Impact of family integrated care on infants’ clinical outcomes in two children’s hospitals in China: a pre-post intervention study

Impact of family integrated care on infants’ clinical outcomes in two children’s hospitals in... Background: Most Neonatal Intensive Care Units (NICUs) in China have restricted visiting policies for parents. This also implicates that parents are not involved in the care of their infant. Family Integrated Care (FIC), empowering parents in direct care delivery and decisions, is becoming the standard in NICUs in many countries and can improve quality-of-life and health outcomes of preterm infants. The aim of this study was to evaluate the impact of a FIC intervention on the clinical outcomes of preterm infants with Bronchopulmonary Dysplasia (BPD). Methods: A pre-post intervention study was conducted at NICUs in two Chinese children’s hospitals. Infants with BPD were included: pre-intervention group (n = 134) from December 2015 to September 2016, post-intervention (FIC) group (n = 115) and their parents from October 2016 to June 2017. NICU nurses were trained between July and September 2016 to deliver the FIC intervention, including parent education and support. Parents had to be present and care for their infant minimal three hours a day. The infants’ outcome measures were length-of-stay, breastfeeding, weight gain, respiratory and oxygen support, and parent hospital expenses. Results: Compared with control group (n = 134), the FIC group (n = 115) had significantly increased breastfeeding rates (83% versus 71%, p = 0.030), breastfeeding time (31 days versus 19 days, p < 0.001), enteral nutrition time (50 days versus 34 days, p < 0.001), weight gain (29 g/day versus 23 g/day, p = 0.002), and significantly lower respiratory support time (16 days versus 25 days, p < 0.001). Oxygen Exposure Time decreased but not significant (39 days versus 41 days p = 0.393). Parents hospital expenses in local Chinese RMB currency was not significant (84 K versus 88 K, p = 0.391). Conclusion: The results of our study suggests that FIC is feasible in two Chinese NICUs and might improve clinical outcomes of preterm infants with BPD. Further research is needed to include all infants admitted to NICUs and should include parent reported outcome measures. Our study may help other NICUs with limited parental access to implement FIC to enhance parental empowerment and involvement in the care of their infant. Keywords: Bronchopulmonary dysplasia, Clinical outcome, Family integrated care, Family centered care, Intensive care, Neonatology, Parents, Preterm infants * Correspondence: 877845375@qq.com Shi-wen He and Yue-e Xiong contributed equally to this work. Nursing Department, Hunan Children’s Hospital, Ziyuan Rd, Changsha, 410007 Hunan Province, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. He et al. Italian Journal of Pediatrics (2018) 44:65 Page 2 of 7 Background their preterm infant during NICU hospitalization after In 2016, the World Health Organization (WHO) reported they have been provided with education and guidance by that there are about 15 million preterm babies born each well-trained neonatal nurses [10]. When parents are year worldwide and the number is still rising. At present, permitted to be closer to their infant and become more the number of preterm infants in China ranks second in involved in providing care with the support of nurses, a the world [1]. Complications from preterm births are the good relationship between parents and nurses is essen- most common cause of death among five-year-old chil- tial. This can result in higher parent satisfaction with dren. About 70% of perinatal diseases occur in preterm care and the parents become more confident in their infants. The incidence of cerebral palsy in preterm infants parental roles [11]. A study in a Dutch NICU showed is 70 to 80 times that of full-term infants, and the rate of that parents rated their involvement in care as very cognitive impairment is also significantly higher in pre- important and they were more satisfied with care if they term infants than in full-term infants [2]. In addition, it receive information about their infant and participate in was found that up to 800 million U.S. dollars (USD) in the development of the treatment plan [12, 13]. Thus, costs are incurred due to preterm infants each year [3], nurses and doctors must recognize and acknowledge the leading to a significantly greater economic burden on wishes of parents based on their social and cultural their families. These expenses decrease as the number needs [14–16]. of gestational weeks and birth weight increases [4]. At The involvement of parents in providing care to infants the same time, the prolonged hospital stays of preterm at the NICU may affect the stability of preterm infants infants have a serious impact on familial, social and and the incidence of disease [17]. Bronchopulmonary dys- medical resources [5]. plasia (BPD) is still a common disease in premature in- The WHO proposed several relevant measures to im- fants [18–20]. Due to immature lung development and prove the quality-of-life and health of preterm infants. few alveolar surfactants, premature infants are prone to These include regularly updating the clinical guidance respiratory distress syndrome and BPD. The use of mech- for management of pregnant women at risk of preterm anical ventilatory strategies may influence the incidence of birth or mothers of preterm infants and guidelines for BPD. Furthermore, in China, many tertiary NICUs are in preterm infant nursing professionals in terms of kangaroo a children’s hospital requiring transport of critically ill in- care, feeding of low birth weight infants, treatment of in- fants from a maternity hospital to these NICUs. Infants fectious and respiratory diseases and family-centered care with delayed transport to a tertiary NICU had a higher [1]. Kangaroo care [6] and family-centered care [7]en- incidence of BPD (57%) compared to transport within courage greater involvement of parents in giving direct 24 h [21]. Given the increased emphasis of early parental care to their infants in the Neonatal Intensive Care Unit education in NICUs, the role of parents can become im- (NICU). For a greater involvement of parents in the care portant in the early stages of a NICU admission and might of their infant the NICUs need to be liberal in the visiting improve infant’s health outcomes. However, research on policies. Most NICUs in China have restricted visiting the effects of FIC on infants with BPD is sparse and over- policies and parents have limited involvement in care. In all the effects of FIC on the general NICU population re- contrast, NICUs in higher resources countries welcome mains limited. Therefore, the aim of the study was to parents without restrictions. However, evidence suggests evaluate the impact of a FIC intervention on the clinical that in some European countries the visiting policies vary. outcomes of preterm infants with BPD. A survey published 10 years ago among 175 NICUs in eight European countries identified that the majority of Methods the participating NICUs in Italy (n =35) and Spain (n = Design 22) had limited visiting hours while one third of the This study used a pre-post intervention design and was French NICU (n = 45) did not have unrestricted visiting conducted between December 2015 and June 2017. hours for parents [8]. More recently, Raiskila and col- leagues documented significant differences between 11 Settings NICUs in six European countries in physical parent–in- Hunan Children’s Hospital is the largest child care center fant closeness and presence [9]. Welcoming parents with- in Hunan province. The NICU is a tertiary neonatology out restrictions and supporting them in the care of center with 60 beds and admitting around 85 BPD infants preterm infants might improve the quality of care. There- every year. Guiyang Children’s Hospital is a specialist hos- fore, the clinical staff should strive for family-centered pital and the NICU is the referral center of neonates in care interventions and integrate the parents in care and Guizhou province. The NICU has 70 beds and annually decision-making processes in the NICU. around 73 infants with BPD are treated. Parents in both Family Integrated Care (FIC) is an approach that al- NICUs are not allowed to visit their infants. Communica- lows parents to provide non-medical routine care for tion with parents is done via the NICU doctors three He et al. Italian Journal of Pediatrics (2018) 44:65 Page 3 of 7 times a week and parents are able to see their infant via a 10:00 and 16:00. In these periods parents were encouraged video-connection. to talk with their infant and play music. Data collection Participants and recruitment Each NICU appointed one nurse (member of the FIC re- Infants were eligible when they met the following four search group) to collect data from the medical records. criteria:1) weight ≥ 1800 g with ventilatory support or Length-of-stay was the number of NICU days because weight ≥ 1500 g with non-invasive oxygen support; 2) all infants are discharged home directly from the NICU. stable hemodynamic condition; 3) some form of re- Oxygen exposure time was defined as the number of spiratory support or oxygen therapy is still required at days the infant received any form of oxygen support. the corrected gestational age of 36 weeks (FiO ≥ 0.3); Respiratory support time was defined as the number of 4) parents agreed to follow a training and take care of days with invasive mechanical ventilatory support. The their child for at least three hours per day. definition of breastfeeding time was the time the infant Exclusion criteria were: 1) severe congenital anomal- received partial or full breastfeeding per day [22]. The ies or respiratory deformities such as laryngeal cartilage enteral nutrition time included the days of breastfeeding dysplasia; 2) surgery; 3) receiving palliative care; 4) brain and formula. Weight gain was calculated by the formula: damage; 5) parents have serious social problems or lan- weight at discharge minus weight at admission divided guage issues; 6) expected discharge within one week. by the length of NICU stay. BPD categorized in recovery, incomplete recovery, and death after NICU discharge. Interventions Readmission within one month after NICU discharge Infants with BPD hospitalized at both NICUs between and hospital expenses were also collected. Hospital ex- December 2015 and September 2016 were the standard penses were retrieved from the medical records and care group, and those admitted between October 2016 were related to the treatment and care expenses the par- and June 2017 were the intervention group. The NICU ents had to pay. nurses were trained from July to September 2016 to effectively deliver the intervention to parents of infants Data analysis in the intervention group. The statistical analysis was performed using SPSS19.0 In the standard care group, parents were asked to follow software. Descriptive statistical methods were used to the routine caring model and comply with the hospital analyze the data. The t-test and χ test were used to com- rules and regulations. The parents were not allowed to be pare the clinical outcomes between the FIC group and the involved in the treatment and care of their infants except standard care group. A p-value of < 0.05 indicates statis- for visits by means of video connection every Monday, tical significance. Wednesday, and Friday. The FIC intervention required parents to accept the FIC Ethical considerations training from qualified nurses before they entered the The study protocol was approved by the Institutional NICU. The training items included: 1) Hand hygiene: Review Board of Hunan Children’s Hospital (HCHLL- Parents were instructed to wash their hands under run- 2015-33). The data of the standard care group were re- ning water in 7 steps, and informed of the times to wash trievedfromthe medicalrecords andmadeanonymous to hands, such as before entering the NICU and before feed- include in the study analysis. Therefore, a signed consent ing. 2) Neonatal feeding: Parents were encouraged to form was waived. Parents in the FIC group received an invi- breastfeed their infant and communicate at the same time tation letter and information about the study. A member of to allow the infant to become familiar with the mother, the FIC research group also verbally explained the study. feel loved and relieve anxiety. 