Abstract
Background and Objective:
The use of telehealth to bring a family member virtually to the bedside for family-centered rounds (FCR) is a promising strategy to increase family members’ access. We aimed to evaluate the impact of offering families the option to use virtual FCR in the neonatal intensive care unit on parental and neonatal outcomes.
Methods:
This two-arm cluster randomized controlled trial assigned families of hospitalized infants to the option of using virtual FCR (intervention) or to usual care (control). Intervention families could also attend FCR in person (usual care). All eligible families of infants who were admitted to this single-site neonatal intensive care unit during the study period were included. Outcomes included FCR attendance, parent experience, family-centered care, parent activation, parent health-related quality of life, length of stay, breastmilk feeding, and neonatal growth.
Results:
From March 2023 to 2024, 486 families were randomized (325 intervention, 161 control). Infants in the intervention arm were estimated to have 4.81 (95% CI 3.65 – 6.32) times the parent attendance rate of infants in the control arm (unadjusted incidence rate ratio: 4.62 [95% CI 3.40 – 6.28]). The intervention arm had 0.37 (95% CI 0.18 – 0.75) times the adjusted odds of a 30-day emergency department revisit compared with the control arm (unadjusted odds ratio: 0.48 [95% CI 0.25 – 0.91]). No statistically significant positive intervention effects were observed for other secondary outcomes.
Conclusions:
Offering virtual FCR increased parent attendance and reduced 30-day emergency department revisits among NICU infants.
Keywords: Pediatrics, Neonatal Intensive Care Units, Neonate, Clinical Trial, Telemedicine, Patient-Centered Care, Patient Reported Outcome Measures
INTRODUCTION
Family-centered rounds (FCR) are multidisciplinary bedside rounds that engage families as active team members.1 Recognized as best practice for hospitalized children,2,3 FCR improves family experience and understanding, parental anxiety, staff teamwork, safety, and length of stay.4–10 However, standard FCR requires families to be at the bedside during the rounding process, which challenges parents or guardians (“parents” hereafter) with infants hospitalized in the neonatal intensive care unit (NICU).
Critically ill infants may have prolonged hospitalizations in regional centers located far from their residence.11 Financial, travel, work, or childcare challenges impede parents’ ability to be physically present in the NICU.12,13 These barriers disproportionately impact low-income and rural families.14
Telehealth is a promising strategy to promote access to FCR by bringing parents virtually to the infant’s bedside to engage in live, bidirectional communications with NICU providers during rounds using audiovisual technology.15 Our team previously demonstrated feasibility of a randomized controlled trial (RCT) of virtual FCR in the NICU.16 This present RCT tests the hypothesis that the option to use virtual FCR would increase FCR parent attendance and improve parent experience, family-centeredness of care, parent activation, parent health-related quality of life (HRQOL), NICU length of stay, safety, and infant feeding and growth.
METHODS
Study Design and Setting
The study protocol was previously published.17 This two-arm superiority cluster RCT used a 2:1 intervention-to-control ratio, with families, comprising infants from the same pregnancy, as the units of randomization. Family units in the intervention arm were offered virtual FCR plus usual care; control arm received only usual care, which was the option to attend FCR in person or not to attend. Enrollment lasted 12 months. Intervention delivery continued for one month after the last enrollment.
This study took place at a 121-bed quaternary care children’s hospital within a university hospital, a referral center across 33-counties spanning 65,000 square miles. The 49-bed level IV NICU admits >900 infants annually and routinely receives patient transfers from 30 hospitals. Pediatric residents are trained in I-PASS FCR,7,18 though NICU FCR practices vary by attending. Per usual care, NICU providers aim to update families daily; if parents in either arm did not attend FCR, a resident or nurse practitioner typically communicated with them after rounds. The study was approved by the [Institution] Institutional Review Board. Trial registration number is NCT05762835.
Study Participants
Eligible infants were <365 days old, admitted to the NICU, and had at least one adult parent or guardian with English language preference. A second parent could have another language preference, with professional interpreters available for both in-person and virtual FCR via the telehealth-integrated interpreting system, Martti™. We excluded infants with child protective services restrictions or repeat NICU admission. Survey data were collected from parents with English language preference.
All enrollment occurred on weekdays, precluding infants with brief NICU stays admitted and discharged over the weekend. Because inpatient telehealth was an existing clinical resource, a waiver of consent was granted. The parent survey packet explained that answering questions signified agreement to participate.
Intervention
Parents in the intervention arm were invited to sign up for virtual FCR and, upon acceptance, provided their preferred contact method (cell phone or email) to receive a secure link to join FCR virtually every weekday morning. For infants with more than one parent listed in the electronic health record (EHR), each received a separate invitation.
The NICU team used a computer on wheels with a speaker and pan-tilt-zoom camera to launch telehealth connections using ExtendedCare Telehealth™, a Health Insurance Portability and Accountability Act compliant application accessed through the EHR. Just prior to each infant’s rounding encounter, a team member sent a text or email link to the parent(s) that opened a browser to join the live videoconference with two-way audio and video. FCR subsequently proceeded as usual with NICU team members and parent(s), with 24/7 technical support available. Typical FCR participants included a neonatologist, neonatal fellow, neonatal nurse practitioners, pediatric residents, charge nurse, bedside nurse, respiratory therapist, pharmacist, and dietician.
FCR occurred on weekdays. Parents in both arms could choose whether to attend FCR in person, while intervention parents could also choose whether to attend virtual FCR. “Mixed” attendance—one parent virtual, one in person—was allowed.
Randomization
The family was the unit of randomization to ensure twins or multiples were assigned to the same study arm. A study statistician generated a random allocation list to assign families with a 2:1 intervention-to-control arm ratio. A non-recruiting team member uploaded the allocation list to the REDCap randomization module, ensuring allocation concealment until after enrollment. Unequal randomization was used to preserve statistical power with only a modest sample size increase (12.5%) while increasing the intervention arm by 50%, allowing greater collection of intervention implementation data.
