This is a title that I hope caught your eye. In the nearly twenty years I have been in the field of Pediatrics the topic of parking being a barrier to parental visitation has come up again and again. A few years ago the concern about the cost of parking was so great that I was asked if I could find a pool of donors to purchase parking passes to offset the burden to the family. The theory of course is based on the idea that if parking were free in the NICU parents would visit more. If parents visit more they will be more involved in the care of their baby, more likely to breastfeed and with both of these situations in play the infant should be discharged earlier than other infants whose parents don’t visit. Try as I might it was a tough sell for donors who tend to prefer buying something more tangible that may bear their name or at least something they can look at and say “I bought that”. This is quite tough when it comes to a parking stall and as such I am still looking for that elusive donor. Having said that, is there any basis to believe that free parking is the solution that will deliver us from minimal visitation by some parents?
A Study May Help Answer The Question
Northrup TF et al published an article that was sent my way and to be honest I couldn’t wait to read it. A freeparking trial to increase visitation and improve extremely low birth weight infant outcomes. This is like the holy grail of studies. A study that gets right to the point and attempts to answer the exact question I and others have been asking for some time. The study took place in Houston, Texas and was set up as an RCT in which families were randomized into two groups. Inclusion criteria were birth weight ⩽1000 g, age 7 to 14 days and deemed likely to survive. Seventy two patients were enrolled in the free parking group while 66 were placed in the usual care. Interestingly the power calculation determined that they would need 140 to show a difference so while 138 is close it wasn’t enough to truly show a difference but let’s see what they found.
Free parking made absolutely no difference for the whole group. Specifically there was no difference in the primary outcome of length of stay or hours spent per visit. Some interesting information though that may not be that surprising was found to be of importance in the table below.
It may not seem like a surprise but the patients who were more affluent and those who had less children tended to visit more. The latter makes a lot of sense as what are many people to do when they have one or more other children to care for at home especially in the face of little support? Would free parking make one iota of difference if the barrier has nothing to do with the out of pocket cost?
The conclusion was that the strategy didn’t work that well but as you may have picked up I think the study was flawed. By applying the strategy to all they were perhaps affected by choosing the wrong inclusion criteria. Taken to an extreme, would a 50 million dollar Powerball winner care one bit about parking vouchers? It wouldn’t make any difference to whether they were going to come or not. Similarly a single mother with 5 other kids who lives below the poverty line and has little support is not going to come more frequently whether they have a voucher or not.
What if the study were redone?
I see a need to redo this study again but with different parameters. What if you randomized people with a car or access to one who lived below a certain income level and had a committed support person who could assure that team that they could care for any other children the family had when called upon? Or one could look at families with no other children and see if offering free parking led to more frequent visitation and then from there higher rates of Kangaroo Care and breastfeeding. I for one haven’t given up on the idea and while I was truly excited to be sent this article and sadly initially dismayed on first read, I am hopeful that this story has not seen it’s end.
It is intuitive to me that for some parents parking is a barrier to visiting. Finding the right population to prove this though is the key to providing the evidence to arm our teams with evidence to gain support from hospital administrations. Without it we truly face an uphill battle to get this type of support for families. Stay tuned…
This is a posting of an article in Pediatrics. Always wondered whether this little venture of mine would be studied. Not this blog in particular but the whole concept in general! The credit of course for this post is not mine but Dr. Moreno who wrote the piece but as the link wouldn’t work well on the Facebook page independently here you go.
Mastering the Media: Physician bloggers identify benefits, barriers to using social media
Megan A.Moreno, M.D., M.S.Ed., M.P.H., FAAP
A growing number of physicians use social media as a professional platform for health communication. This trend is not lost on medical students and residents, who are among the demographic described as “most connected” via social media.In 2014, a medical student asked me to serve as her mentor for a public health research project. The student, Lauren Campbell, was interested in studying how physician bloggers see themselves and their role as bloggers, as well as the benefits and risks of blogging as a doctor. Given the newness of physician blogging, the purpose of the study was to understand the perspectives and experiences of physicians who could be considered early adopters of using social media to distribute health information.
We recruited physicians to take part in the study through website searches for physician bloggers, and in-depth telephone interviews were conducted with those who agreed to participate. At the end of the interview, participants were asked if they could recommend other physician bloggers, a technique known as “snowball sampling.”
Seventeen physicians participated in the study, which recently was published in BMC Medical Informatics and Decision Making (http://bit.ly/2bFtno9). About one-third were female and 76% were pediatricians.
Transcripts were analyzed for common themes mentioned across interviews.
Participants identified multiple perceived benefits and barriers to social media use by physicians. Benefits included forwarding career endeavors, keeping up with medical literature and increasing public exposure for their practice. Barriers included time, administrative hurdles to get permission from their institution to blog and fear of saying the wrong thing.
