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Figure.  Family Presence at Tracheal Intubations by Site
Family Presence at Tracheal Intubations by Site
Table 1.  Patient Characteristics Categorized by Family Presence (N = 4030)
Patient Characteristics Categorized by Family Presence (N = 4030)
Table 2.  Clinician and Practice Characteristics Along With Family Presence (N = 4030)
Clinician and Practice Characteristics Along With Family Presence (N = 4030)
Table 3.  TI Process and Outcomes Categorized by Family Presence (N = 4030)
TI Process and Outcomes Categorized by Family Presence (N = 4030)
Table 4.  Association of TI Process and Outcomes and Family Presence Adjusted for Site, Patient, and Clinician Factorsa
Association of TI Process and Outcomes and Family Presence Adjusted for Site, Patient, and Clinician Factorsa
1.
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American Association of Critical-Care Nurses. AACN practice alert: family presence during resuscitation and invasive procedures. http://www.aacn.org/wd/practice/docs/practicealerts/family-presence-during-resuscitation-invasive-procedures.pdf. Accessed November 12, 2015.
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Howlett  MS, Alexander  GA, Tsuchiya  B.  Health care providers’ attitudes regarding family presence during resuscitation of adults: an integrated review of the literature.  Clin Nurse Spec. 2010;24(3):161-174.PubMedGoogle ScholarCrossref
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Paplanus  L, Salmond  S, Jadotte  Y, Viera  D.  A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally, part I: perspectives of patients and families.  JBI Library Syst Rev. 2012;10(3):1883-2017.Google Scholar
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Egging  D, Crowley  M, Arruda  T,  et al; 2009 ENA Emergency Nursing Resource Development Committee.  Emergency nursing resource: family presence during invasive procedures and resuscitation in the emergency department.  J Emerg Nurs. 2011;37(5):469-473.PubMedGoogle ScholarCrossref
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Lederman  Z, Garasic  M, Piperberg  M.  Family presence during cardiopulmonary resuscitation: who should decide?  J Med Ethics. 2014;40(5):315-319.PubMedGoogle ScholarCrossref
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Leske  JS, McAndrew  NS, Brasel  KJ.  Experiences of families when present during resuscitation in the emergency department after trauma.  J Trauma Nurs. 2013;20(2):77-85.PubMedGoogle ScholarCrossref
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Rittenmeyer  L, Huffman  D.  How families and health care practitioners experience family presence during resuscitation and invasive procedures.  JBI Library Syst Rev. 2012;10(31):1785-1882.Google Scholar
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Sanders  RC  Jr, Giuliano  JS  Jr, Sullivan  JE,  et al; National Emergency Airway Registry for Children Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network.  Level of trainee and tracheal intubation outcomes.  Pediatrics. 2013;131(3):e821-e828.PubMedGoogle ScholarCrossref
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Nishisaki  A, Turner  DA, Brown  CA  III, Walls  RM, Nadkarni  VM; National Emergency Airway Registry for Children (NEAR4KIDS); Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network.  A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs.  Crit Care Med. 2013;41(3):874-885.PubMedGoogle ScholarCrossref
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Nishisaki  A, Ferry  S, Colborn  S,  et al; National Emergency Airway Registry (NEAR); National Emergency Airway Registry for Kids (NEAR4KIDS) Investigators.  Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit.  Pediatr Crit Care Med. 2012;13(1):e5-e10.PubMedGoogle ScholarCrossref
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Nett  S, Emeriaud  G, Jarvis  JD, Montgomery  V, Nadkarni  VM, Nishisaki  A; NEAR4KIDS Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network.  Site-level variance for adverse tracheal intubation-associated events across 15 North American PICUs: a report from the national emergency airway registry for children.  Pediatr Crit Care Med. 2014;15(4):306-313.PubMedGoogle ScholarCrossref
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Dingeman  RS, Mitchell  EA, Meyer  EC, Curley  MA.  Parent presence during complex invasive procedures and cardiopulmonary resuscitation: a systematic review of the literature.  Pediatrics. 2007;120(4):842-854.PubMedGoogle ScholarCrossref
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Robinson  SM, Mackenzie-Ross  S, Campbell Hewson  GL, Egleston  CV, Prevost  AT.  Psychological effect of witnessed resuscitation on bereaved relatives.  Lancet. 1998;352(9128):614-617.PubMedGoogle ScholarCrossref
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Bauchner  H, Waring  C, Vinci  R.  Parental presence during procedures in an emergency room: results from 50 observations.  Pediatrics. 1991;87(4):544-548.PubMedGoogle Scholar
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Sacchetti  A, Lichenstein  R, Carraccio  CA, Harris  RH.  Family member presence during pediatric emergency department procedures.  Pediatr Emerg Care. 1996;12(4):268-271.PubMedGoogle ScholarCrossref
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Boie  ET, Moore  GP, Brummett  C, Nelson  DR.  Do parents want to be present during invasive procedures performed on their children in the emergency department? a survey of 400 parents.  Ann Emerg Med. 1999;34(1):70-74.PubMedGoogle ScholarCrossref
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Powers  KS, Rubenstein  JS.  Family presence during invasive procedures in the pediatric intensive care unit: a prospective study.  Arch Pediatr Adolesc Med. 1999;153(9):955-958.PubMedGoogle ScholarCrossref
26.
Paplanus  L, Salmond  S, Jadotte  Y, Viera  D.  A systematic review of family witnessed resuscitation and family witnessed invasive procedures in adults in hospital settings internationally, part II: perspectives of healthcare providers.  JBI Library Syst Rev. 2012;10(33):2018-2294.Google Scholar
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Jarvis  AS.  Parental presence during resuscitation: attitudes of staff on a paediatric intensive care unit.  Intensive Crit Care Nurs. 1998;14(1):3-7.PubMedGoogle ScholarCrossref
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Helmer  SD, Smith  RS, Dort  JM, Shapiro  WM, Katan  BS; American Association for the Surgery of Trauma. Emergency Nurses Association.  Family presence during trauma resuscitation: a survey of AAST and ENA members.  J Trauma. 2000;48(6):1015-1022.PubMedGoogle ScholarCrossref
29.
Sacchetti  A, Carraccio  C, Leva  E, Harris  RH, Lichenstein  R.  Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience.  Pediatr Emerg Care. 2000;16(2):85-87.PubMedGoogle ScholarCrossref
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Jabre  P, Belpomme  V, Azoulay  E,  et al.  Family presence during cardiopulmonary resuscitation.  N Engl J Med. 2013;368(11):1008-1018.PubMedGoogle ScholarCrossref
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O’Connell  KJ, Farah  MM, Spandorfer  P, Zorc  JJ.  Family presence during pediatric trauma team activation: an assessment of a structured program.  Pediatrics. 2007;120(3):e565-e574.PubMedGoogle ScholarCrossref
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Nigrovic  LE, McQueen  AA, Neuman  MI.  Lumbar puncture success rate is not influenced by family-member presence.  Pediatrics. 2007;120(4):e777-e782.PubMedGoogle ScholarCrossref
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Edwards  EE, Despotopulos  LD, Carroll  DL.  Changes in provider perceptions of family presence during resuscitation.  Clin Nurse Spec. 2013;27(5):239-244.PubMedGoogle ScholarCrossref
Original Investigation
March 7, 2016

