assess the children’s anxiety before and during the process of receiving inhalation anesthetics. RESULTS:All subjects were similar in their age and anxiety scores before entering the operating rooms. Children in the video distraction group were significantly less anxious at induction and showed a significantly smaller change in anxiety from holding to induction than did children in the control group. CONCLUSIONS:Playing video clips during the inhaled induction of children undergoing ambulatory surgery is an effective method of reducing anxiety. Therefore, pediatric anesthesiologists may consider using video distraction as a useful, valid, alternative strategy for achieving a smooth transition to the anesthetized state.

Preoperative anxiety in adolescents undergoing surgery: a pilot study

Objectives:  The purpose of this study was to conduct a prospective assessment of preoperative anxiety in adolescents undergoing surgery.

Time-Window Sequential Analysis: An Introduction for Pediatric Psychologists

OBJECTIVE Pediatric psychologists are often interested in interactions among individuals (e.g., doctors and patients, parents and children). Most research examining the nature of these interactions has used correlational analyses. Sequential analysis provides greater detail on contingencies during interactions and the way that interactions play out over time. The purpose of this article is to offer a non-technical introduction to sequential analyses for pediatric psychologists. METHODS A more recent derivation of the basic method, called time-window sequential analysis, is introduced and distinguished from other forms of sequential analysis. RESULTS A step-by-step pediatric psychology example of time-window sequential analysis is provided and the integration of sequential analysis with traditional statistical methods is discussed. An example of physician-child interaction during anesthesia induction is used to illustrate the technique. CONCLUSION Sequential analysis is a technique that is useful to pediatric psychologists who are interested in contingencies among data collected over time.

Adult-child interactions in the postanesthesia care unit: behavior matters.

Background:Many children experience significant distress before and after surgery. Previous studies indicate that healthcare providers’ and parents’ behaviors may influence children’s outcomes. This study examines the influence of adults’ behaviors on children’s distress and coping in the postanesthesia care unit. Methods:Children aged 2–10 yr were videotaped during their postanesthesia care unit stay (n = 146). Adult and child behaviors were coded from video, including the onset, duration, and order of behaviors. Correlations were used to examine relations between behaviors, and time-window sequential statistical analyses were used to examine whether adult behaviors cued or followed children’s distress and coping. Results:Sequential analysis demonstrated that children were significantly less likely to become distressed after an adult used empathy, distraction, or coping/assurance talk than they were at any other time. Conversely, if a child was already distressed, children were significantly more likely to remain distressed if an adult used reassurance or empathy than they were at any other time. Children were more likely to display coping behavior (e.g., distraction, nonprocedural talk) after an adult used this behavior. Conclusions:Adults can influence children’s distress and coping in the postanesthesia care unit. Empathy, distraction, and assurance talk may be helpful in keeping a child from becoming distressed, and nonprocedural talk and distraction may cue children to cope. Reassurance should be avoided when a child is already distressed.

Understanding Shared Decision Making in Pediatric Otolaryngology

Objective The aim of this study was to describe the level of decisional conflict experienced by parents considering surgery for their children and to determine if decisional conflict and perceptions of shared decision making are related. Study design Prospective cohort study. Setting Academic pediatric otolaryngology clinic. Subjects and methods Sixty-five consecutive parents of children who underwent surgical consultation for elective otolaryngological procedures were prospectively enrolled. Participants completed the Shared Decision Making Questionnaire and the Decisional Conflict Scale. Surgeons completed the Shared Decision Making Questionnaire–Physician version. Results Eleven participants (16.9%) scored over 25 on the Decisional Conflict Scale, a previously defined clinical cutoff indicating significant decisional conflict. Parent years of education and parent ratings of shared decision making were significantly correlated with decisional conflict (positively and negatively correlated, respectively). A logistic regression indicated that shared decision making but not education predicted the presence of significant decisional conflict. Parent and physician ratings of shared decision making were not related, and there was no correlation between physician ratings of shared decision making and parental decisional conflict. Conclusions Many parents experienced considerable decisional conflict when making decisions about their child’s surgical treatment. Parents who perceived themselves as being more involved in the decision-making process reported less decisional conflict. Parents and physicians had different perceptions of shared decision making. Future research should develop and assess interventions to increase parents’ involvement in decision making and explore the impact of significant decisional conflict on health outcomes.

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.