In addition, four major themes were commonly discussed across interviews. First, participants often saw themselves as “rugged individualists” who set their own rules for social media health communications, like cowboys taming the Wild West.
Second, participants expressed uncertainty about boundaries and strategies for social media use. They identified many gray areas such as what to post, how to post and how to set boundaries.
Third, an interesting and unexpected finding was that most of the physician bloggers described using social media much like traditional media, as a one-way communication platform or “soapbox” rather than as an interactive forum.
Finally, participants had disparate views regarding the time involved in social media use; some felt they could fit blogging into their day, while others saw it as an impediment to patient care.
From this study, we concluded that much uncertainty remains regarding roles and responsibilities of physicians providing medical content within social media, and opportunities exist for providers to use social media platforms interactively and to their full potential.
It’s worth considering how the AAP Council on Communications and Media or the Academy could develop best practices to address some of this uncertainty and provide physicians with training or tools to use social media for its true interactive purpose. The hope is that future studies will investigate these key topics so the “Wild West” of physician blogging will become an integrated metropolis.
Dr. Moreno is a member of the AAP Council on Communications and Media Executive Committee.
Campaign Closed October 13,2016! Thank you everyone for the $9359.00 raised!
First off I would like to thank everyone who has contributed to the fundraiser that All Things Neonatal has organized. Each gift no matter how small makes a difference one person at a time. I am overwhelmed not just by the generosity of the people who follow the Facebook page and this blog but by the numbers of people that have an interest in well… All things that are neonatal! The same day as the campaign began the Facebook page passed 10000 likes and that is saying something. When I started I had no idea where this would go and here we are just a year and a half in and by definition we can now say goodbye to our classification as a town and consider ourselves a city having reached 10000!
With respect to the subject of generosity though I would like to make special mention and a public thank you to two very large donations that came today. The first is from Vickar Community Chevrolet who gave $500 towards the cause. Given that I was looking for donations as small as $1 per member on the site I consider this to be quite amazing. It is quite inspiring to think that a company operating completely outside of the health care field still takes the time to recognize the importance of the needs of babies in our hospital.
The second “shout out” I feel the need to give is to a company that to be honest I had not heard of until today. The company is The Nanny Company Inc who operate out of Winnipeg and I am sure would be of use to many of the families that I have discharged who themselves may find themselves in need of such help. The Nanny Company today gave $1000 towards the fundraiser and with their donation I am proud to say we crossed the first threshold of $2000 and I am proud to announce we can officially buy one milk warmer for the NICU in Winnipeg!
It is these kind of selfless acts that make me believe in the power of community. Whether you live in Winnipeg or not it doesn’t really matter. We all share space on this planet of ours and whether a baby is in Winnipeg, LA, Auckland or Capetown they all need our help. With that I ask you again whether you have followed this page or not if you can spare the cost of a cheap cup of coffee and use the power that we have with 10000 members to reach our goal of at least 4 milk warmers. If you would consider it click on this link below to Hold Their Hand and do something that you will feel great about this Weekend!
Campaign Closed October 13,2016! Thank you everyone for the $9359.00 raised!
Each day the number of people following these sites grows and at the time of this post, the largest following on Facebook has over 8200 people who receive the feed on a daily basis. That is nothing short of remarkable and I hope that each of you gets something out of my writings and postings. I recognise that each post may not “light it up” in your mind but if you get at least a few “a ha” moments along the way then I am very happy that you have found these sites!
What This Is Not!
As I begin hinting at money, many of you may be thinking “here we go”, he is finally asking for some payment for this site! To be clear I have no interest in personal financial gain from this hobby I have developed, but rather find my joy in sharing ideas, getting your feedback and helping to generate interest overall in topics pertaining to Neonatology. I have no intention of ever asking for such payment but that doesn’t mean that I might not want to help someone else. For those of you who make philanthropy a part of your lives you will know the joy that comes from helping others. Being able to help others need not take tremendous dollars per donor when you have many people banding together to help a cause. This is the power that I am hoping to harness through this initiative and make a difference in care to our babies in hospital.
For the past year and a half, I have put my fingers to the keyboard to hopefully share my knowledge and expertise with you about an industry I am so passionate about.
My Philanthropic Side
When I am not busy finding content for the sites or being a Neonatologist, I am quite dedicated to philanthropy. One thing people may not realise about our province/country is that the government helps out the best they can financially but with the heavy demands of our province, they can’t meet all the needs. That’s why I’m proud of my partnership with the Children’s Hospital Foundation of Manitoba. The Foundation’s donors have helped bridge the gap so our hospital doesn’t go without the specialised items they need. From ultrasounds, starting a breast milk depot, specialised pediatric equipment and funding a position to support Quality Improvement in our unit to a soon to be announced Family Support coordinator position and so much more. But now, I turn to you to help us make the next difference in our unit.