Family Presence During Pediatric Tracheal Intubations

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
Abstract

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.

Introduction

The merits of family presence (FP) during resuscitative efforts and invasive procedures have been advocated for nearly 30 years.1 The nursing community has long been a strong proponent of FP, with position statements supporting the practice from leading national organizations, such as the Emergency Nurses Association and American Association of Critical Care Nurses, with several medical organizations following suit, including the American Heart Association and the American Academy of Pediatrics.2-6 Family-centered care, which supports FP during procedures, is now a widely accepted standard at health care facilities that care for children.7

There are numerous family-, patient-, clinician-, and institution-level factors that can either hinder or facilitate inclusion of the family during procedures and/or resuscitation. Barriers to FP include concern about family interference, lack of a hospital policy, potential increase in stress for the clinicians and family, performance anxiety, and concern for litigation.8,9 Evidence supports that the emotional benefits of FP often outweigh the risks and that families should have the right to be present.9,10 Many family members want to be present during procedures and find being present comforting to themselves and the patient. These families assert they would choose to be present in the future and would recommend FP to others.11-14

The extent of FP during pediatric procedures performed in the hospital setting is not known, especially in the pediatric intensive care unit (PICU). To enhance our understanding of FP during airway management events, we evaluated the incidence of FP during tracheal intubation (TI) across multiple centers as well as the potential effect on TI performance including attempt success, occurrence of adverse TI-associated events (TIAEs), occurrence of oxygen desaturation less than 80%, and reported team stress level.

Box Section Ref ID

Key Points

  • Question: How often are families present during tracheal intubation of their children and does this affect procedure outcomes?