3) Neonatal contact: Parents Parents could withdraw participation without reason. A were told to touch the infant in the sequence of head and signed informed consent was required and collected. face, chest, abdomen, limbs, hands and feet then back with moderate to intense force and rub large muscle groups. 4) Patting on the back of the infant: Parents were instructed Results to smoothly pat the back of their infant with hollow hands A total of 319 cases were eligible, of which 58 cases were from the outside to the inside and from top to the bottom excluded because parents did not want to participate or 30 min before a meal or two hours after. 5) Involvement were unable to stay for the required hours per day. of care: Parents were encouraged to bath the infant, Among the remaining 261 cases, 13 infants died or were change diapers, and perform other basic care. in palliative care. Included in the final analysis were 115 Parents in the FIC group were involved in non-medical infants in the FIC group and 134 in the standard care care of their infant for at least three hours a day between group (Fig. 1). He et al. Italian Journal of Pediatrics (2018) 44:65 Page 4 of 7 Fig. 1 Flowchart of study participants. Legend. FIC=Family Integrated care Characteristics of infants and parents Clinical outcomes of infants with BPD A total of 249 infants were included in the study, of Table 2 shows the clinical outcomes of infants with BPD. which 168 were male. The mean gestational age and There were significant differences (P < 0.05) in respira- birth weight of infants in the FIC group were signifi- tory support time (invasive or non-invasive ventilator cantly lower than in the standard care group (P < 0.05). support), breastfeeding rate, breastfeeding time, enteral Also, father’s education was higher in the FIC group nutrition time and weight gain rate between the infants (Table 1). of the FIC group and standard care group. No significant differences (P > 0.05) were found in length-of-stay, hospitalization expenses, oxygen exposure time and BPD Table 1 Infant and Parent Characteristics outcome. Characteristics FIC Control P value (n = 115) (n = 134) Discussion Male (n, %) 75 (65.2) 93 (69.4) 0.482 The FIC model was implemented in the NICUs of two Female (n, %) 40 (34.8) 41 (30.6) Chinese children’s hospitals to test the feasibility of this Gestational age; weeks 29.9 (1.8) 30.79 (2.0) <0.001 model. Our study provides evidence that FIC might (mean, SD) improve the clinical outcomes of infants with BPD and Birth weight; gram 1352.6 (267.5) 1441.2 (376.8) 0.021 could provide a reference for further utilization of FIC (mean, SD) in other children’s hospitals in China. A survey of 129 Father’s age; years 33 (5.8) 32 (6.3) 0.401 pediatric nurses in Hunan Province about the know- (mean, SD) ledge, attitudes and behaviors of FIC before and after a Father’s education training course revealed that most nurses (74%) were (n,%) willing to deliver the FIC model regardless of the train- Below high school 31 (27.0) 61 (45.5) 0.004 ing [23]. Consequently, with the results of this interven- High school 32 (27.8) 36 (26.9) tion study we now participate in a larger multi-center Above high school 52 (45.2) 37 (27.6) RCT to test FIC in a larger NICU population [24]. Mother’s age; years 30.(4.8) 29 (4.9) 0.087 The FIC model allows the parents of infants with BPD (mean, SD) to participate in the care and provides them with train- Mother’s education ing to better understand the methods and benefits of (n, %) breastfeeding. The breastfeeding rate and time in our Below high school 38 (33.0) 55 (41.0) 0.293 study was significantly higher in infants in the FIC group High school 26 (22.7) 32 (23.9) than in the standard care group. Verma and colleagues also confirmed in their study that providing training to Above high school 51 (44.3) 47 (35.1) 1 2 2 parents and involving parents in care (n = 148) increases Chi-square test (χ ); Student t-test; FIC Family Integrated Care, SD Standard Deviation the breastfeeding rates to 80% [25]. He et al. Italian Journal of Pediatrics (2018) 44:65 Page 5 of 7 Table 2 Infants’ Clinical Outcomes FIC and Control Group Outcomes FIC Control P value n = 115 n = 134 Length-Of-Stay; days (mean, SD) 52 (10.5) 49 (20.2) 0.084 Hospital expenses (RMB, mean, SD) 84,409 (27,766.2) 87,602 (37,343.5) 0.391 Oxygen exposure time; days (mean, SD) 39 (14.9) 41 (13.8) 0.393 Respiratory support time; days (mean, SD) 16 (10.8) 25 (13.0) < 0.001 Breastfeeding Yes (%) 95 (82.6) 95 (70.9) 0.030 No (%) 20 (17.4) 39 (29.1) Breastfeeding time; days (mean, SD) 31 (20.2) 19 (19.5) < 0.001 Enteral nutrition time; days (mean, SD) 50 (15.9) 34 (22.9) < 0.001 Weight gain rate; grams/day (mean, SD) 28.5 (14.6) 23.3 (9.9) 0.002 BPD outcome Complete recovery (n, %) 81 (70.4) 86 (64.2) 0.422 Incomplete recovery (n, %) 34 (29.6) 45 (33.6) Death (n, %) 0 3 (2.2) Re-admission within 1 Month Yes (n, %) 14 (12.2) 21 (15.7) 0.492 No (n, %) 101 (87.8) 113 (84.3) 1 2 2 Chi-square test (χ ); Student t-test; FIC Family Integrated Care, SD Standard Deviation, BPD Bronchopulmonary Disease, RMB RenMinBi (Chinese Yuan) We found that the respiratory support time for infants more time with the increase of the demands of the in- with BPD in the FIC group was significantly reduced. fant for breastfeeding [10]. The clinical outcomes of the Ortenstrand, et al. [26] also demonstrated that family in- infants showed a significant positive weight gain and a volvement in care significantly reduced the number of significant increase in breastfeeding. We acknowledge infants with moderate to severe BPD from 6% in the that the length of time of parents taking care of their in- standard care group