Outcome Measures
FCR Parent Attendance:
The primary outcome was FCR parent attendance, defined at the family unit level as the number of FCR encounters with at least one parent present virtually or in-person (‘numerator’) among the total number of possible FCR encounters (‘denominator’).
Parent-Reported Outcomes:
Parent experience was assessed using two overall experience items from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey, with top-box scoring.19,20 Family-centered care was assessed using the Family-Centered Care Experience (FACCE) survey.21 Parent activation was assessed using the Parent-Patient Activation Measure (P-PAM), which evaluates parents’ knowledge, skills, and confidence in managing their child’s health.22,23 Parent HRQOL was assessed using the PedsQL™ Family Impact Module, which includes eight subscales (physical, emotional, social, cognitive, communication, worry, daily activities, family relationships) and three summary scores (total, parent, family).24
Eligible parents received these instruments as a survey packet when their infant was discharged from the NICU and the PedsQL™ at 30, 60, and 90 days post-discharge. For families with multiple enrolled infants, packets were distributed based on the last discharge date among their infants. Separate packets were distributed to each parent; respondents received a $15 gift card per completed packet.
Infant Outcomes:
Infant outcomes included NICU length of stay (days), 30-day unplanned revisits to an emergency department (ED), 30-day unplanned hospital readmissions, and medical errors and adverse events. Errors and adverse events were collected through an established process25,26 using the incident reporting system and solicited reports. Two neonatologists, blinded to study arm, independently categorized each event as harmful error, non-harmful error, non-preventable adverse event, or exclusion26 (65.6% agreement; kappa, 0.37; 95% confidence interval [CI], 0.28 − 0.46), with discordances reconciled by discussion.
Dichotomous breastmilk feeding measures included initiation, any feeding at NICU discharge (and 90 days later), and exclusive feeding at NICU discharge (and 90 days later). Breastmilk feeding included any delivery method (bottle, tube, breast). We measured postnatal growth failure at NICU discharge using sex-specific Fenton growth charts, defined as a weight-for-gestational-age Z-score decline of >0.8 standard deviations (SD) from birth to discharge.27,28 Growth failure was categorized as none (decline ≤0.8 SD), mild (>0.8 and ≤1.2 SD), moderate (>1.2 and ≤2 SD), or severe (>2 SD). Feeding and growth outcomes were included based on pilot trial quantitative16 and qualitative29 findings suggesting virtual FCR supported breastmilk feeding through growth and nutrition discussions during rounds that provided reinforcement, education, and troubleshooting.
Sample size
As detailed in our published protocol,17 target enrollment of 447 family units, assuming 4% attrition, would yield a sufficient sample (429 family units) to provide 80% power (2-sided testing, alpha=5%) to detect a minimally clinically important difference of 25% reduction in geometric mean length of stay. The sample size estimation for length of stay met requirements for all other outcomes of interest, except the exploratory outcomes of errors and adverse events.
Statistical Analysis
Using Stata/SE, we analyzed all available data from participating family units, with groups defined as randomized (intervention versus control). We did not replace missing data with imputed values. We adjusted confidence intervals for descriptive statistics using methods for clustered survey data.30 Data from families with child protective services restrictions after randomization and infants still in the NICU at the end of the 13-month intervention period were excluded from secondary and exploratory outcome analyses. We included FCR attendance data from these participants up to the date of restriction, infant death, or end of intervention delivery.
We used generalized linear mixed models to estimate intervention effect sizes and confidence intervals and to test hypotheses. We used outcome-specific sets of covariates. Covariates were selected a priori based on expected association with the outcome and assumed position outside the causal pathway.31 Race/ethnicity was included given evidence of FCR attendance disparities and potential for virtual FCR to reduce them.32 Infant race/ethnicity was obtained from the EHR, and parent race/ethnicity from surveys using the same EHR categories, with multiple selection allowed.
Regression models included random intercepts to accommodate nesting of longitudinal measurements within parents and nesting of parents and infants within family units. For the primary outcome, we used Poisson regression to compare FCR parent attendance between intervention and control groups, using the outcome numerator as the dependent variable and the logarithm of the number of possible rounding encounters as an offset term. We repeated the analysis considering only in-person type of attendance, hypothesizing that virtual attendance increased parents’ perceived value of FCR, thus promoting in-person attendance, yielding a positive intervention effect. The length of stay outcome distribution was right-skewed. Thus, we log transformed values before estimating mean differences. Coefficients were back transformed by exponentiation to estimate the between-group geometric mean length of stay ratio.
We performed subgroup analyses of the primary outcome and explored heterogeneity of treatment effects, using interaction terms for the candidate effect modifier and the intervention effect term(s). Candidate effect modifiers were specified a priori17 and included residence-to-NICU distance; neighborhood health condition using the California Healthy Places Index score (composite measure of census-level indicators linked to life expectancy [e.g., education, housing, economic opportunity, air quality]);33 and birthing parent race, ethnicity, transportation insecurity, employment, device access, internet access, and digital literacy score.34
RESULTS
As shown in Figure 1, from March 2023 to March 2024, 571 family units were screened, and 486 families were included and randomly assigned (325 intervention, 161 control). Intervention and control groups had similar infant and family characteristics (Table 1) and survey respondent characteristics (Table 2).
Figure 1: Trial Flowchart.