  • Findings: Family presence for tracheal intubation was highly variable across the 22 pediatric intensive care units studied. First attempt success rate, occurrence of any tracheal intubation–associated events, occurrence of severe tracheal intubation–associated events, multiple attempts, oxygen desaturation, and self-reported team stress level were not significantly different between the groups with and without family presence.

  • Meaning: Family presence during tracheal intubation can safely be implemented as part of a family-centered care model in the pediatric intensive care unit.

Methods

The NEAR4KIDS registry (National Emergency Airway Registry for Children) is an international multicenter collaborative, collecting TI quality and safety data across participating PICUs. Data collection has been either approved or declared exempt by the institutional review board at each of the 22 participating sites. A central institutional review board system was not used, as a central institutional review board was not uniformly accepted at all institutions at the time of study inception and data collection. The data coordinating center was approved to use the limited data set from all participating centers by the institutional review board and through data use agreements between each site and the data coordinating center. Patient consent was not obtained because the NEARKIDS registry was considered a quality-improvement project.

Each site project leader developed a site-specific compliance plan to ensure greater than 95% TI encounter capture rate and the highest accuracy of the data. Two compliance officers reviewed and approved the compliance plan for each site based on the available local resources. Prospective data collection occurs shortly after intubation by the supervising attending or fellow and includes patient demographics, process information, intubating clinician demographics, equipment used, and outcomes of the TI encounter (see the eAppendix in the Supplement for the data collection form). An illness severity score: Paediatric Index of Mortality (PIM2) was captured at the time of PICU admission.15 For each TI, an encounter was defined as 1 completed episode of advanced airway management intervention.16,17 Within each TI encounter, a course encompassed one method or approach to secure an artificial airway while an attempt was defined as a distinct advanced airway maneuver (eg, insertion of a device, such as a laryngoscope or laryngeal mask, into the patient’s mouth). Family presence was defined as 1 or more family members present at the bedside or in a patient room during any part of the TI encounter.

Inclusion/Exclusion Criteria

THE NEAR4KIDS registry data in this study included all TIs performed across 22 international PICUs from July 2010 to March 2014. Encounters in which the status of FP was documented were included. We excluded tracheal tube change or routine tracheostomy cannula change.

Definition of Outcomes

Our primary outcome of interest was the occurrence of any adverse TIAEs.16-19 Nonsevere and severe TIAEs were defined a priori. Severe TIAEs were defined as cardiac arrest with or without return of spontaneous circulation, esophageal intubation with delayed recognition (as determined by decrease in oxygen saturations via pulse oximetry), emesis with witnessed aspiration, hypotension requiring intervention (fluid and/or vasopressors), laryngospasm, pneumothorax or pneumomediastinum, or direct airway injury. Nonsevere TIAEs included mainstem bronchial intubation (confirmed by chest radiograph), esophageal intubation with immediate recognition, emesis without aspiration, hypertension requiring therapy, epistaxis, dental or lip trauma, medication error, arrhythmia, or pain and/or agitation requiring additional medication with delay in TI. Multiple TI attempts were defined as 3 or more attempts during the initial TI course. Oxygen desaturation was defined as oxygen saturation as measured by pulse oximetry less than 80% during the TI course when the initial oxygen saturation after preoxygenation was greater than 80%. A clinician with a supervising role during the TI encounter documented the self-reported team stress level from 1 (high stress) to 7 (low stress). The team stress level was scored on a Likert scale based on a composite of the supervising attending, fellow, charge nurse, and senior respiratory therapist’s assessment as long as they were not the actual laryngoscopist and included input from as many team members as possible.

Statistical Analysis

The primary exposure of interest was TIs with FP vs without FP. The primary outcome was occurrence of any TIAEs for each TI course. Secondary outcomes included occurrence of severe TIAEs, need for multiple TI attempts, and oxygen desaturation less than 80%. Summary statistics are provided as percentages for categorical variables or median and interquartile range (IQR) for nonnormally distributed variables. Dichotomous categorical variables were analyzed using χ2 test, while continuous variables were compared using Wilcoxon rank-sum test. Statistical analysis was performed with Stata version 11.2 (StataCorp). A random-effect multivariate logistic regression model was developed with clustering by site and occurrence of any TIAE as a dichotomous outcome. Factors associated with FP status in the univariate analysis (P < .10) and also those known to be associated with TIAEs in previous studies, a priori, were included as covariates in this model. P values of less than .05 were considered statistically significant.

