Objective To determine the factors associated with second attempt success and the risk of adverse events following a failed first attempt at neonatal tracheal intubation. Design Retrospective analysis of prospectively collected data on intubations performed in the neonatal intensive care unit (NICU) and delivery room from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Setting Eighteen academic NICUs in NEAR4NEOS. Patients Neonates requiring two or more attempts at intubation between October 2014 and December 2021. Main outcome measures The primary outcome was successful intubation on the second attempt, with severe tracheal intubation-associated events (TIAEs) or severe desaturation (≥20% decline in oxygen saturation) being secondary outcomes. Multivariate regression examined the associations between these outcomes and patient characteristics and changes in intubation practice. Results 5805 of 13 126 (44%) encounters required two or more intubation attempts, with 3156 (54%) successful on the second attempt. Second attempt success was more likely with changes in any of the following: intubator (OR 1.80, 95% CI 1.56 to 2.07), stylet use (OR 1.65, 95% CI 1.36 to 2.01) or endotracheal tube (ETT) size (OR 2.11, 95% CI 1.74 to 2.56). Changes in stylet use were associated with a reduced chance of severe desaturation (OR 0.74, 95% CI 0.61 to 0.90), but changes in intubator, laryngoscope type or ETT size were not; no changes in intubator or equipment were associated with severe TIAEs. Conclusions Successful neonatal intubation on a second attempt was more likely with a change in intubator, stylet use or ETT size.

BackgroundApproximately 50% of all neonatal endotracheal intubation attempts are unsuccessful and associated with airway injury and cardiorespiratory instability. The aim of this study was to describe intubation practice at a high-risk Neonatal Intensive Care Unit (NICU) and identify factors associated with successful intubation at the first attempt.MethodsRetrospective cohort study of all infants requiring intubation within the Royal Children's Hospital NICU over three years. Data was collected from the National Emergency Airway Registry for Neonates (NEAR4NEOS). Outcomes were number of attempts, level of operator training, equipment used, difficult airway grade, and clinical factors. Univariate and multivariate analysis were performed to determine factors independently associated with first attempt success.ResultsThree hundred and sixty intubation courses, with 538 attempts, were identified. Two hundred and twenty-five (62.5%) were successful on first attempt, with similar rates at subsequent attempts. On multivariate analysis, increasing operator seniority increased the chance of first attempt success. Higher glottic airway grades were associated with lower chance of first attempt success, but neither a known difficult airway nor use of a stylet were associated with first attempt success.ConclusionIn a NICU with a high rate of difficult airways, operator experience rather than equipment was the greatest determinant of intubation success.ImpactNeonatal intubation is a high-risk lifesaving procedure, and this is the first report of intubation practices at a quaternary surgical NICU that provides regional referral services for complex medical and surgical admissions.Our results showed that increasing operator seniority and lower glottic airway grades were associated with increased first attempt intubation success rates, while factors such as gestational age, weight, stylet use, and known history of difficult airway were not.Operator factors rather than equipment factors were the greatest determinants of first attempt success, highlighting the importance of team selection for neonatal intubations in a high-risk cohort of infants.

AIMS AND OBJECTIVES:To understand how the pandemic environment impacted the delivery of FCC of children and families from a nursing perspective in a major tertiary paediatric hospital.BACKGROUND:Family-centred care (FCC) is a well-established framework to promote parental involvement in every aspect of a child's hospitalization, however, rules and restrictions in place during the COVID-19 pandemic affected the ways in which Family-centred Care could be delivered in practice.DESIGN:This is a qualitative exploratory descriptive study to elicit the perspective of paediatric nurses delivering care to children in a hospital during the COVID-19 pandemic in Victoria, Australia.METHODS:Nurses from all subspecialties in a tertiary paediatric hospital were invited to participate in virtual focus groups to discuss their experience of delivering FCC during the COVID-19 pandemic. Focus groups were recorded and transcribed, then analysed using Framework Analysis.RESULTS:Nineteen nurses participated across seven focus groups during June and July 2020. The four themes-Advocating with empathy, Enabling communication, Responding with flexibility, and Balancing competing considerations-and the eight subthemes that were generated, outline how nurses deliver FCC, and how these FCC actions were impacted by the COVID-19 environment and the related hospital restrictions.CONCLUSION:This study documents the experiences, resilience and resourcefulness of paediatric nurses in Australia during the COVID-19 pandemic as well as moving Family-centred Care from a theoretical framework into a practical reality.IMPACT:The findings from this study should inform consideration of the impacts of public health policies during infectious disease outbreaks moving forward. In addition by describing the core actions of Family-centred Care, this study has implications for educational interventions on how to translate FCC theory into practice. No public or patient contribution as this study explored nursing perceptions only.