FCR – family-centered rounds; NICU – neonatal intensive care unit; CPS – child protective services
a Reasons for ineligibility of parent/guardian: 38 families (43 infants) with no parent/guardian with English proficiency; 3 families (3 infants) with no parent/guardian aged 18 years or older; 1 family (1 infant) no un-incarcerated parent/guardian
b Infant admitted and discharged on a weekend or during other periods of time when a research assistant was not working
c Identification of the lack of an eligible parent or guardian occurred after study arm allocation
d 278 families (278 infants) assigned to the intervention group had a nonzero number of possible FCR encounters; 139 families (139 infants) assigned to the control group had a nonzero number of possible FCR encounters
e Restrictions placed after study arm allocation
Table 1:
Infant and Family Unit Characteristics by Intervention versus Control Group
| Intervention n=345 infants |
Control n=169 infants |
|||
|---|---|---|---|---|
| Infant Characteristics | ||||
| Gestational Age, weeks, mean (95% CI) | 35.3 | (34.8 – 35.8) | 35.3 | (34.6 – 36.0) |
| Admission Age, days, mean (95% CI) | 4.4 | (2.6 – 6.2) | 4.5 | (2.3 – 6.8) |
| Admission Age, days, median (IQR) | 0 | (0 – 0) | 0 | (0 – 2) |
| Birth Location, n (%) | ||||
| Inborn Delivery | 224 | (65.1%) | 99 | (58.9%) |
| Outborn Delivery | 120 | (34.9%) | 69 | (41.1%) |
| Sex, n (%) | ||||
| Male | 191 | (55.4%) | 100 | (59.2%) |
| Female | 154 | (44.6%) | 69 | (40.8%) |
| Race, n (%) a | ||||
| White | 138 | (40.0%) | 61 | (36.1%) |
| Asian | 28 | (8.1%) | 18 | (10.7%) |
| Black or African American | 36 | (10.4%) | 10 | (5.9%) |
| American Indian or Alaska Native | 3 | (0.9%) | 1 | (0.6%) |
| Native Hawaiian or other Pacific Islander | 0 | (0%) | 2 | (1.2%) |
| Other | 121 | (35.1%) | 66 | (39.1%) |
| Unknown | 19 | (5.5%) | 11 | (6.5%) |
| Ethnicity, n (%) | ||||
| Not Hispanic or Latino | 242 | (70.1%) | 115 | (68.1%) |
| Hispanic or Latino | 79 | (22.9%) | 42 | (24.9%) |
| Unknown | 24 | (7.0%) | 12 | (7.1%) |
| Insurance, n (%) | ||||
| Public | 201 | (58.3%) | 85 | (50.3%) |
| Private | 130 | (37.7%) | 76 | (45.0%) |
| Other | 14 | (4.1%) | 8 | (4.7%) |
| Birth Weight, kilograms, mean (95% CI) | 2.504 | (2.397 – 2.611) | 2.528 | (2.374 – 2.682) |
| Invasive Ventilator Use, n (%) | 82 | (26.7%) | 49 | (31.2%) |
| Disposition, n (%) | ||||
| Discharged Home | 224 | (64.9%) | 107 | (63.3%) |
| Transfer to Other Unit | 86 | (24.9%) | 44 | (24.0%) |
| Transfer to Other Hospital | 13 | (3.8%) | 8 | (4.7%) |
| Still in the NICU at Trial Primary Endpoint | 9 | (2.6%) | 4 | (2.4%) |
| Died | 13 | (3.8%) | 6 | (3.6%) |
| Neighborhood Health Condition b | ||||
| 1st quartile (worst health) | 95 | (31.3%) | 42 | (26.9%) |
| 2nd quartile | 78 | (25.7%) | 49 | (31.4%) |
| 3rd quartile | 99 | (32.6%) | 47 | (30.1%) |
| 4th quartile (best health) | 32 | (10.5%) | 18 | (11.5%) |
| Residence-to-NICU Distance, miles, mean (95% CI) | 56.6 | 44.4 – 68.8 | 41.2 | 34.5 – 47.9 |
| Residence-to-NICU Distance, miles, median (IQR) | 36.7 | 10.4 – 73.9 | 34.8 | 10.9 – 56.9 |
| Intervention n=325 families |
Control n=161 families |
|||
| Family Unit Characteristics | ||||
| Number of Infants per Family Unit, n (%) | ||||
| One | 308 | (94.8%) | 153 | (95.0%) |
| Two | 14 | (4.3%) | 8 | (5.0%) |
| Three | 3 | (0.9%) | 0 | (0%) |
| Birthing Parent Age, mean (95% CI) | 30.6 | (29.9 – 31.2) | 31.4 | (30.4 – 32.3) |
| Birthing Parent Parity, mean (95% CI) | 1.6 | 1.4 – 1.7 | 1.3 | 1.1 – 1.6 |
| Birthing Parent Parity, median (IQR) | 1 | 0 – 2 | 1 | 0 – 2 |
CI – confidence interval. NICU – neonatal intensive care unit. IQR – interquartile range.
Race data obtained from the electronic health record using the existing electronic health record categories. Response options included “other” and allowed for multiple selection.
Neighborhood health condition quartiles based on the California Healthy Places Index.