Results

A total of 4969 TI encounters were reported from July 2010 to March 2014 across 24 academic and private PICUs (median, 118 TI encounters per site; IQR, 56-277). The median time from admission to TI was 20 hours (IQR, 2-114 hours). Data regarding FP were missing in 837 TIs (17%). One site had no documentation of FP and all TIs (n = 99) were removed from the data set. Another site had just initiated the data collection and only 3 TIs were recorded; therefore, these data were removed from the analysis. Thus, FP status (with/without) was documented for 4030 TI encounters (81%) from 22 PICUs and these encounters were included for analysis. The average percentage of FP during TI was 19% (762 of 4030); however, this varied widely across the 22 participating PICUs (median, 12%; IQR, 2%-31%; range, 0%-43%; P < .001) (Figure).

Patient Characteristics

The median age of children for TI encounters with FP was 2 years (IQR, 0-7 years) compared with 1 year (IQR, 0-6 years) for TI encounters without FP (P < .04) (Table 1). The PIM2 scores were significantly lower for the children with FP vs without FP (1.6% vs 2.5%; P < .001). The most common primary diagnosis was respiratory in nature in both groups (Table 1). Tracheal intubations performed for a procedural indication were similar in both groups (16%, n = 123 vs 17%, n = 568). Time of day (daytime vs nighttime) was not associated with FP status (P = .08) (Table 1). Among the 12 ICUs with the highest FP rates (>10%), the patient age was higher in TIs with FP (median age, 2 years; IQR, 0-7 years) compared with TIs without FP (median age, 1 year; IQR, 0-6 years; P = .02). The PIM2 score was similar between TIs with FP vs without FP (1.5% for both). The indications between TIs with FP and without FP were similar to the overall analysis with the exception of procedure: 17% of TIs with FP were for procedural indication, and 20% of TIs without FP were for procedural indication (P = .04).

Clinician and Practice Characteristics

A pediatric resident was more commonly the first airway clinician in TIs with FP vs TIs without FP (23%, n = 179 vs 18%,  = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7) (Table 2). Direct laryngoscopy was used most frequently as the first device in both groups (Table 2). With regard to sedating medications, fentanyl was used more often in cases with family absent vs FP (63%, n = 2060 vs 56%, n = 428; P < .001), whereas midazolam was used more often when the family was present vs absent (63%, n = 477 vs 56%, n = 1821; P = .001) (Table 2). Neuromuscular blockade use was common in both groups without significant difference.

Tracheal Intubation Success and Adverse Tracheal Intubation–Associated Events

First attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), occurrence of any TIAEs (OR, 1.06; 95% CI, 0.85-1.30), occurrence of severe TIAEs (OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (>3) (OR, 1.03; 95% CI, 0.82-1.28), and oxygen desaturation (<80% oxygen saturation as measured by pulse oximetry) (OR, 0.97; 95% CI, 0.80-1.18) were not significantly different between the 2 groups (Table 3). The self-reported team stress level was also not significantly different between FP vs no FP (Table 3). After adjusting for patient and clinician factors and clustering by site, FP again was not associated with first attempt success (OR, 1.04; 95% CI, 0.86-1.26), occurrence of any TIAEs (OR, 0.94; 95% CI, 0.73-1.19), occurrence of severe TIAEs (OR, 0.92; 95% CI, 0.63-1.33), multiple attempts (≥3) (OR, 0.90; 95% CI, 0.70-1.16), oxygen desaturation (<80%) (OR, 0.90; 95% CI, 0.72-1.12), or self-reported team stress level (OR, 1.11; 95% CI, 0.90-1.36) (Table 4).

Discussion

To our knowledge, our study is one of the few to report on FP specifically during TIs and to assess associations between FP and procedural outcomes in the PICU setting. Our large prospective study across 22 PICUs demonstrated that FP is highly variable, ranging from 0% to 43%. Interestingly, the presence of a family member was most common when the resident was the first clinician attempting TI. In addition, FP was more likely when the median age of the child was a little older (2 years vs 1 year) and when children had a lower risk for mortality as estimated by the PIM2 score. There was no significant association between FP and TI performance as assessed by first attempt success, the need for multiple attempts (≥3), adverse TIAEs, oxygen desaturation (<80%), or self-reported team stress level.