to 1.6% in the family care group. fant could have influenced our results. Secondly, private Thus, FIC might suggest that parents’ involvement in rooms were not available for parents and their infants to care might have a positive effect on the infants’ health spend time together due to lack of space in the NICU. and outcomes. Therefore, we placed a screen at the infant’s bedside to Although the length-of-stay in our study did not show provide privacy for parents to interact with their infant. significant improvements, Melnyk et al. [7] and Bhutta et A systematic review identified the benefits of single al. [27] demonstrated that allowing parents to care for room designed NICUs and conclude that single family their infant can reduce length-of-stay. However, Welch et room NICUs might decrease length-of-stay and reduce al. [28] argued that although the average length-of-stay of readmissions [29]. Thirdly, we observed a substantial infants in a FIC model was 3.4 days less than that for in- imbalance of the number of cases in the FIC interven- fants under routine care and the median length-of-stay tion group between the two hospitals; 37 infants were was 4 days less, there was no statistical significance. Our included from Guiyang Children’s Hospital in the FIC results indicated no significant difference even though the group compared to 83 infants from Hunan Children’s length-of-stay of infants in the FIC group was longer than Hospital (n = 83). It was unclear how the differences the control group, which may be associated with the sig- occurred. A reason could be the termination of the nificantly lower gestational age of infants in the FIC group one-child policy beginning 2016 which might have led than the standard care group. The respiratory support to differences in birth rate in the two provinces. The time of infants in our FIC group was significantly lower differences in proportion of infants from the two hospi- than the standard care group, but the oxygen exposure tals between the pre and post-intervention groups time and length-of-stay of the FIC group were significantly could represent a bias for the results and a larger study higher than the standard care group, resulting in higher in the future is needed to test the effect of a FIC inter- average hospitalization expenses of the FIC group. There- vention. Finally, the Chinese tradition of “zuo yuezi” fore, the impact of the FIC model on length-of-stay and (sitting the month) means that mothers are expected to hospitalization expenses needs to be further studied. rest indoors and avoid heavy physical activity for one Our study is subject to some limitations. Firstly, par- full month after giving birth. Therefore, several infants ents only stay for a minimum of three hours a day, were cared for by their fathers but after discharge were which is short and fragmented. A recent study used the then cared for by the mothers at home. Therefore, spe- inclusion criteria of a minimum of eight hours and even cific information about discharge planning that might He et al. Italian Journal of Pediatrics (2018) 44:65 Page 6 of 7 have influenced the readmission rate could not be shared data collection; data analysis and interpretation; writing the first draft of the manuscript; agrees to be accountable for all aspects of the work in ensuring with the mothers. that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Conclusion Our study suggests that the FIC model is feasible in Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board of Hunan NICUs and might result in significant improvements Children’s Hospital, Changsha, China. (reference number HCHLL-2015-33). The of infants’ clinical outcomes such as weight gain, data of the standard care group were retrieved from the medical records and breastfeeding time, breastfeeding rate and respiratory made anonymous to include in the study analysis. Therefore, a signed consent form was waived. Parents in the FIC group received an invitation letter and support time. Therefore, this study might be support- information about the study. A member of the FIC research group also verbally ive to all NICUs who consider implementing the in- explained the study. Parents could withdraw participation without reason. A volvement and empowerment of parents in the care signed informed consent was required and collected. and decision making of their infant. However, further studies are needed to explore the benefits of FIC in Competing interests The authors declare that they have no competing interests. infants and parent reported outcomes. Abbreviations Publisher’sNote BPD: Broncho-pulmonary Disease; FIC: Family Integrated Care; NICU: Neonatal Springer Nature remains neutral with regard to jurisdictional claims in Intensive Care Unit; RMB: RenMinBi (Chinese Yuan); SD: mean and standard published maps and institutional affiliations. deviation; USD: U.S. dollar; WHO: the World Health Organization Author details Acknowledgements Nursing Department, Hunan Children’s Hospital, Ziyuan Rd, Changsha, We thank all the staff of the NICUs of Hunan Children’s Hospital and Guiyang 410007 Hunan Province, China. Hunan University of Traditional Chinese Children’s Hospital for delivering the intervention and their engagement in Medicine, Xueshi Rd, Changsha, Hunan, China. Division of Neonatal the study. We thank the parents who agreed to participate in the study. Medicine, Hunan Children’s Hospital, Ziyuan Rd, Changsha, 41007 Hunan Province, China. Nursing Department, Maternal and Child Health Hospital of Funding Guiyang Province, Ruijinnan Rd, Guiyang, Guizhou, China. School of Nursing This study was financially supported by the Beijing Children Hospital Group and and Midwifery, Faculty of Health and Human Sciences, University of the Health and Family Planning Commission of Hunan Province (B2016031). Plymouth, Plymouth, UK. Availability of data and materials Received: 10 February 2018 Accepted: 28 May 2018 The dataset and analyses are available from the corresponding author on request. Authors’ contributions References All authors have approved the final manuscript. SH contributed to the data 1. World Health Organization. Preterm birth. 2018. http://www.who.int/ collection, arrangement and analysis; writing the first draft of the manuscript mediacentre/factsheets/fs363/zh/. Accessed 27 Apr 2018. and revised it; agrees to be accountable for all aspects of the work in 2. Hack M. Adult outcomes of preterm children. 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Impact of family integrated care on infants’ clinical outcomes in two children’s hospitals in China: a pre-post intervention study