Table 2:
Parent or Guardian Survey Participant Characteristics by Intervention versus Control Group
| Intervention n=242 |
Control n=119 |
|||
|---|---|---|---|---|
| Birthing Parent Characteristics a | ||||
| Age, mean (95% CI) | 31.1 | 30.4 – 31.9 | 31.7 | 30.6 – 32.7 |
| Gender, n (%) | ||||
| Female | 238 | (98.4%) | 118 | (99.2%) |
| Male | 2 | (0.8%) | 1 | (0.8%) |
| Non-binary or Other | 0 | (0%) | 0 | (0%) |
| Unknown | 2 | (0.8%) | 0 | (0%) |
| Race, n (%) b | ||||
| White | 103 | (42.6%) | 62 | (52.1%) |
| Asian | 29 | (12.0%) | 15 | (12.6%) |
| Black or African American | 27 | (11.2%) | 7 | (5.9%) |
| American Indian or Alaska Native | 10 | (4.1%) | 3 | (2.5%) |
| Native Hawaiian or other Pacific Islander | 5 | (2.1%) | 3 | (2.5%) |
| Multiple | 22 | (9.1%) | 9 | (7.6%) |
| Other | 42 | (17.4%) | 19 | (16.0%) |
| Unknown | 4 | (1.7%) | 1 | (0.8%) |
| Ethnicity, n (%) | ||||
| Not Hispanic or Latino | 164 | (67.8%) | 84 | (70.6%) |
| Hispanic or Latino | 76 | (31.4%) | 35 | (29.4%) |
| Unknown | 2 | (0.8%) | 0 | (0.0%) |
| Education, n (%) | ||||
| 8th Grade or Less | 1 | (0.4%) | 1 | (0.8%) |
| Some High School | 16 | (6.6%) | 5 | (4.2%) |
| High School Graduate or GED | 64 | (26.5%) | 24 | (20.2%) |
| Some College or 2-Year Degree | 77 | (31.8%) | 45 | (37.8%) |
| 4-Year College Graduate | 40 | (16.5%) | 22 | (18.5%) |
| More than 4-Year College Degree | 42 | (17.4%) | 22 | (18.5%) |
| Unknown | 2 | (0.8%) | 0 | (0.0%) |
| Employment in Past 12 Months, n (%) c | ||||
| No Weeks Worked | 78 | (32.2%) | 28 | (23.5%) |
| 1–25 Weeks Worked | 29 | (12.0%) | 14 | (11.8%) |
| 26–47 Weeks Worked | 54 | (22.3%) | 29 | (24.4%) |
| 48–52 Weeks Worked | 56 | (23.1%) | 33 | (27.7%) |
| Unknown | 25 | (10.3%) | 15 | (12.6%) |
| Transportation Insecurity in Past Month, n (%) d | ||||
| Often | 11 | (4.6%) | 9 | (7.6%) |
| Sometimes | 38 | (15.7%) | 10 | (8.4%) |
| Never | 191 | (78.9%) | 100 | (84.0%) |
| Unknown | 2 | (0.8%) | 0 | (0.0%) |
| Marital Status, n (%) | ||||
| Currently Married | 139 | (57.4%) | 73 | (61.3%) |
| Divorced, Separated, or Widowed | 17 | (7.0%) | 6 | (5.0%) |
| Never Married | 84 | (34.7%) | 40 | (33.6%) |
| Unknown | 2 | (0.8%) | 2 | (0.8%) |
| Housing, n (%) | ||||
| One-Family House | 175 | (72.3%) | 90 | (75.6%) |
| Apartment Building | 47 | (19.4%) | 22 | (18.5%) |
| Mobile Home | 14 | (5.8%) | 3 | (2.5%) |
| Vehicle (e.g., car, RV) or Unhoused | 4 | (1.7%) | 2 | (1.7%) |
| Unknown | 2 | (0.8%) | 2 | (1.7%) |
| Device Access, n (%) | ||||
| No Smartphone or Computer | 0 | (0.0%) | 1 | (0.8%) |
| Smartphone Only | 24 | (9.9%) | 11 | (9.2%) |
| Desktop or Laptop Only | 5 | (2.1%) | 4 | (3.4%) |
| More than One Device Type | 211 | (87.2%) | 103 | (86.6%) |
| Unknown | 2 | (0.8%) | 0 | (0.0%) |
| Internet/Cellular Access in Household, n (%) | ||||
| No Access | 0 | (0.0%) | 0 | (0.0%) |
| Cellular Data Only | 32 | (13.2%) | 18 | (15.1%) |
| Dial-up or Other Non-Broadband Internet | 16 | (6.6%) | 18 | (15.1%) |
| Broadband (High-Speed) Internet | 184 | (76.0%) | 80 | (67.2%) |
| Unknown | 10 | (4.1%) | 3 | (2.5%) |
| Digital Literacy Score, mean (95% CI) e | 10.2 | 9.9 – 10.6 | 10.3 | 9.9 – 10.8 |
| Intervention n=188 |
Control n=100 |
|||
| Second Parent/Guardian Characteristics | ||||
| Age, mean (95% CI) | 33.5 | 32.5 – 34.6 | 34.3 | 32.8 – 35.8 |
| Gender, n (%) | ||||
| Female | 9 | (4.8%) | 3 | (3.0%) |
| Male | 177 | (94.1%) | 97 | (97.0%) |
| Non-binary or Other | 1 | (0.5%) | 0 | (0.0%) |
| Unknown | 1 | (0.5%) | 0 | (0.0%) |
| Race, n (%) b | ||||
| White | 89 | (47.3%) | 56 | (56.0%) |
| Asian | 24 | (12.8%) | 12 | (12.0%) |
| Black or African American | 14 | (7.5%) | 7 | (7.0%) |
| American Indian or Alaska Native | 4 | (2.1%) | 4 | (4.0%) |
| Native Hawaiian or Other Pacific Islander | 2 | (1.1%) | 0 | (0.0%) |
| Multiple | 19 | (10.1%) | 5 | (5.0%) |
| Other | 33 | (17.6%) | 15 | (15.0%) |
| Unknown | 3 | (1.6%) | 1 | (1.0%) |
| Ethnicity, n (%) | ||||
| Not Hispanic or Latino | 138 | (73.4%) | 75 | (75.0%) |
| Hispanic or Latino | 49 | (26.1%) | 25 | (25.0%) |
| Unknown | 1 | (0.5%) | 0 | (0.0%) |
| Education, n (%) | ||||
| 8th Grade or Less | 2 | (1.1%) | 1 | (1.0%) |
| Some High School | 8 | (4.3%) | 4 | (4.0%) |
| High School Graduate or GED | 59 | (31.4%) | 29 | (29.0%) |
| Some College or 2-Year Degree | 59 | (31.4%) | 35 | (35.0%) |
| 4-Year College Graduate | 28 | (14.9%) | 18 | (18.0%) |
| More than 4-Year College Degree | 31 | (16.5%) | 13 | (13.0%) |
| Unknown | 1 | (0.5%) | 0 | (0.0%) |
| Employment in Past 12 Months, n (%) c | ||||
| No Weeks Worked | 13 | (6.9%) | 7 | (7.0%) |
| 1–25 Weeks Worked | 23 | (12.2%) | 11 | (11.0%) |
| 26–47 Weeks Worked | 37 | (19.7%) | 12 | (12.0%) |
| 48–52 Weeks Worked | 104 | (55.3%) | 58 | (58.0%) |
| Unknown | 11 | (5.9%) | 12 | (12.0%) |
| Transportation Insecurity in Past Month, n (%) d | ||||
| Often | 9 | (4.8%) | 1 | (1.0%) |
| Sometimes | 14 | (7.5%) | 1 | (1.0%) |