The other day as the Facebook page hit 8,000 followers a thought struck me. What if I asked everyone on the page to just give $1 towards the purchase of a piece of equipment for babies in our units?
Hold Their Hand
In the Neonatal Intensive Care Unit (NICU), they are watched closely to make sure they are getting the right balance of fluids and nutrition. Incubators or special warmers help babies maintain their body temperature. This reduces the energy the babies have to use to stay warm and allow them to use that energy elsewhere.
Premature babies need to receive good nutrition so they grow at a rate close to that of babies still inside the womb. Babies born under 38 weeks have different nutritional needs than babies born at full term (after 38 weeks). They often have problems feeding from a bottle or a breast. This is because they are not yet mature enough to coordinate sucking, breathing, and swallowing.
Many NICUs will give donor milk from a milk bank to high-risk babies who cannot get enough milk from their own mother. But because the baby must be kept at a certain temperature to stay warm, so does their milk.
Thanks to the generous support of donors to the Children’s Hospital Foundation of Manitoba, 12 milk warmers have been purchased. However, we need 24 more warmers to keep up with demand. Each one costs $2,000 and will make a huge impact. An impact to help our babies get the nutrition they need at the temperature they require to survive and thrive.
So let’s hold their hand and let’s do it together! Has this journey of learning been worth at least $1 to you? If it has, then please help make a difference by giving at least $1. Giving more will only increase the power of this campaign! If you aren’t able to donate $1 or more, I ask that you share this post and challenge your friends to help make a difference to the over 1,000 patients we see a year. Click the link below to donate and make your difference today.
A question that we are asked from time to time is whether a home apnea monitor should be purchased after discharge from the hospital. The typical parent is one who has experienced the ups and downs of apnea of prematurity and is faced with the disturbing notion of coming off monitors and going home. “What if he has an event at home and I don’t know”? This leads to a search on the web for home monitors which finds numerous options to choose from. This is where things get interesting from a North American perspective.
In the two centres I have worked at in Canada our answer to such a question is to save your money and not buy one. Contrast this with two families I know in the US who were sent home by the hospital with home apnea monitors. How can the advice between the two nations be so different? I suspect the great risk of a lawsuit in the US is responsible at least in part but it may have to do with risk tolerance as well.
What does the evidence say?
First off, one might surmise that the use of a home apnea monitor helps hospitals move patients to the home faster than those centres that don’t prescribe them. A 2001 Cochrane systematic review on the subject noted that this was not the case and determined that out of nearly 15000 neonates studied the greatest predictor of sending such babies home on monitors was physician preference.
In the largest home monitoring study of its kind, the Collaborative Home Infant Monitoring Evaluation (CHIME) demonstrated some very important information. First off, ex-preterm infants have events and some of them quite significant after discharge. What the study which followed discharged infants at risk of SIDS in the home environment found though was that term infants also have events although less severe. Does this mean that everyone should run out and buy such monitoring equipment though? No! The main reason was that while the study did show that events may continue after discharge, it failed to show that these events had any relation to SIDS. The apneic events noted in hospital disappeared long before the arrival of a risk for SIDS. They really are separate entities.
The other issue with such monitors pertains to false alarms which can lead to sleepless nights, anxiety in parents and eventual abandonment of such technology. This led the AAP in 2005 to declare that they did not endorse such practice. Having said that, it is clear from my own experience with two US ex-preterm infants that this practice remains alive and well.
This monitor has me a little excited as it brings the home apnea monitor into the modern era with smart phone connectivity and at the same time helps the developers of this technology use data collected every two seconds to get a clearer picture on breathing patterns in infants that have been sent home. The saturation monitor in a sock is at the core of this technology which is meant to keep the probe in a relatively stable location. It brings another angle to the concept of wearable tech! What I find most interesting is the claim by the manufacturer that the device has a false alarm rate similar to that of a hospital saturation probe which would make it quite reliable.
I note though that the product has not received FDA approval yet (at least on the source I looked at) but is being worked on. The challenge though is whether this will truly make a difference. It may well have an excellent detection rate and it may in fact detect true apnea leading to bradycardia and cyanosis. What it won’t do though is change the natural history of these events once home. It may capture them very well but I suspect the four events that the mother in the video describes may have been self resolving if she hadn’t intervened. We know from the CHIME study that the events seen in the home did not lead to death from SIDS so I see no reason why these would be different.
Is it useless?