Family-centered care is at the forefront in the medical management of pediatric patients.7 Several studies have evaluated the role of FP in the context of pediatric procedures and during resuscitation.20 One study assessed the effect on relatives during resuscitations in an emergency department (ED) setting. Many relatives who were present demonstrated a trend toward lower degrees of intrusive imagery, posttraumatic avoidance behavior, and symptoms of grief when assessed 3 months after the resusucitation.21 Bauchner et al22 observed that 62% of parents remained present for an ED procedure (venipuncture or intravenous cannulation) largely owing to the perception that they could provide support to their child; importantly, 42% of the parents who were not present would have preferred to be present if given the chance. In pediatric studies that included TIs, many parents and families felt that their presence benefited the child in regard to providing relief for anxiety and assisting the health care team.23-25 One study performed in a PICU reported both nurses and parents thought the family’s presence was helpful during invasive procedures including TI.25

The wide variability of FP in our data set, without obvious association with other patient or clinician factors, is consistent with other investigations that observed that clinicians do not universally support the practice of FP during invasive procedures. Many factors, such as clinician years of experience in nursing or critical care, physical environment (eg, logistics of ICU design and room size), and supportive institutional policy, play a critical role in shaping clinicians’ perceptions of FP.26 Although supported as a best practice by leading national organizations, support for FP varies among clinicians and settings. In university-based PICUs in the United Kingdom and the United States, most nurses and physicians believed that parents should be given the option of being present during resuscitation.27 In contrast, our findings suggest that the attitudes of the clinician performing TIs in the PICU may not be uniform given the lack of consistency of FP across the spectrum of PICUs. Our results are consistent with the findings in care areas that manage critically ill children, such as the ED where physicians were not uniformly in favor of FP during trauma28 and medical resuscitations, especially among those physicians who had little or no FP experience.29 Furthermore, similar findings have been reported in the PICU regarding lack of physician approval for FP during resuscitation.27

We found no significant negative effect of documented FP during TIs on clinician, team stress, or patient outcomes. To our knowledge, very few studies specifically include pediatric TIs in the context of FP. Our observations are consistent with the findings of other investigators who found little evidence that FP interferes with usual resuscitation procedures, negatively affects patient outcomes, or increases clinicians’ stress.4,30 In a study of 197 pediatric patients treated in a trauma ED who required many interventions including TIs, only approximately 10% of the family members needed to be excluded from the ED, primarily for emotional reasons. Moreover, no family member interfered with medical care.31 Nigrovic et al32 reported no difference in pediatric lumbar puncture success rate in an ED setting with FP (87%) vs without FP (84%). With regard to the findings of differential use of midazolam and fentanyl, we can speculate whether the use of midazolam was prevalent in the FP group owing to the older children potentially having more anxiety or owing to a desire to have medications with amnestic properties in these children; however, based solely on our findings, this is not certain. Similarly, it is unclear why a higher percentage of patients with no FP received fentanyl. Did these patients seem to have more pain or the need to preserve good hemodynamics? Given the preponderance of evidence that FP is beneficial during pediatric medical care combined with our evidence that there are no significant negative effects associated with FP during TIs in the PICU setting, we should further evaluate the specific risks and benefits of FP.

Our study had several limitations. This was an observational study and there was no randomization of FP for the TIs. It is likely that there was some subjective selection bias for participation in FP by clinicians and by families. We do not have data about the presence of a formal policy for all study sites stating criteria of when families were allowed to be present, whether families declined after being given the opportunity to be present, or whether support personnel were available to offer explanations and answer questions during TIs. Consequently, we were unable to demonstrate a causal association. It is unclear whether there were site-specific cultural influences or biases related to allowing families to be present or not during TI based on patient acuity, physician concerns, or perceived urgency, which could have influenced the observed outcomes. Team stress level was assessed using a Likert scale by a composite of the supervising attending, fellow, charge nurse, and senior respiratory therapist after gathering feedback from all the team members; however, there was no specific formula used in quantifying each team member’s level of stress in determining this overall stress level. Thus, there is the possibility of supervising clinician bias in the reported team stress levels. In addition, specific feedback was not gathered from clinicians regarding their experiences with FP during TIs. Seventeen percent of the TIs were without documentation of FP (missing data). The TI encounters without documentation occurred in less sick patients, with a similar occurrence of TIAEs and less frequent severe TIAEs. This could have biased our results.