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Abstract

Background: Most Neonatal Intensive Care Units (NICUs) in China have restricted visiting policies for parents. This also implicates that parents are not involved in the care of their infant. Family Integrated Care (FIC), empowering parents in direct care delivery and decisions, is becoming the standard in NICUs in many countries and can improve quality-of-life and health outcomes of preterm infants. The aim of this study was to evaluate the impact of a FIC intervention on the clinical outcomes of preterm infants with Bronchopulmonary Dysplasia (BPD). Methods: A pre-post intervention study was conducted at NICUs in two Chinese children’s hospitals. Infants with BPD were included: pre-intervention group (n = 134) from December 2015 to September 2016, post-intervention (FIC) group (n = 115) and their parents from October 2016 to June 2017. NICU nurses were trained between July and September 2016 to deliver the FIC intervention, including parent education and support. Parents had to be present and care for their infant minimal three hours a day. The infants’ outcome measures were length-of-stay, breastfeeding, weight gain, respiratory and oxygen support, and parent hospital expenses. Results: Compared with control group (n = 134), the FIC group (n = 115) had significantly increased breastfeeding rates (83% versus 71%, p = 0.030), breastfeeding time (31 days versus 19 days, p < 0.001), enteral nutrition time (50 days versus 34 days, p < 0.001), weight gain (29 g/day versus 23 g/day, p = 0.002), and significantly lower respiratory support time (16 days versus 25 days, p < 0.001). Oxygen Exposure Time decreased but not significant (39 days versus 41 days p = 0.393). Parents hospital expenses in local Chinese RMB currency was not significant (84 K versus 88 K, p = 0.391). Conclusion: The results of our study suggests that FIC is feasible in two Chinese NICUs and might improve clinical outcomes of preterm infants with BPD. Further research is needed to include all infants admitted to NICUs and should include parent reported outcome measures. Our study may help other NICUs with limited parental access to implement FIC to enhance parental empowerment and involvement in the care of their infant. Keywords: Bronchopulmonary dysplasia, Clinical outcome, Family integrated care, Family centered care, Intensive care, Neonatology, Parents, Preterm infants * Correspondence: 877845375@qq.com Shi-wen He and Yue-e Xiong contributed equally to this work. Nursing Department, Hunan Children’s Hospital, Ziyuan Rd, Changsha, 410007 Hunan Province, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. He et al. Italian Journal of Pediatrics (2018) 44:65 Page 2 of 7 Background their preterm infant during NICU hospitalization after In 2016, the World Health Organization (WHO) reported they have been provided with education and guidance by that there are about 15 million preterm babies born each well-trained neonatal nurses [10]. When parents are year worldwide and the number is still rising. At present, permitted to be closer to their infant and become more the number of preterm infants in China ranks second in involved in providing care with the support of nurses, a the world [1]. Complications from preterm births are the good relationship between parents and nurses is essen- most common cause of death among five-year-old chil- tial. This can result in higher parent satisfaction with dren. About 70% of perinatal diseases occur in preterm care and the parents become more confident in their infants. The incidence of cerebral palsy in preterm infants parental roles [11]. A study in a Dutch NICU showed is 70 to 80 times that of full-term infants, and the rate of that parents rated their involvement in care as very cognitive impairment is also significantly higher in pre- important and they were more satisfied with care if they term infants than in full-term infants [2]. In addition, it receive information about their infant and participate in was found that up to 800 million U.S. dollars (USD) in the development of the treatment plan [12, 13]. Thus, costs are incurred due to preterm infants each year [3], nurses and doctors must recognize and acknowledge the leading to a significantly greater economic burden on wishes of parents based on their social and cultural their families. These expenses decrease as the number needs [14–16]. of gestational weeks and birth weight increases [4]. At The involvement of parents in providing care to infants the same time, the prolonged hospital stays of preterm at the NICU may affect the stability of preterm infants infants have a serious impact on familial, social and and the incidence of disease [17]. Bronchopulmonary dys- medical resources [5]. plasia (BPD) is still a common disease in premature in- The WHO proposed several relevant measures to im- fants [18–20]. Due to immature lung development and prove the quality-of-life and health of preterm infants. few alveolar surfactants, premature infants are prone to These include regularly updating the clinical guidance respiratory distress syndrome and BPD. The use of mech- for management of pregnant women at risk of preterm anical ventilatory strategies may influence the incidence of birth or mothers of preterm infants and guidelines for BPD. Furthermore, in China, many tertiary NICUs are in preterm infant nursing professionals in terms of kangaroo a children’s hospital requiring transport of critically ill