| Never | 164 | (87.2%) | 98 | (98.0%) |
| Unknown | 1 | (0.5%) | 0 | (0.0%) |
| Marital Status, n (%) | ||||
| Currently Married | 125 | (66.5%) | 69 | (69.0%) |
| Divorced, Separated, or Widowed | 10 | (5.3%) | 4 | (4.0%) |
| Never Married | 50 | (26.6%) | 26 | (26.0%) |
| Unknown | 3 | (1.6%) | 1 | (1.0%) |
| Housing, n (%) | ||||
| One-Family House | 138 | (73.4%) | 84 | (84.0%) |
| Apartment Building | 30 | (16.0%) | 13 | (13.0%) |
| Mobile Home | 15 | (8.0%) | 2 | (2.0%) |
| Vehicle (e.g., car, RV) or Unhoused | 4 | (2.1%) | 1 | (1.0%) |
| Unknown | 1 | (0.5%) | 0 | (0.0%) |
| Device Access, n (%) | ||||
| No Smartphone or Computer | 2 | (1.1%) | 0 | (0.0%) |
| Smartphone Only | 17 | (9.0%) | 9 | (9.0%) |
| Desktop or Laptop Only | 3 | (1.6%) | 5 | (5.0%) |
| More than One Device Type | 164 | (87.2%) | 84 | (84.0%) |
| Unknown | 2 | (1.1%) | 2 | (2.0%) |
| Internet/Cellular Access in Household, n (%) | ||||
| No Access | 0 | (0.0%) | 0 | (0.0%) |
| Cellular Data Only | 24 | (12.8%) | 16 | (16.0%) |
| Dial-up or Other Non-Broadband Internet | 15 | (8.0%) | 5 | (5.0%) |
| Broadband (High-Speed) Internet | 145 | (77.1%) | 76 | (76.0%) |
| Unknown | 4 | (2.1%) | 3 | (3.0%) |
| Digital Literacy Score, mean (95% CI) e | 10.2 | 9.8 – 10.6 | 9.8 | 9.1 – 10.5 |
CI – confidence interval. NICU – neonatal intensive care unit. IQR – interquartile range. GED – general education diploma.
The number of eligible birth parent survey respondents was 427; the number of eligible second parent/guardian survey respondents was 371. Birth parent survey response rates for the 0-, 30-, 60-, and 90-day post-discharge survey periods were 74.5%, 66.0%, 66.5%, and 61.8%, respectively. Second parent/guardian survey response rates for those survey periods were 63.9%, 55.5%, 51.2%, and 53.1%.
Three of the parents categorized as the “birth parent” were adoptive or intended parents (i.e., surrogacy); these three parents were in the intervention arm.
Race data obtained via parent survey; response options included “other” and allowed for multiple selection.
Includes paid time off and weeks where only worked a few hours.
Assessed by asking respondent to report: “In the past 30 days, how often were you unable to leave the house when you wanted to because of a problem with transportation?”
Assessed using the three-item Digital Health Care Literacy Scale, using a sum score of the three items such that higher scores indicate higher digital health care literacy. Possible sum score for the three items ranged from 0 to 12.
FCR Parent Attendance:
The FCR parent attendance rate was 0.56 (95% CI 0.51 – 0.61) among those assigned to the intervention arm and 0.12 (95% CI 0.09 – 0.16) in the control arm. On average, intervention arm parents attended 56% of possible rounding encounters, an absolute difference of 44 percentage points (95% CI 38 – 50) compared with the control arm. Adjusting for covariates, infants in the intervention arm had 4.81 (95% CI 3.65 – 6.32) times the parent attendance rate of infants in the control arm (unadjusted incidence rate ratio: 4.62 [95% CI 3.40 – 6.28]).
Figure 2 shows subgroup analyses of the intervention effect on FCR parent attendance rate. The intervention increased FCR parent attendance for almost every subgroup of interest, except for parents who only had a desktop or laptop device and parents with low digital literacy (0–5 on a scale of 0–12). Figure 3 presents within-arm relative FCR parent attendance rates comparing subgroups defined by race/ethnicity and neighborhood health conditions. In the control arm, disparities in attendance by neighborhood conditions were evident, whereas in the intervention arm, relative attendance rates were not statistically different from parity. However, formal statistical testing did not reveal significant interactions between either race/ethnicity or neighborhood health conditions and the intervention.
Figure 2: Subgroup Analyses of the Intervention Effect on Family-Centered Rounds Parent Attendance Rate.
FCR – family-centered rounds; CI – confidence interval.
Neighborhood health condition quartiles based on the California Healthy Places Index. Ethnicity, race, transportation insecurity, internet access, employment, device access, and internet access describe the birthing parent’s characteristics collected via survey. Logarithmic scale is employed on the horizontal axis. Adjusted rate ratios estimated in separate Poisson regression models, each model adjusting for birthing parent’s race, ethnicity, education, employment, transportation insecurity, housing, and neighborhood health condition. Point estimates favor the intervention, compared to the control, for all subgroups except for Native Hawaiian or Other Pacific Islander, those with access to a desktop/laptop only, and those with the lowest digital literacy score (0).
Figure 3: Impact of Virtual FCR Intervention on Closing FCR Attendance Disparities.
