Team Stress and Adverse Events during Neonatal Tracheal Intubations: A Report from NEAR4NEOS

Abstract

Objective This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations.

Study Design TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated.

Result In this study, 208 of 2,009 TIs (10%) had high stress levels (score < 4). Oxygenation failure, hemodynamic instability, and family presence were associated with high stress level. Video laryngoscopy and premedication were associated with lower stress levels. High stress level TIs were associated with adverse TI-associated event rates (31 vs. 16%, p < 0.001), which remained significant after adjusting for potential confounders including patient, provider, and practice factors associated with high stress (odds ratio: 1.90, 96% confidence interval: 1.36–2.67, p < 0.001).

Conclusion High team stress levels during TI were more frequently reported among TIs with adverse events.

Keywords

stress - adverse events - neonatal - tracheal intubations - teamwork

Authors' Contributions

All authors are responsible for the reported research and have participated in the following: concept and design; acquisition, analysis, and interpretation of data; drafting and revising the article; approval of the version submitted.

Publication History

Received: 23 March 2019

Accepted: 13 June 2019

Article published online:
31 July 2019

• References

• 1 Sawyer T, French H, Ades A, Johnston L. Neonatal-perinatal medicine fellow procedural experience and competency determination: results of a national survey. J Perinatol 2016; 36 (07) 570-574
• 2 Foglia EE, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors associated with adverse events during tracheal intubation in the NICU. Neonatology 2015; 108 (01) 23-29
• 3 Hatch LD, Grubb PH, Lea AS. et al. Endotracheal intubation in neonates: a prospective study of adverse safety events in 162 infants. J Pediatr 2016; 168: 62-66
• 4 Foglia EE, Ades A, Sawyer T. et al; NEAR4NEOS Investigators. Neonatal intubation practice and outcomes: an international registry study. Pediatrics 2019; 143 (01) e20180902
• 5 Li S, Rehder KJ, Giuliano Jr JS. et al; National Emergency Airway Registry for Children (NEAR4KIDS) Investigators; Pediatric Acute Lung Injury and Sepsis Investigator PALISI Network Investigators. Development of a quality improvement bundle to reduce tracheal intubation-associated events in pediatric ICUs. Am J Med Qual 2016; 31 (01) 47-55
• 6 Sawyer T, Foglia E, Hatch LD. et al. Improving neonatal intubation safety: a journey of a thousand miles. J Neonatal Perinatal Med 2017; 10 (02) 125-131
• 7 Dietz AS, Driskell JE, Sierra MJ, Weaver SJ, Driskell T, Salas E. Teamwork under Stress. In: Salas E, Rico R, Passmore J. , eds. The Wiley Blackwell Handbook of the Psychology of Team Working and Collaborative Processes. Hoboken, NJ: Wiley-Blackwell; 2017: 297-315
• 8 Weaver JL, Bowers CA, Salas E. Stress and teams: performance effects and interventions. In: Hancock PA, Desmond PA. , eds. Stress, Workload, and Fatigue. Mahwah, NJ: Lawrence Erlbaum Associates; 2001
• 9 LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T. Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care 2005; 9 (04) 439-444
• 10 Harvey A, Bandiera G, Nathens AB, LeBlanc VR. Impact of stress on resident performance in simulated trauma scenarios. J Trauma Acute Care Surg 2012; 72 (02) 497-503
• 11 Hunziker S, Semmer NK, Tschan F, Schuetz P, Mueller B, Marsch S. Dynamics and association of different acute stress markers with performance during a simulated resuscitation. Resuscitation 2012; 83 (05) 572-578
• 12 Hunziker S, Laschinger L, Portmann-Schwarz S, Semmer NK, Tschan F, Marsch S. Perceived stress and team performance during a simulated resuscitation. Intensive Care Med 2011; 37 (09) 1473-1479
• 13 Leblanc VR, Regehr C, Tavares W, Scott AK, Macdonald R, King K. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med 2012; 27 (04) 369-374
• 14 Bjørshol CA, Myklebust H, Nilsen KL. et al. Effect of socioemotional stress on the quality of cardiopulmonary resuscitation during advanced life support in a randomized manikin study. Crit Care Med 2011; 39 (02) 300-304
• 15 Nater UM, La Marca R, Florin L. et al. Stress-induced changes in human salivary alpha-amylase activity -- associations with adrenergic activity. Psychoneuroendocrinology 2006; 31 (01) 49-58
• 16 Nater UM, Rohleder N. Salivary alpha-amylase as a non-invasive biomarker for the sympathetic nervous system: current state of research. Psychoneuroendocrinology 2009; 34 (04) 486-496
• 17 Harvey A, Nathens AB, Bandiera G, Leblanc VR. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Med Educ 2010; 44 (06) 587-594
• 18 Driskell JE, Salas E, Johnston J. Does stress lead to a loss of team perspective?. Group Dyn 1999; 3 (04) 291
• 19 Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13 (Suppl. 01) i85-i90
• 20 Sawyer T, Laubach VA, Hudak J, Yamamura K, Pocrnich A. Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Netw 2013; 32 (01) 26-33
• 21 Sawyer T, Leonard D, Sierocka-Castaneda A, Chan D, Thompson M. Correlations between technical skills and behavioral skills in simulated neonatal resuscitations. J Perinatol 2014; 34 (10) 781-786
• 22 Smith KA, High K, Collins SP, Self WH. A preprocedural checklist improves the safety of emergency department intubation of trauma patients. Acad Emerg Med 2015; 22 (08) 989-992
• 23 Hatch LD, Grubb PH, Lea AS. et al. Interventions to improve patient safety during intubation in the neonatal intensive care unit. Pediatrics 2016; 138 (04) e20160069
• 24 Nishisaki A, Nguyen J, Colborn S. et al. Evaluation of multidisciplinary simulation training on clinical performance and team behavior during tracheal intubation procedures in a pediatric intensive care unit. Pediatr Crit Care Med 2011; 12 (04) 406-414
• 25 Griffin T. Family-centered care in the NICU. J Perinat Neonatal Nurs 2006; 20 (01) 98-102
• 26 Voos KC, Ross G, Ward MJ, Yohay A-L, Osorio SN, Perlman JM. Effects of implementing family-centered rounds (FCRs) in a neonatal intensive care unit (NICU). J Matern Fetal Neonatal Med 2011; 24 (11) 1403-1406
• 27 Sanders Jr RC, Nett ST, Davis KF. et al; National Emergency Airway Registry for Children NEAR4KIDS Investigators; Pediatric Acute Lung Injury and Sepsis Investigators Network. Family presence during pediatric tracheal intubations. JAMA Pediatr 2016; 170 (03) e154627
• 28 Krick J, Gray M, Umoren R, Lee G, Sawyer T. Premedication with paralysis improves intubation success and decreases adverse events in very low birth weight infants: a prospective cohort study. J Perinatol 2018; 38 (06) 681-686
• 29 O'Shea JE, Thio M, Kamlin CO. et al. Videolaryngoscopy to teach neonatal intubation: a randomized trial. Pediatrics 2015; 136 (05) 912-919
• 30 O'Donnell CP, Kamlin CO, Davis PG, Morley CJ. Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. Pediatrics 2006; 117 (01) e16-e21