in- care, feeding of low birth weight infants, treatment of in- fants from a maternity hospital to these NICUs. Infants fectious and respiratory diseases and family-centered care with delayed transport to a tertiary NICU had a higher [1]. Kangaroo care [6] and family-centered care [7]en- incidence of BPD (57%) compared to transport within courage greater involvement of parents in giving direct 24 h [21]. Given the increased emphasis of early parental care to their infants in the Neonatal Intensive Care Unit education in NICUs, the role of parents can become im- (NICU). For a greater involvement of parents in the care portant in the early stages of a NICU admission and might of their infant the NICUs need to be liberal in the visiting improve infant’s health outcomes. However, research on policies. Most NICUs in China have restricted visiting the effects of FIC on infants with BPD is sparse and over- policies and parents have limited involvement in care. In all the effects of FIC on the general NICU population re- contrast, NICUs in higher resources countries welcome mains limited. Therefore, the aim of the study was to parents without restrictions. However, evidence suggests evaluate the impact of a FIC intervention on the clinical that in some European countries the visiting policies vary. outcomes of preterm infants with BPD. A survey published 10 years ago among 175 NICUs in eight European countries identified that the majority of Methods the participating NICUs in Italy (n =35) and Spain (n = Design 22) had limited visiting hours while one third of the This study used a pre-post intervention design and was French NICU (n = 45) did not have unrestricted visiting conducted between December 2015 and June 2017. hours for parents [8]. More recently, Raiskila and col- leagues documented significant differences between 11 Settings NICUs in six European countries in physical parent–in- Hunan Children’s Hospital is the largest child care center fant closeness and presence [9]. Welcoming parents with- in Hunan province. The NICU is a tertiary neonatology out restrictions and supporting them in the care of center with 60 beds and admitting around 85 BPD infants preterm infants might improve the quality of care. There- every year. Guiyang Children’s Hospital is a specialist hos- fore, the clinical staff should strive for family-centered pital and the NICU is the referral center of neonates in care interventions and integrate the parents in care and Guizhou province. The NICU has 70 beds and annually decision-making processes in the NICU. around 73 infants with BPD are treated. Parents in both Family Integrated Care (FIC) is an approach that al- NICUs are not allowed to visit their infants. Communica- lows parents to provide non-medical routine care for tion with parents is done via the NICU doctors three He et al. Italian Journal of Pediatrics (2018) 44:65 Page 3 of 7 times a week and parents are able to see their infant via a 10:00 and 16:00. In these periods parents were encouraged video-connection. to talk with their infant and play music. Data collection Participants and recruitment Each NICU appointed one nurse (member of the FIC re- Infants were eligible when they met the following four search group) to collect data from the medical records. criteria:1) weight ≥ 1800 g with ventilatory support or Length-of-stay was the number of NICU days because weight ≥ 1500 g with non-invasive oxygen support; 2) all infants are discharged home directly from the NICU. stable hemodynamic condition; 3) some form of re- Oxygen exposure time was defined as the number of spiratory support or oxygen therapy is still required at days the infant received any form of oxygen support. the corrected gestational age of 36 weeks (FiO ≥ 0.3); Respiratory support time was defined as the number of 4) parents agreed to follow a training and take care of days with invasive mechanical ventilatory support. The their child for at least three hours per day. definition of breastfeeding time was the time the infant Exclusion criteria were: 1) severe congenital anomal- received partial or full breastfeeding per day [22]. The ies or respiratory deformities such as laryngeal cartilage enteral nutrition time included the days of breastfeeding dysplasia; 2) surgery; 3) receiving palliative care; 4) brain and formula. Weight gain was calculated by the formula: damage; 5) parents have serious social problems or lan- weight at discharge minus weight at admission divided guage issues; 6) expected discharge within one week. by the length of NICU stay. BPD categorized in recovery, incomplete recovery, and death after NICU discharge. Interventions Readmission within one month after NICU discharge Infants with BPD hospitalized at both NICUs between and hospital expenses were also collected. Hospital ex- December 2015 and September 2016 were the standard penses were retrieved from the medical records and care group, and those admitted between October 2016 were related to the treatment and care expenses the par- and June 2017 were the intervention group. The NICU ents had to pay. nurses were trained from July to September 2016 to effectively deliver the intervention to parents of infants Data analysis in the intervention group. The statistical analysis was performed using SPSS19.0 In the standard care group, parents were asked to follow software. Descriptive statistical methods were used to the routine caring model and comply with the hospital analyze the data. The t-test and χ test were used to com- rules and regulations. The parents were not allowed to be pare the clinical outcomes between the FIC group and the involved in the treatment and care of their infants except standard care group. A p-value of < 0.05 indicates statis- for visits by means of video connection every Monday, tical significance. Wednesday, and Friday. The FIC intervention required parents to accept the FIC Ethical considerations training from qualified nurses before they entered the The study protocol was approved by the Institutional NICU. The training items included: 1) Hand hygiene: Review Board of Hunan Children’s Hospital (HCHLL- Parents were instructed to wash their hands under run- 2015-33). The data of the standard care group were re- ning water in 7 steps, and informed of the times to wash trievedfromthe medicalrecords andmadeanonymous to hands, such as before entering the NICU and before feed- include in the study analysis. Therefore, a signed consent ing. 2) Neonatal feeding: Parents were encouraged to form was waived. Parents in the FIC group received an invi- breastfeed their infant and communicate at the same time tation letter and information about the study. A member of to allow the infant to become familiar with the mother, the FIC research group also verbally explained the study. feel loved and relieve anxiety. 