DISTRESS IN CAREGIVERS ACCOMPANYING PATIENTS TO AN EMERGENCY DEPARTMENT: A SCOPING REVIEW

Screening Two authors (TR, DM) screened abstracts in tandem. One hundred and twenty-seven abstracts, including 17 records identified by review of full-text citation lists were screened. Thirteen disagreements were reconciled. Fifty-five records were advanced to full-text screening.


INTRODUCTION
Studies have shown that caregivers (e.g., partners, children, and parents) of patients in many inpatient settings, including intensive care units (ICUs) and hospital wards, experience significant objective and subjective distress during and after a patient's stay (1-6).
Research suggests that accompanying a loved one to an emergency department (ED) is similarly distressing, particularly when resuscitation or painful procedures ensue, notably in pediatric patients (7). The impact of family presence during resuscitations has been a topic of interest (8). In additional to the ethical obligation to provide comfort and patient-and family-centered care, growing emphasis is being placed on consumer satisfaction in the ED; it is reasonable to expect that families' experience can have an influence on this increasingly important metric (9). Such factors have motivated development of interventions to mitigate distress, including aromatherapy, ambient lighting, and storytelling (10-12).
A 2003 review yielded insights about caregiver needs, but was conducted by a single reviewer and limited to critically ill patients (13). An updated, broad review is indicated. Our scoping review sought to map primary research on the subject of caregiver distress in the ED, and to identify key concepts underpinning the research area (14,15). We surveyed the quantity, research RECEIVED: 27 January 2017; ACCEPTED: 24 March 2017 questions, methodologies, and populations of existing research. Such a map may guide future research by informing the selection of research questions, designs, and interventions.

Study Design
Scoping reviews aim to map the literature on a topic or research area by identifying key concepts, gaps, and types of evidence to inform practice, policymaking, and research (16). No consensus definition or procedure exists (14,15). We modeled our approach after Arksey and O'Malley's iterative six-stage process, which has been widely adopted. We elected to omit the optional sixth stage (consultation exercise) (15-17).
A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 flow diagram depicts stages 2 and 3, including reasons for exclusion (18).

STAGE 1: IDENTIFYING THE RESEARCH QUESTION
Based on an informal literature review, we posed the following question: ''What are the objectives, methodologies, interventions, populations and presentations of interest, limitations, and directional findings of primary research regarding distress in caregivers of ED patients?''

STAGE 3: STUDY SELECTION
Study selection consisted of title screening, abstract screening, and full-text screening using a priori criteria. The same criteria were used for each phase. Reasons for exclusion at each level are displayed in Figure 1.

Inclusion Criteria
Population of study includes caregivers. ''Caregiver'' includes a parent, child, partner, spouse, loved one, or other family member accompanying a patient in the ED at any point before discharge or transfer to another care setting.
Study discusses caregiver distress. ''Distress'' includes subjective or objective anxiety, stress, worry, fear, or similar phenomena as experienced by caregivers.
Study is set in an emergency department. ''Emergency department'' includes any facility specializing in emergency medicine, and excludes, for example, family practices, walk-in clinics, and ICUs.

Exclusion Criteria
Not in English Published before 1980 Invalid study type (not primary research; abstracts) Duplicate Setting was not an ED (as defined here already) Study population did not include at least one caregiver (as defined here already) Study did not discuss caregiver distress (as defined here already)

Title Screening
One author (TR) screened 2121 titles. One hundred and ten records were advanced to abstract screening.

Abstract Screening
Two authors (TR, DM) screened abstracts in tandem. One hundred and twenty-seven abstracts, including 17 records identified by review of full-text citation lists were screened. Thirteen disagreements were reconciled. Fifty-five records were advanced to full-text screening.

Full-Text Screening
Two authors (TR, DM) screened 55 studies in tandem. Citation lists of all full-text studies were reviewed for additional records. Seven disagreements were reconciled. Reasons for exclusion are displayed in Figure 1. Twenty-nine studies were included (10-12,19-44).

STAGE 4: DATA EXTRACTION
Two authors (DM, AM) extracted descriptive information from the 29 included studies in tandem, as well as