Introduction: K-wire removal is a common procedure in the paediatric outpatient clinic that is a source of pain and anxiety. This study examined the current parental experience of k wire removal. Methods: Twenty-six parents of children having k-wires removed in a paediatric outpatient clinic were asked to complete an electronic survey immediately post procedure. Questions explored prior knowledge, sedation and analgesia for the procedure. Data analysis used descriptive statistics. Results: Verbal information from the ward prior to the procedure was the greatest information source for parents 22/26(85%). Thirty-eight % (10/26) of parents had expected sedation but only 6/10(23%) reported receiving sedation information. Only 7/26(27%) of parents reported their child receiving analgesia from themselves or medical staff pre-procedure. Discussion: Parents recommended the need for more procedural information beforehand, especially regarding pain and sedation. Parents were unaware of the option of sedation and wanted analgesia before the procedure.

Introduction: Patient's under-going cardiac surgery commonly experience transient arrhythmias in the post-operative period which can lead to acute deterioration. Temporary epicardial pacing can be a lifesaving adjunct for optimising cardiac output and assisting in the diagnosis and suppression of arrhythmias. In the Paediatric Intensive Care Unit (PICU) at the Royal Children's Hospital, completing pacemaker checks is a medical task. However, nurses are trained how to complete checks as part of their post-graduate studies. To transition pacemaker checks in becoming a dual responsibility, nursing re-education is required for nurses to perform these checks competently. Objectives/Aims: To design and evaluate a temporary epicardial pacing learning package for PICU nurses and evaluate their perceived confidence and readiness to perform temporary epicardial pacing checks. Methods: The pilot was a before-and-after study investigating an educational intervention, the newly developed learning package. Eighty-eight Team Support Nurses (TSN) were emailed to complete a survey before and after completing the learning package. The survey was designed from two areas of Kirkpatrick's model of learning evaluation, reaction and learning. Descriptive data analyses were undertaken from the survey results. Any free text comments were themed and summarised. Results: Fifteen TSN consented to participate. All participants had a post-graduate degree or higher. Post-learning intervention there was a 15% increase in the participant's perceived knowledge of pacing check concepts. Post learning package 73% of TSN felt confident they could safely perform output and sensitivity threshold checks, which was a 58% increase from pre-learning package. Common themes arising from the survey comments included; requirement for more medical collaboration, nursing education, guideline changes and 'nurse-led' care. Conclusion: The learning package on temporary epicardial pacing improved the perceived knowledge and confidence of PICU critical care nurses. More practical education is required to further improve confidence levels and readiness to perform pacing checks.

BACKGROUND:The neonatal Pain Assessment Tool (PAT) is considered a reliable and valid tool for assessing neonatal pain. No research has been conducted on the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. OBJECTIVE:The objective of the study was to determine the clinical utility of the PAT when assessing pain in ventilated, sedated, and muscle-relaxed neonates. METHODS:Neonatal nurses from the Royal Children's Hospital completed online surveys to assess the clinical utility of the PAT. Three focus groups were then conducted to further explore the variation of pain scores from the survey and clarify the challenges in interpreting the pain score. RESULTS:Nurses perceived the PAT clinically useful in neonates who were ventilated and minimally sedated. However, the PAT was not clinically useful in neonates who were ventilated and heavily sedated or muscle-relaxed. Further exploration via focus groups highlighted two themes related to the 'variation in the timing of the pain score' and the 'integration of critical thinking and judgement' used when assessing pain in neonates. CONCLUSIONS:The clinical utility of the PAT is acceptable for minimally sedated neonates; however, it decreases the more sedated a neonate becomes, and the PAT's usefulness is extremely poor in the muscle-relaxed neonate. A better understanding of the timing and interpretation of the pain score in relation to the neonate's clinical status may enable improved decision-making and pain management. The PAT requires further validity, reliability, and clinical utility research, particularly in critically ill and muscle-relaxed neonates.