3) Neonatal contact: Parents Parents could withdraw participation without reason. A were told to touch the infant in the sequence of head and signed informed consent was required and collected. face, chest, abdomen, limbs, hands and feet then back with moderate to intense force and rub large muscle groups. 4) Patting on the back of the infant: Parents were instructed Results to smoothly pat the back of their infant with hollow hands A total of 319 cases were eligible, of which 58 cases were from the outside to the inside and from top to the bottom excluded because parents did not want to participate or 30 min before a meal or two hours after. 5) Involvement were unable to stay for the required hours per day. of care: Parents were encouraged to bath the infant, Among the remaining 261 cases, 13 infants died or were change diapers, and perform other basic care. in palliative care. Included in the final analysis were 115 Parents in the FIC group were involved in non-medical infants in the FIC group and 134 in the standard care care of their infant for at least three hours a day between group (Fig. 1). He et al. Italian Journal of Pediatrics (2018) 44:65 Page 4 of 7 Fig. 1 Flowchart of study participants. Legend. FIC=Family Integrated care Characteristics of infants and parents Clinical outcomes of infants with BPD A total of 249 infants were included in the study, of Table 2 shows the clinical outcomes of infants with BPD. which 168 were male. The mean gestational age and There were significant differences (P < 0.05) in respira- birth weight of infants in the FIC group were signifi- tory support time (invasive or non-invasive ventilator cantly lower than in the standard care group (P < 0.05). support), breastfeeding rate, breastfeeding time, enteral Also, father’s education was higher in the FIC group nutrition time and weight gain rate between the infants (Table 1). of the FIC group and standard care group. No significant differences (P > 0.05) were found in length-of-stay, hospitalization expenses, oxygen exposure time and BPD Table 1 Infant and Parent Characteristics outcome. Characteristics FIC Control P value (n = 115) (n = 134) Discussion Male (n, %) 75 (65.2) 93 (69.4) 0.482 The FIC model was implemented in the NICUs of two Female (n, %) 40 (34.8) 41 (30.6) Chinese children’s hospitals to test the feasibility of this Gestational age; weeks 29.9 (1.8) 30.79 (2.0) <0.001 model. Our study provides evidence that FIC might (mean, SD) improve the clinical outcomes of infants with BPD and Birth weight; gram 1352.6 (267.5) 1441.2 (376.8) 0.021 could provide a reference for further utilization of FIC (mean, SD) in other children’s hospitals in China. A survey of 129 Father’s age; years 33 (5.8) 32 (6.3) 0.401 pediatric nurses in Hunan Province about the know- (mean, SD) ledge, attitudes and behaviors of FIC before and after a Father’s education training course revealed that most nurses (74%) were (n,%) willing to deliver the FIC model regardless of the train- Below high school 31 (27.0) 61 (45.5) 0.004 ing [23]. Consequently, with the results of this interven- High school 32 (27.8) 36 (26.9) tion study we now participate in a larger multi-center Above high school 52 (45.2) 37 (27.6) RCT to test FIC in a larger NICU population [24]. Mother’s age; years 30.(4.8) 29 (4.9) 0.087 The FIC model allows the parents of infants with BPD (mean, SD) to participate in the care and provides them with train- Mother’s education ing to better understand the methods and benefits of (n, %) breastfeeding. The breastfeeding rate and time in our Below high school 38 (33.0) 55 (41.0) 0.293 study was significantly higher in infants in the FIC group High school 26 (22.7) 32 (23.9) than in the standard care group. Verma and colleagues also confirmed in their study that providing training to Above high school 51 (44.3) 47 (35.1) 1 2 2 parents and involving parents in care (n = 148) increases Chi-square test (χ ); Student t-test; FIC Family Integrated Care, SD Standard Deviation the breastfeeding rates to 80% [25]. He et al. Italian Journal of Pediatrics (2018) 44:65 Page 5 of 7 Table 2 Infants’ Clinical Outcomes FIC and Control Group Outcomes FIC Control P value n = 115 n = 134 Length-Of-Stay; days (mean, SD) 52 (10.5) 49 (20.2) 0.084 Hospital expenses (RMB, mean, SD) 84,409 (27,766.2) 87,602 (37,343.5) 0.391 Oxygen exposure time; days (mean, SD) 39 (14.9) 41 (13.8) 0.393 Respiratory support time; days (mean, SD) 16 (10.8) 25 (13.0) < 0.001 Breastfeeding Yes (%) 95 (82.6) 95 (70.9) 0.030 No (%) 20 (17.4) 39 (29.1) Breastfeeding time; days (mean, SD) 31 (20.2) 19 (19.5) < 0.001 Enteral nutrition time; days (mean, SD) 50 (15.9) 34 (22.9) < 0.001 Weight gain rate; grams/day (mean, SD) 28.5 (14.6) 23.3 (9.9) 0.002 BPD outcome Complete recovery (n, %) 81 (70.4) 86 (64.2) 0.422 Incomplete recovery (n, %) 34 (29.6) 45 (33.6) Death (n, %) 0 3 (2.2) Re-admission within 1 Month Yes (n, %) 14 (12.2) 21 (15.7) 0.492 No (n, %) 101 (87.8) 113 (84.3) 1 2 2 Chi-square test (χ ); Student t-test; FIC Family Integrated Care, SD Standard Deviation, BPD Bronchopulmonary Disease, RMB RenMinBi (Chinese Yuan) We found that the respiratory support time for infants more time with the increase of the demands of the in- with BPD in the FIC group was significantly reduced. fant