Institutional or unit-based policies are needed to support clinicians’ acceptance and use of FP. Clinicians in an ICU setting viewed FP more favorably following an education session and guideline development about the risks and benefits of FP, and more families were invited to be present at resuscitations and invasive procedures following that education.33 In future studies, the perspective of all clinicians involved with pediatric TIs with FP needs to be understood in order to effectively institute improvements. Determining patient acuity just prior to TI will also provide more insight into the factors that may affect FP. In addition, interviewing family members after pediatric TIs will provide invaluable insight on the perceptions of the care being provided.

Conclusions

Wide variability exists in FP during TI across PICUs. Family presence was not associated with worse first attempt success, adverse TIAEs, 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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Article Information

Corresponding Author: Ronald C. Sanders Jr, MD, MS, Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, 1 Children’s Way, Slot 512-12, Little Rock, AR 72202-3591 (rcsanders@uams.edu).

Accepted for Publication: December 1, 2015.

Published Online: March 7, 2016. doi:10.1001/jamapediatrics.2015.4627.

Author Contributions: Dr Nishisaki had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sanders, Bysani, Cheifetz, Graciano, Jarvis, Krishna, Nagai, Saito, Thompson, Turner, Nadkarni, Nishisaki.

Acquisition, analysis, or interpretation of data: Sanders, Nett, Davis, Parker, Adu-Darko, Bird, Derbyshire, Emeriaud, Giuliano, Graciano, Hagiwara, Hefley, Ikeyama, Jarvis, Kamat, A. Lee, J. H. Lee, Li, Meyer, Montgomery, Pinto, Rehder, Shenoi, Taekema, Tarquinio, Thompson, Turner, Nishisaki.

Drafting of the manuscript: Sanders, Nett, Davis, Parker, Hefley, Ikeyama, Kamat, Nagai, Saito, Shenoi, Nadkarni, Nishisaki.

Critical revision of the manuscript for important intellectual content: Sanders, Nett, Davis, Parker, Bysani, Adu-Darko, Bird, Cheifetz, Derbyshire, Emeriaud, Giuliano, Graciano, Hagiwara, Jarvis, Krishna, A. Lee, J. H. Lee, Li, Meyer, Montgomery, Pinto, Rehder, Taekema, Tarquinio, Thompson, Turner, Nadkarni, Nishisaki.

Statistical analysis: Giuliano, Nishisaki.

Obtained funding: Emeriaud, Nadkarni, Nishisaki.

Administrative, technical, or material support: Sanders, Derbyshire, Hefley, Jarvis, Kamat, Rehder, Tarquinio, Thompson, Nishisaki.

Study supervision: Sanders, Nett, Bird, Cheifetz, Krishna, Thompson, Nadkarni, Nishisaki.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by Agency for Healthcare Research and Quality grants 1R03HS021583-01 and 1 R18 HS022464-01 and the Endowed Chair of Critical Care Medicine held by Dr Nadkarni at The Children’s Hospital of Philadelphia. Dr Nadkarni also has Agency for Healthcare Research and Quality funding (grant 1 R18 HS022469-01), and Dr Nishisaki is supported by funding from the Agency for Healthcare Research and Quality.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The National Emergency Airway Registry for Children (NEAR4KIDS) Investigators include Ronald C. Sanders Jr, MD, MS, and Glenda Hefley, RN, MNSc (University of Arkansas for Medical Sciences/Arkansas Children’s Hospital, Little Rock); Keiko Tarquinio, MD (Rhode Island/Hasbro Children’s Hospital, Providence); Ana Lia Graciano, MD, FCCM (Children’s Hospital of Central California); Ann E. Thompson, MD, and Dennis Simon, MD (Pittsburgh Children’s Hospital); Angela Doucette, CCRP, and Alberty Orioles, MD (Children’s Hospitals and Clinics of Minnesota); Sholeen T. Nett, MD, PhD, and J. Dean Jarvis, RN, MBA (Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire); Kyle J. Rehder, MD, and David A. Turner, MD (Duke Children’s Hospital, Durham, North Carolina); Pradip Kamat, MD, MBA (Emory University School of Medicine, Children’s Hospital of Atlanta, Atlanta, Georgia); Jan Hau Lee MBBS, MRCPCH, MCI (KK Women’s and Children’s Hospital); Asha N. Shenoi, MD, and Ashwin S. Krishna, MD (Kentucky Children’s Hospital, University of Kentucky, Lexington); Vicki L. Montgomery, MD, FCCM, and Janice E. Sullivan, MD (University of Louisville and Kosair Children’s Hospital, Louisville, Kentucky); Simon Li, MD, and Matthew Pinto, MD (Maria Fareri Children’s Hospital, Westchester, New York); Kris Bysani, MD, and Tracey Monjure, RN (Medical City Children’s Hospital, Dallas, Texas); Keith Meyer, MD (Miami Children’s Hospital, Miami, Florida); Jill Popelka, RN, BS, and Anthony Lee, MD (Nationwide Children’s Hospital, Ohio State University, Columbus); Ashley T. Derbyshire MSN, RN, PNP-AC, and Conrad Krawiec, MD (Penn State Hershey Children’s Hospital); Hester Christianne Taekema, MD, MSc, and Gabrielle A Nuthall, FRACP, FCICM, MBChB (PICU Starship Children’s Health, Auckland, New Zealand); Margaret M. Parker, MD, MCCM, and Kathleen Culver, RN, NP (Stony Brook University); Vinay Nadkarni, MD, and Akira Nishisaki, MD, MSCE (The Children’s Hospital of Philadelphia, Pennsylvania); Osamu Saito and Yusuke Hagiwara (Tokyo Metropolitan Children’s Medical Center); Guillaume Emeriaud, MD, and Mariana Dumitrascu (Sainte-Justine University Hospital Center, Montreal, Quebec, Canada); Michelle Adu-Darko, MD (University of Virginia Children’s Hospital); Joy D. Howell, MD, FCCM (Presbyterian Weill Cornell Medical College); John S. Giuliano Jr, MD (Yale University School of Medicine); and Joanna Tala (Yale New Haven Children’s Hospital).