P-values reflect the comparison between relative attendance rates for Subgroups (A)-to-(B) – expressed as ratio of incidence rate ratios (IRR) – within each figure. P-value obtained from an interaction term of the intervention with the variable of interest: (3a) race/ethnicity and (3b) neighborhood health. Dashed line indicates parity. Race and ethnicity describe the birthing parents’ self-reported identity collected by survey; birthing parents who did provide their race/ethnicity data via survey are not included in Figure 3a. Neighborhood health condition defined by the California Healthy Places Index, whereby worse health is the lower three quartiles and better health is the highest quartile.
In the intervention group, FCR parent attendance consisted of 1,981 (69.6%) virtual-only, 779 (27.4%) in-person-only, and 84 (3.0%) mixed encounters. The adjusted in-person attendance rate (in-person-only plus mixed) was 1.57 times higher (95% CI 1.20 – 2.06) in the intervention arm than in the control arm (unadjusted incidence rate ratio: 1.42 [95% CI 1.03 – 1.96]).
Parent-Reported Outcomes:
Table 3 presents parent-reported outcome items and summary scores. The adjusted difference between study arms in FACCE top-box summary scores was −4.89 (95% CI −8.93 – −0.85), indicating lower experienced family-centeredness among parents offered virtual FCR. No statistically significant between-arm differences were observed for parent activation, HRQOL total scores, and HCAHPS top-box scores. Results remained consistent in sensitivity analyses excluding infants not discharged home (Supplement A). HRQOL subscale score comparisons are provided in Supplement B.
Table 3:
Parent-Reported Outcomes Items and Summary Scores
| Outcome | Intervention | Control | Intervention Effect | |||
|---|---|---|---|---|---|---|
| No | % (95% CI) | No | % (95% CI) | Unadjusted Difference (95% CI) | Adjusted Difference (95% CI) a | |
| Child HCAHPS, % Top-Box b | ||||||
| Overall Hospital Rating | 371 | 74.39 (69.26 – 79.53) | 185 | 81.62 (74.93 – 88.31) | −7.23 (−15.64 – 1.18) | −6.66 (−15.10 – 1.79) |
| Willingness to Recommend Hospital | 370 | 81.89 (77.39 – 86.39) | 180 | 89.44 (84.16 – 94.73) | −7.55 (−14.48 – −0.62) | −6.92 (−14.08 – 0.25) |
| FACCE, % Top-Box b c | 370 | 87.76 (84.96 – 90.56) | 184 | 92.65 (89.80 – 95.50) | −4.89 (−8.88 – −0.90) | −4.89 (−8.93 – −0.85) |
| Interested in your worries | 370 | 92.70 (89.63 – 95.78) | 184 | 97.83 (95.73 – 99.93) | −5.12 (−8.84 – −1.40) | −5.49 (−9.20 – −1.79) |
| Feel comfortable sharing your ideas | 366 | 88.25 (84.77 – 91.74) | 183 | 93.99 (90.61 – 97.37) | −5.74 (−10.59 – −0.89) | −6.09 (−11.10 – −1.07) |
| Focus on what matters to you the most | 369 | 85.91 (81.89 – 89.92) | 184 | 92.39 (88.37 – 96.41) | −6.48 (−12.15 – −0.82) | −6.70 (−12.60 – −0.79) |
| Clearly explain to you | 369 | 86.99 (83.18 – 90.80) | 184 | 91.85 (87.21 – 96.48) | −4.86 (−10.85 – 1.13) | −4.69 (−10.62 – 1.25) |
| Give you information in ways that you understood | 368 | 89.13 (85.73 – 92.53) | 184 | 91.30 (86.59 – 96.02) | −2.17 (−7.97 – 3.63) | −2.38 (−8.18– 3.42) |
| Encourage you to ask questions | 368 | 89.13 (85.88 – 92.38) | 183 | 91.26 (86.77 – 95.75) | −2.13 (−7.65 – 3.40) | −1.42 (−6.90 – 4.06) |
| Involve you in making decisions | 369 | 79.13 (74.61 – 83.66) | 184 | 85.33 (79.44 – 91.21) | −6.19 (−13.60 – 1.22) | −5.85 (−13.38 – 1.68) |
| Propose next steps that were acceptable to you | 369 | 83.20 (78.91 – 87.48) | 184 | 91.30 (86.57 – 96.04) | −8.11 (−14.48 – −1.73) | −7.75 (−14.50 – −1.00) |
| Address your child’s needs | 368 | 91.58 (88.27 – 94.89) | 184 | 95.65 (92.39 – 98.92) | −4.08 (−8.72 – 0.56) | −4.21 (−8.91 – 0.49) |
| Treat you with respect | 368 | 91.58 (88.18 – 94.97) | 182 | 95.60 (92.27 – 98.93) | −4.03 (−8.77 – 0.72) | −3.70 (−8.64 – 1.25) |
| Parent Activation Score | 312 | 78.63 (76.63 – 80.64) | 122 | 80.67 (77.16 – 84.19) | −2.04 (−6.07 – 2.00) | −2.43 (−6.60 – 1.75) |
| HRQOL Total Score at Discharge d | 371 | 76.69 (74.8 – 78.57) | 185 | 77.10 (74.64 – 79.56) | −0.42 (−3.51 – 2.68) | −0.34 (−3.24 – 2.56) |
| Parent Summary Score | 371 | 75.59 (73.64 – 77.53) | 185 | 75.83 (73.27 – 78.40) | −0.25 (−3.46 – 2.97) | −0.14 (−3.15 – 2.86) |
| Family Functioning Summary Score | 370 | 78.08 (75.84 – 80.32) | 185 | 79.35 (76.44 – 82.26) | −1.27 (−4.94 – 2.40) | −1.67 (−5.14– 1.80) |
| HRQOL Total Score at 30 Days Post-Discharge d | 325 | 75.38 (73.29 – 77.48) | 164 | 76.90 (74.37 – 79.43) | −1.51 (−4.80 – 1.77) | −1.43 (−4.62 – 1.75) |
| Parent Summary Score | 325 | 74.35 (72.17 – 76.54) | 163 | 75.91 (73.24 – 78.59) | −1.56 (−5.01 – 1.89) | −1.47 (−4.82 – 1.88) |
| Family Functioning Summary Score | 325 | 74.86 (72.43 – 77.29) | 163 | 76.74 (73.68 – 79.80) | −1.88 (−5.78 – 2.03) | −2.29 (−6.02 – 1.44) |
| HRQOL Total Score at 60 Days Post-Discharge d | 316 | 75.61 (73.58 – 77.65) | 157 | 77.27 (74.44 – 80.10) | −1.66 (−5.14 – 1.83) | −1.44 (−4.89 – 2.02) |
| Parent Summary Score | 316 | 74.53 (72.45 – 76.61) | 157 | 76.16 (73.20 – 79.13) | −1.63 (−5.26 – 1.99) | −1.38 (−4.96– 2.20) |
| Family Functioning Summary Score | 316 | 74.62 (72.26 – 76.98) | 157 | 77.44 (74.03 – 80.86) | −2.82 (−6.97 – 1.33) | −3.06 (−7.14 – 1.02) |