for breastfeeding [10]. The clinical outcomes of the Ortenstrand, et al. [26] also demonstrated that family in- infants showed a significant positive weight gain and a volvement in care significantly reduced the number of significant increase in breastfeeding. We acknowledge infants with moderate to severe BPD from 6% in the that the length of time of parents taking care of their in- standard care group to 1.6% in the family care group. fant could have influenced our results. Secondly, private Thus, FIC might suggest that parents’ involvement in rooms were not available for parents and their infants to care might have a positive effect on the infants’ health spend time together due to lack of space in the NICU. and outcomes. Therefore, we placed a screen at the infant’s bedside to Although the length-of-stay in our study did not show provide privacy for parents to interact with their infant. significant improvements, Melnyk et al. [7] and Bhutta et A systematic review identified the benefits of single al. [27] demonstrated that allowing parents to care for room designed NICUs and conclude that single family their infant can reduce length-of-stay. However, Welch et room NICUs might decrease length-of-stay and reduce al. [28] argued that although the average length-of-stay of readmissions [29]. Thirdly, we observed a substantial infants in a FIC model was 3.4 days less than that for in- imbalance of the number of cases in the FIC interven- fants under routine care and the median length-of-stay tion group between the two hospitals; 37 infants were was 4 days less, there was no statistical significance. Our included from Guiyang Children’s Hospital in the FIC results indicated no significant difference even though the group compared to 83 infants from Hunan Children’s length-of-stay of infants in the FIC group was longer than Hospital (n = 83). It was unclear how the differences the control group, which may be associated with the sig- occurred. A reason could be the termination of the nificantly lower gestational age of infants in the FIC group one-child policy beginning 2016 which might have led than the standard care group. The respiratory support to differences in birth rate in the two provinces. The time of infants in our FIC group was significantly lower differences in proportion of infants from the two hospi- than the standard care group, but the oxygen exposure tals between the pre and post-intervention groups time and length-of-stay of the FIC group were significantly could represent a bias for the results and a larger study higher than the standard care group, resulting in higher in the future is needed to test the effect of a FIC inter- average hospitalization expenses of the FIC group. There- vention. Finally, the Chinese tradition of “zuo yuezi” fore, the impact of the FIC model on length-of-stay and (sitting the month) means that mothers are expected to hospitalization expenses needs to be further studied. rest indoors and avoid heavy physical activity for one Our study is subject to some limitations. Firstly, par- full month after giving birth. Therefore, several infants ents only stay for a minimum of three hours a day, were cared for by their fathers but after discharge were which is short and fragmented. A recent study used the then cared for by the mothers at home. Therefore, spe- inclusion criteria of a minimum of eight hours and even cific information about discharge planning that might He et al. Italian Journal of Pediatrics (2018) 44:65 Page 6 of 7 have influenced the readmission rate could not be shared data collection; data analysis and interpretation; writing the first draft of the manuscript; agrees to be accountable for all aspects of the work in ensuring with the mothers. that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Conclusion Our study suggests that the FIC model is feasible in Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board of Hunan NICUs and might result in significant improvements Children’s Hospital, Changsha, China. (reference number HCHLL-2015-33). The of infants’ clinical outcomes such as weight gain, data of the standard care group were retrieved from the medical records and breastfeeding time, breastfeeding rate and respiratory made anonymous to include in the study analysis. Therefore, a signed consent form was waived. Parents in the FIC group received an invitation letter and support time. Therefore, this study might be support- information about the study. A member of the FIC research group also verbally ive to all NICUs who consider implementing the in- explained the study. Parents could withdraw participation without reason. A volvement and empowerment of parents in the care signed informed consent was required and collected. and decision making of their infant. However, further studies are needed to explore the benefits of FIC in Competing interests The authors declare that they have no competing interests. infants and parent reported outcomes. Abbreviations Publisher’sNote BPD: Broncho-pulmonary Disease; FIC: Family Integrated Care; NICU: Neonatal Springer Nature remains neutral with regard to jurisdictional claims in Intensive Care Unit; RMB: RenMinBi (Chinese Yuan); SD: mean and standard published maps and institutional affiliations. deviation; USD: U.S. dollar; WHO: the World Health Organization Author details Acknowledgements Nursing Department, Hunan Children’s Hospital, Ziyuan Rd, Changsha, We thank all the staff of the NICUs of Hunan Children’s Hospital and Guiyang 410007 Hunan Province, China. Hunan University of Traditional Chinese Children’s Hospital for delivering the intervention and their engagement in Medicine, Xueshi Rd, Changsha, Hunan, China. Division of Neonatal the study. We thank the parents who agreed to participate in the study. Medicine, Hunan Children’s Hospital, Ziyuan Rd, Changsha, 41007 Hunan Province, China. 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Journal

Italian Journal of PediatricsSpringer Journals

Published: Jun 5, 2018

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