I suppose that depends on your perspective. From a data collection point, obtaining data every two seconds in a cloud based storage environment will allow this company to describe the natural history of respiratory patterns in ex-preterm infants better than I suspect has ever been done before. From a population standpoint I suppose that is something! At an individual level I suppose it depends on your strength of “needing to know”. This may well be the best monitor out there and it may one day be the most reliable. Will it save your baby’s life? I doubt it but might it give you piece of mind if it false alarms very infrequently? I think it just might but based on the low likelihood of it changing the outcome of your baby you won’t see me recommending it. If I come across one make no mistake about it, I will want to play with it myself!
As I said in another post on this topic I have been a huge advocate of RSV prophylaxis since my days as a Pediatric resident. When I started my residency we were not using Palivizumab (Synagis) and I recall admitting 10+ patients per day at times with bronchiolitis. With the use of passive immunization this rate dropped dramatically in Manitoba although rates in other areas of the country may have not seen such significant impacts. Manitoba may be somewhat different from many areas due to the communities in Nunavut being so impacted when RSV enters these areas and can infect many of the children due to crowded living conditions and inability to really isolate kids from one and other. The lack of benefit in other areas though, has no doubt led to controversy among practitioners who often wonder if giving 5 IM injections during the RSV season is indeed worth it. The real question has not necessarily been does it work but to whom should it be given so that you get the most benefit.
In preterm infants without CLD born before 30 + 0 weeks’ GA who are <6 months of age at the start of RSV season, it is reasonable (but not essential) to offer palivizumab. Infants born after 30 + 0 weeks’ GA have RSV admission rates that are consistently ≤7% (Figure 3), yielding a minimum number needed to treat of 18 (90 doses of palivizumab to prevent one RSV admission) if one assumes 80% efficacy and five doses per infant. Therefore, palivizumab should not be prescribed for this group.
Gone are recommendations for treating those from 30 – 32 weeks and moreover 33- 35 weeks if meeting certain conditions. There is a provision for those in Northern communities to expand these criteria to 36 0/7 weeks if such infants would require medical transport to receive care for bronchiolitis. What is not really clear though is what is meant by Northern communities in terms of criteria to determine suitability exactly.
“The burden of RSV disease and costs associated with transport from remote locations may result in a broader use of palivizumab for RSV prevention in Alaska Native populations and possibly in selected other American Indian populations.”
The American guideline also states that it is for those infants who are “well” and under 29 weeks that RSV prophylaxis is appropriate but from 29 – 32 weeks use should be restricted to those babies who are on oxygen at 28 days of life.
The authors of this study found that while during the RSV season admission for RSV bronchiolitis was lower from 29 – 32 weeks in those infants who had received Synagis. This would argue that it should be given in this group except for the fact that as the authors state it was a “wash” since hospitalization for non-RSV bronchiolitis in the same population was increased by a similar amount. In essence if you didn’t get RSV you wound up getting something else that still put you in hospital. The conclusion here is that the decision to drop the criterion for prophylaxis to under 29 weeks is supported since from 29 – 32 weeks you can’t prevent hospitalization from viruses that take the place of RSV.
A Few Thoughts Though Before We Conclude It Has No Place
As I stated upfront I am not totally free of bias having seen a very large impact up here in Manitoba. What I worry about though is that we have in medicine a tendency to try and capture the “gist” of a guideline rather than committing it in its entirety to memory. We can’t help ourselves as the volume of information we are asked to remember is growing daily. What this may lead to however is changes to our practice that may expose vulnerable infants. The AAP guideline was designed to recommend changes for the otherwise healthy infant under 29 weeks. What I think we are really talking about are the truly exceptional babies. In our institution babies born at less than 29 weeks and certainly those closer to 24 weeks often spend as much as a month on CPAP. At 28 days even if the patient were on room air it might only be due to the fact that they were on distending pressure. Put them on nasal prongs and they would qualify.
Another important consideration is the remote location point. Here in Canada the majority of the population lives along the border with the US. Take a look though at our population density and you can see that for our Aboriginal (Indian) and Inuit populations as well as all those living in the north we have a significant need to protect them. Living conditions in these places involve overcrowding and high smoking levels both ideal breeding grounds for transmission of RSV and an intolerance to handling the inflammation in your bronchioles. The same is likely true of many parts of Alaska for my US readers.
It would be too easy to simply state “I only need to give Synagis to those babies under 29 weeks now” but that would do a disservice to the populations in our remote communities both here and in the US.
In case you are wondering, I am not employed by the makers of Synagis here or in the US nor do I have any financial or conflicts otherwise. I am someone I suppose who has seen the difference of before and after and while I will let others debate the merits of giving Synagis from 29 – 32 weeks and above, I wrote this as a reminder that not all populations are the same and therefore we should not paint all susceptible patients with one brush.