The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network includes Maureen Quaid, MD, and Fasiha Saeed, MD (Advocate Lutheran General Hospital, Park Ridge, Illinois); Michael L. Forbes, MD, FCCM, and Christopher Page-Goertz, MD (Akron Children’s Hospital, Akron, Ohio); Denise M. Goodman, MD, MS, and Neethi Pinto, MD, MS (Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois); Nancy Jaimon, MSN, BSN, CCRP, and Heather Chandler, MD, MPH (Baylor College of Medicine/Texas Children’s Hospital); Joshua Salvin, MD, MPH, and Emily Levy, MD (Boston Children’s Hospital, Boston, Massachusetts); Jennifer Liedel, MD, and Michael Ushay, MD, PhD (Children at Montefiore Medical Center); Edward Truemper, MD, and Andrea Talukdar, MD (Children’s Hospital and Medical Center, University of Nebraska); Nivedita Mohari, MD, and Malcolm Anderson, DO (Children’s Hospital Colorado); Barry Markovitz, MD, MPH, and Christopher Newth, MD (Children’s Hospital Los Angeles); Ann Thompson, MD, and Diana Pang, MD (Children’s Hospital of Pittsburgh); Timothy E. Bunchman, MD, and Michelle Hoot, PhD (Children’s Hospital of Richmond at VCU); Rainer Gedeit, MD, and Sheila Hanson, MD (Children’s Hospital of Wisconsin/Medical College of Wisconsin); Darci Evans, DO, and Adam Schwarz, MD (Children’s Hospital Orange County); Nihal Godiwala, MD, Matthew Sharron, MD (Children’s National Medical Center); Robert Russell, MD, MPH, and Margaret Winkler, MD (Children’s of Alabama/University of Alabama at Birmingham); Vinay Nadkarni, MD, and Akria Nishisaki, MD (The Children’s Hospital of Philadelphia); Alexis F. Turgeon, MD, MSc, FRCPC, and Josee Larochelle, MD (CHU de Québec–Université Laval); Guillaume Emeriaud, MD, MPH, and Sze Man Tse, MDCM, MPH (CHU Sainte Justine, Université de Montréal); Kelli Howard, RN, BSN, MS, and Ranjit Chima, MD (Cincinnati Children’s Hospital Medical Center); Leslie Lehmann, MD, and Christine Duncan, MD (Dana Farber Cancer Institute/Boston Children’s Hospital); Sholeen Nett, MD, PhD, and J. Dean Jarvis, RN, MBA (Dartmouth Hitchcock Medical Center); LeeAnn Christie, RN, MSc, and Renee Higgerson, MD (Dell Children’s Medical Center of Central Texas); Kyle Rehder, MD, and Ira Cheifetz, MD (Duke Children’s Hospital); James Fortenberry, MD, MCCM, and Nina A. Guzzetta, MD (Emory University School of Medicine/Children’s Healthcare of Atlanta); Elizabeth Prentice, DO, and Brian Boville, MD (Helen DeVos Children’s Hospital); Gwenn McLaughlin, MD, MSPH, and Asumthia Jeyapalan, DO (Holtz Children’s Hospital/University of Miami); Sapna Kudchadkar, MD, and Kristen Nelson, MD (Johns Hopkins University); Lauren Marsillio, MD, and Christopher Schneller, MD (Lurie Children’s Hospital); Simon Li, MD, MPH, and Matthew Pinto, MD (Maria Fareri Children’s Hospital); Roberta Adams, MD, and Grace Arteaga, MD (Mayo Clinic); G. Kris Bysani, MD, and Tracey Monjure, RN (Medical City Children’s Hospital); Jennifer McArthur, DO, and Kathy Murkowski, MD (Medical College of Wisconsin/Children’s Hospital of Wisconsin); Fernando Beltramo, MD, and Asumthia Jeyapalan, DO (Miami Children’s Hospital); Rajinder Bajwa, MD, and Kathleen Nicol, MD (Nationwide Children’s Hospital); Toah Nkromah, DO, MPH, and Debbie Spear, CCRN (Penn State Hershey Children’s Hospital); Eleanor