| HRQOL Total Score at 90 Days Post-Discharge d | 312 | 75.29 (73.04 – 77.54) | 147 | 77.92 (75.05 – 80.79) | −2.63 (−6.27 – 1.01) | −2.35 (−5.93 – 1.22) |
| Parent Summary Score | 312 | 73.87 (71.57 – 76.16) | 147 | 76.49 (73.41 – 79.57) | −2.62 (−6.47 – 1.22) | −2.32 (−6.04 – 1.41) |
| Family Functioning Summary Score | 312 | 74.30 (71.68 – 76.93) | 147 | 77.96 (74.71 – 81.21) | −3.65 (−7.83 – 0.52) | −3.88 (−8.02 – 0.26) |
HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems
FACCE – Family-Centered Care Experience
HRQOL – Health-Related Quality of Life
NICU – neonatal intensive care unit
Bolded font indicates total scale scores; non-bolded rows below total scale scores represent individual survey item or summary scores. Negative intervention effect differences indicate lower scores (worse parent-reported outcomes) for the intervention arm relative to the control arm.
HCAHPS and FACCE outcomes adjusted for parent role, insurance type, neighborhood health condition, ethnicity, employment, and transportation insecurity. HRQOL and parent activation outcomes adjusted for parent role, insurance type, neighborhood health condition, race, ethnicity, employment, transportation insecurity, education, invasive ventilator use, and gestational age.
Top-box scores for items were the percentage of respondents selecting the most positive response options (“yes, definitely”). Top-box scores for overall hospital rating were the percentage of respondents who selected 9 or 10 on the 11-point Likert scale. Top-box scores for willingness to recommend the hospital were the percentage of respondents who selected “definitely yes.”
Top-box summary scores were the mean of the item top-box scores within that outcome measure.
HRQOL Total Score was the mean of the scores for the 36-item measure. HRQOL Parent Summary Score consisted of the Physical, Emotional, Social, and Cognitive Functioning subscales; it was the mean of the scores for the 20 items comprising those subscales. HRQOL Family Functioning Summary Score consisted of the Daily Activities and Family Relationships subscales; it was the mean of the scores for the 8 items comprising those subscales.
Infant Outcomes:
Utilization, breastmilk feeding, and growth failure outcomes data are shown in Table 4. Regarding 30-day unplanned revisits to any ED, 22 (7.4%) intervention arm infants and 21 (14.3%) control arm infants experienced a revisit. Infants in the intervention arm had 63% lower odds of a revisit (adjusted odds ratio: 0.37 [95% CI 0.18 – 0.75]) than infants in the control arm. The adjusted probability of revisit was 6.1% (95% CI 3.2 – 8.9) for the intervention arm and 14.5% (95% CI 8.4 – 20.6) for the control arm, yielding an absolute risk difference of −8.4 percentage points (95% CI −15.2 – −1.7). Revisit and readmission results remained consistent in sensitivity analyses excluding infants not discharged home (Supplement A). No statistically significant differences were observed between treatment groups for the other outcomes in Table 4.
Table 4:
Infant Outcomes by Intervention versus Control Group
| Infant Outcome | Intervention | Control | Intervention Effect | |||
|---|---|---|---|---|---|---|
| Mean (95% CI) | Unadjusted Odds Ratio (95% CI) | Adjusted Odds Ratio (95% CI) | ||||
| Breastmilk Feeding, % | ||||||
| Breastmilk Feeding Initiation | 81.19 (76.76 – 85.61) | 81.21 (74.86 – 87.55) | 1.00 (0.60 – 1.67) | 1.19 (0.68 – 2.06) a | ||
| Any Breastmilk at NICU Discharge | 60.07 (54.52 – 65.61) | 61.07 (53.15 – 68.99) | 0.96 (0.63 – 1.46) | 1.02 (0.64 – 1.63) a | ||
| Exclusive Breastmilk at NICU Discharge | 21.78 (17.11 – 26.46) | 24.16 (17.21 – 31.11) | 0.87 (0.55 – 1.40) | 1.00 (0.60 – 1.68) a | ||
| Any Breastmilk at 90 Days Post-Discharge | 58.65 (51.90 – 65.40) | 51.51 (41.50 – 61.53) | 1.34 (0.80 – 2.22) | 1.55 (0.87 – 2.78) a | ||
| Exclusive Breastmilk at 90 Days Post-Discharge | 25.48 (19.51 – 31.45) | 25.25 (16.54 – 33.96) | 1.01 (0.58 – 1.78) | 1.09 (0.57 – 2.07) a | ||
| Growth Failure from Birth to NICU Discharge, % | 21.00 (16.36 – 25.64) | 22.45 (15.62 – 29.27) | 0.92 (0.57 – 1.49) | 0.97 (0.58 – 1.60) b | ||
| 30-Day Unplanned ED Revisit, % | 7.36 (4.38 – 10.33) | 14.29 (8.56 – 20.01) | 0.48 (0.25 – 0.91) | 0.37 (0.18 – 0.75) a | ||
| 30-Day Unplanned Hospital Readmission, % | 10.00 (6.59 – 13.41) | 6.80 (2.68 – 10.92) | 1.52 (0.69 – 3.35) | 1.51 (0.67 – 3.41) a | ||
| # of Events | Incidence Rate c (95% CI) | # of Events | Incidence Rate c (95% CI) | Unadjusted Incidence Rate Ratio (95% CI) | Adjusted Incidence Rate Ratio (95% CI) | |
| Overall Medical Errors | 118 | 14.51 (11.52 – 18.28) | 57 | 13.75 (9.69 – 19.51) | 1.06 (0.69 – 1.61) | 1.06 (0.71 – 1.59) a |
| Non-Harmful Errors | 96 | 11.84 (9.29 – 15.08) | 48 | 11.58 (7.93 – 16.91) | 1.02 (0.65 – 1.60) | 1.01 (0.65 – 1.58) a |
| Harmful Errors | 22 | 2.67 (1.65 – 4.34) | 9 | 2.17 (1.21 – 4.20) | 1.23 (0.54 – 2.79) | 1.25 (0.58 – 2.71) a |
| Non-Preventable Adverse Events | 11 | 1.40 (0.78 – 2.52) | 5 | 1.21 (0.53 – 2.77) | 1.16 (0.42 – 3.21) | 1.56 (0.49 – 5.01) a |
| Median (IQR) | C-statistic (95% CI) | |||||
