Journal Club: Intubation in the presence of family

[piatkat]

On behalf of the 99nicu Team, I would like to invite you to participate in our newest initiative- a Journal Club. The objective of this club is to share and discuss articles of interest to all neonatal healthcare professionals. 

The article we chose this time (https://fn.bmj.com/content/early/2021/01/20/archdischild-2020-319709) describes the current practice regarding family presence during intubation of their infant in the NICU and examines association with the outcomes (e.g. success rate within the first attempt).

Some of the questions we would like to discuss are below. 

What is current practice on your ward?

What do you think are the strengths of this study?

What do you think are some of the limitations?

What are the key risks of “bias” in this study design- do you think that  has influenced the results? What “confounders” might there be?

Is the population similar to your own clinical area? Does this matter? 

We are looking forward to hearing your thoughts and opinions!

[Vicky Payne]

I am really excited to see what the @99nicu.orgcommunity makes of this paper, and look forward to hearing everyone's comments! 

Lets start a conversation and share examples of practice, or what we might think future practice should look like 😍

[Francesco Cardona]

On 4/9/2021 at 8:06 PM, piatkat said:

What is current practice on your ward?

We don't do it. And I believe a lot of NICU staff young and older are scared to do it. I do believe there are benefits. Though maybe not in all situations? How best to prepare?

 

[bimalc]

In my units, provider preference, though as far as I am aware we all invite families to remain with the baby. Assuming it is a controlled intubation, I do warn parents that they cannot get in the way of staff and so should remain off to the side, preferably seated, just in case they become faint or ill watching the intubation and I emphasize to them that all our attention will be on the baby and if they think they will become a distraction to the team that they may want to go for a walk or sit in the waiting room instead. I would say 75-80% of families say they'll step out and wait for us to get them, the rest choose to stay. It has never particularly bothered me, but I've had parents watch me perform intubation since I was an intern so it is all I've ever known.

[Vicky Payne]

On 4/12/2021 at 9:06 AM, Francesco Cardona said:

 

Do you think the evidence provided in this paper would change your practice @Francesco Cardona?

@bimalc  makes a good point about parent choice and options- has anyone asked them (parents) what impact this might have on them?

[piatkat]

54 minutes ago, Vicky Payne said:

 

@bimalc  makes a good point about parent choice and options- has anyone asked them (parents) what impact this might have on them?

 @Vicky Payne- this is a really good question. It has reminded me of a blog entry I "committed" some time ago- not about intubation in presence of family, but about intubation on parent's chest 🔥🔥🔥 link is here below ⬇️⬇️ Of course, the level of evidence is anecdotal, but it's just a reminder for me that the impact on parents could be related to their very unique situation in the Unit. Are they only infrequent visitors there, or maybe primary caretakers? I think that might change their perspective a lot! 

 

[Ruth]

Great idea to have a journal club. Currently although parental presence is encouraged it occurs very seldom in our units.

[M C Fadous Khalife]

I like the idea, Believe it has benefits, but I am sure it is very disturbing to my staff 

[piatkat]

5 minutes ago, M C Fadous Khalife said:

I like the idea, Believe it has benefits, but I am sure it is very disturbing to my staff 

@M C Fadous KhalifeWhat about the paper itself? How do you evaluate the evidence there?

[Stefan Johansson]

I like the underlying principal, that we shall empower and engage parents. I see the major take-home message as being how few parents were present, something that can certainly be improved. From a methodology perspective, I think there are some major limitations (I know, I take the role as Reviewer #3 now...😞

• the cohort is from 2014-7, so the findings may (hopefully!) be outdated, that more parents are present nowadays
• the association between parental presence and the lack of positive or negative impact on intubation outcomes: this may be baised by differences in who the professionals were having parents present/absent, and whom were the parents that did attend. I think both professionals and parents may have impacted the "chance to be present", this may have pushed the point estimates in various directions... i.e. the groups with no-presence vs presence may be less comparable

So I feel mostly a bit confused on a higher level, which is also not a bad thing

When I was a fellow, we always asked parents to go out before intubation, but I'd say this was for something we wanted, not be nervous by parents looking at how we succeeded. Nowadays, my own principle is that we shall do as much as possible with parents attending, of course respecting parents' own preference. I believe that fantasies are worse than reality, i.e. better to experience and "see" what is actually happening than to be told afterwards.

As @bimalc shared above, I also experience that many parents decide to leave the room when their child will be intubated. But I also had one experience some years ago, when a parent stayed at hold the infant together with a nurse, during intubation. For myself, this was an emotional experience, to see how a parent comforted so well during a rather dramatic and stressful situation for this infant. It strengthened my belief that family-centered care is the way to go.

 

[Francesco Cardona]

We have a few replies on twitter on the topic  

They can stay if they want to but it does increase the stress of junior trainees

— Joyce O'Shea (@oshea_jem) April 10, 2021

Done it a few times, with parents to patients with long stays. It has worked well, but I my opinion is that a very certain impression of the parents likely responses are needed to make sure it’s a relevant experience for them.

— J Padkær Petersen (@padkaer) April 10, 2021

[M C Fadous Khalife]

Sad because I can't even suggest it to my staff 

On 4/14/2021 at 2:28 PM, piatkat said:

@M C Fadous KhalifeWhat about the paper itself? How do you evaluate the evidence there?

 

[M C Fadous Khalife]

This study has lot of limitations: retrospective study, more chronic patients with parents obviously familiarized to their preemies problems, with video laryngoscope use and no nasal TI and only 9,4% of parents

If we distribute a questionnaire for stress to parents in acute phase immediately after delivery and later we can maybe realize it would be impossible in the first hours to have parents for suurfactant delivery and immediate care