Gradidge, MD, and David Tellez, MD (Phoenix Children’s Hospital); Andrew Beardsley, MD, and Courtney Rowan, MD (Riley Hospital for Children and Indiana University School of Medicine); Felicia Su, MD, and Deborah Franzon, MD (Stanford Children’s Health/Lucile Packard Children’s Hospital); Margaret Packer, MD, MCCM, and Robert I. Parker, MD (Stony Brook University); Bhushan Katira, MD, and Steven Schwarz, MD (The Hospital for Sick Children); Paula Silva, MD, PCCM, and Yu Kawai, MD, PCCM (The University of Michigan); Ronald Sanders Jr, MD, and Richard T. Fiser, MD (University of Arkansas for Medical Sciences/Arkansas Children’s Hospital); Matt Zinter, MD, and Natalie Z. Cvijanovich, MD (University of California, San Francisco, Benioff Children’s Hospitals); Aline Maddux, MD, and Tellen Bennett, MD (University of Colorado School of Medicine, Children’s Hospital Colorado); Julie S. Baines, MD, and Christian Kegg, MD (University of Florida); Stacey Valentine, MD, MPH, and Scot Bateman, MD (University of Massachusetts Children’s Medical Center); Nicole Zantek, MD, PhD, and Ashley Loomis, MD (University of Minnesota Masonic Children’s Hospital); Martha A. Q. Curley, PhD, and Robert Kapito, PhD (University of Pennsylvania); Jill M. Cholette, MD, and Louis Eugene Daugherty, MD (University of Rochester–Strong Memorial Hospital); Rebecca Dixon, MD, and Ellie Hirshberg, MD (University of Utah/Primary Children’s Hospital); Scott Watson, MD, MPH, and Lincoln Smith, MD (University of Washington and Seattle Children’s Hospital); Timothy E. Bunchman, MD, and Michelle Hoot, PhD (Children’s Hospital of Richmond at VCU); Philip C. Spinella, MD, and Allan Doctor, MD (Washington University in St Louis School of Medicine); Emily Wasserman, MD, and Steven Pon, MD (Weill Cornell Medical College/New York Presbyterian Hospital); Abraar Quraishi, MD, and Ryan Breuer, MD (Women and Children’s Hospital of Buffalo); Lee A. Polikoff, MD, and Josep Paniello, MD (Yale–New Haven Children’s Hospital); James Schneider, MD (Cohen Children’s Medical Center); Katherine Biagas, MD (Columbia University Medical Center); and Aileen Kirby, MD (Oregon Health and Science University/Doernbecher Children’s Hospital).

Additional Contributions: The Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network reviewed and endorsed the study as a quality-improvement research project; and The National Emergency Airway Registry for Children (NEAR4KIDS) Investigators reviewed and revised the data collection instruments, contributed data from the 22 sites, and reviewed and approved the final manuscript as submitted. We thank Hayley Buffman, MPH, for her tireless effort as the coordinator for the multicenter NEAR4KIDS registry and Stephanie Tuttle, MBA, for her administrative support. Ms Buffman received compensation from the funding agency. Dr Sanders thanks Richard “Tad” Fiser, MD (University of Arkansas for Medical Sciences/Arkansas Children’s Hospital), for his invaluable insight, advice, and friendship. In addition, we thank all of our colleagues, fellows, nurses, and respiratory therapists for their efforts and contributions to this work in striving to make airway management safer in our pediatric intensive care units.

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