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Original Investigation |

Family Presence During Pediatric Tracheal Intubations Online Only

Ronald C. Sanders Jr, MD, MS1; Sholeen T. Nett, MD, PhD2; Katherine Finn Davis, PhD, RN3; Margaret M. Parker, MD4; G. Kris Bysani, MD5; Michelle Adu-Darko, MD6; Geoffrey L. Bird, MD, MSIS7; Ira M. Cheifetz, MD, FCCM8; Ashley T. Derbyshire, MSN, RN, PNP-AC9; Guillaume Emeriaud, MD, PhD10; John S. Giuliano Jr, MD11; Ana Lia Graciano, MD12; Yusuke Hagiwara, MD13; Glenda Hefley, RN, MNSc1; Takanari Ikeyama, MD13; J. Dean Jarvis, RN, MBA2; Pradip Kamat, MD, MBA14; Ashwin S. Krishna, MD15; Anthony Lee, MD16; Jan Hau Lee, MBBS, MRCPCH, MCI17; Simon Li, MD18; Keith Meyer, MD19; Vicki L. Montgomery, MD, FCCM20; Yuki Nagai, MD13; Matthew Pinto, MD18; Kyle J. Rehder, MD8; Osamu Saito, MD13; Asha N. Shenoi, MD15; Hester Christianne Taekema, MD, MSc21; Keiko M. Tarquinio, MD22; Ann E. Thompson, MD23; David A. Turner, MD8; Vinay M. Nadkarni, MD24; Akira Nishisaki, MD, MSCE24 ; for the National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
[+] Author Affiliations
1Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Little Rock
2Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
3Center for Pediatric Nursing Research and Evidence Based Practice, Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
4Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children’s Hospital, Stony Brook, New York
5Pediatric Acute Care Associates of North Texas PLLC, Medical City Children’s Hospital, Dallas
6University of Virginia Children’s Hospital, Charlottesville
7Division of Cardiac Critical Care Medicine, Department of Pediatrics and Anesthesia/Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
8Division of Critical Care, Department of Pediatrics, Duke Children’s Hospital, Durham, North Carolina
9Penn State Hershey Children’s Hospital, Hershey, Pennsylvania
10Sainte-Justine University Hospital Center, Montreal, Quebec, Canada
11Yale University School of Medicine, New Haven, Connecticut
12Pediatric Critical Care Medicine, Children’s Hospital of Central California, Fresno
13Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
14Department of Pediatrics, Emory University School of Medicine, Children’s Hospital of Atlanta, Atlanta, Georgia
15Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children’s Hospital, University of Kentucky School of Medicine, Lexington
16Nationwide Children’s Hospital, Ohio State University, Columbus
17KK Women’s and Children’s Hospital, Singapore
18Pediatric Intensive Care Unit, Maria Fareri Children’s Hospital, Westchester, New York
19Division of Critical Care Medicine, Miami Children’s Hospital, Miami, Florida
20Division of Critical Care, Department of Pediatrics, University of Louisville and Kosair Children’s Hospital, Louisville, Kentucky
21Starship Hospital, Auckland, New Zealand
22Critical Care Medicine, Rhode Island/Hasbro Children’s Hospital, Providence
23Critical Care Medicine and Pediatrics, Pittsburgh Children’s Hospital, Pittsburgh, Pennsylvania
24Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
JAMA Pediatr. 2016;170(3):e154627. doi:10.1001/jamapediatrics.2015.4627.
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Importance  Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated.

Objective  To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs.

Design, Setting, and Participants  Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs.

Exposures  Family presence and no FP during TI in the PICU.

Main Outcomes and Measures  The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level.

Results  A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders.

Conclusions and Relevance  Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.

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