| Length of Stay, days | 13 (5 – 32) | 13 (6 – 33) | 0.91 (0.72 – 1.16) d | |||
CI – confidence interval. ED – emergency department. IQR – interquartile range.
Adjusted for infant gestational age, invasive ventilator use, insurance, neighborhood health conditions, birthing parent’s education.
Adjusted for infant gestational age, invasive ventilator use, insurance. Growth failure defined as weight-for-gestational-age Z-score decline of more than 0.8 standard deviations (SD) from birth to discharge. We also categorized the degree of growth failure as none (no decline or a decline ≤0.8 SD), mild (>0.8 and ≤1.2 SD), moderate (>1.2 and ≤2 SD), or severe (>2 SD). For the categorical growth failure outcome, the adjusted coefficient for the intervention was −0.27 (95% CI −1.17 – 0.62).
Incidence rate expressed as number of events per 1000 patient days.
We used the c-statistic with 95% CI to estimate the probability that a randomly chosen length of stay from the intervention arm would be less than or equal to a randomly chosen length of stay from the control arm. They were calculated by transforming the corresponding Somers’ D point and interval estimates using the transformation C=0.5(D+1).
DISCUSSION
In this two-arm cluster RCT, providing parents of infants hospitalized in the NICU the option to participate in virtual FCR resulted in a nearly five-fold increase in FCR parent attendance compared with usual care. Infants in the intervention arm also had lower odds of returning to the ED within 30 days of discharge. Subgroup analyses of the primary outcome (FCR parent attendance) demonstrated the intervention was more effective in most relevant subgroups; however, those with lower digital literacy and those lacking a smartphone did not experience the same benefit. To our knowledge, this is the largest RCT to date evaluating the impact of virtual FCR for hospitalized children.
Although prior studies explored the use of telehealth to facilitate remote family participation in FCR,35–43 the literature currently includes one RCT, a pilot trial conducted by our team.16 In that pilot, offering parents virtual FCR in the NICU was technically feasible and did not increase duration of rounds.16 Post hoc subgroup analysis suggested the intervention had greater FCR attendance benefits for parents from racial and ethnic minority backgrounds, those with no college education, and those from neighborhoods with worse health conditions.32 However, the pilot did not test intervention efficacy and did not pre-specify subgroup analyses. This present trial addresses these limitations. Results align with our previous findings and strengthen the evidence that virtual FCR improves parent attendance and promotes more equitable healthcare delivery practices.
The finding that the intervention arm had lower odds of a 30-day ED revisit demonstrates that availability of virtual FCR may yield benefits for healthcare utilization. Prior literature supports that FCR promotes parent empowerment, understanding and knowledge, and discharge readiness.10,44,45 Prior qualitative research also indicates that both parents and providers perceive virtual FCR as enhancing discharge planning and preparedness by improving FCR access and attendance.29
While our intervention improved FCR attendance and ED revisits, it did not improve parent experience nor family-centeredness of care. Rather, the intervention arm had lower parent-reported family-centeredness scores. These findings differ from our virtual FCR pilot trial, wherein HCAHPS top-box composite scores were higher in the intervention arm.16 A possible explanation for this discrepancy is that increased FCR attendance alone does not inherently translate to more family-centered care. The lower FACCE scores may reflect provider burden from the higher volume of parent attendees or challenges in maintaining family-centered communication. Our intervention improved FCR attendance, but it was not designed to improve how FCR was conducted. We prioritized FCR parent attendance as our primary outcome because FCR is not possible without parent attendance, and because this upstream outcome is known to be worse for socially disadvantaged groups.46–51 Improving FCR attendance is a necessary first step to improve care delivery and motivate more inclusive research on FCR.
In usual care, families from neighborhoods with worse health conditions had lower FCR attendance, whereas no such differences were seen in the intervention arm, suggesting that offering virtual FCR may mitigate neighborhood-based disparities. Similar patterns—based on point estimates—were observed when stratifying by race/ethnicity. Although the study was not powered to detect meaningful disparity reductions, these suggestive results are notable given longstanding disparities in family-centered care based on income, insurance, race, or ethnicity.52,53 Although virtual FCR is not a comprehensive remedy, it provides flexibility, potentially expanding access to care discussions and promoting more inclusive and effective parent-provider communication.
FCR attendance did not improve among parents with only desktop/laptop access or with low digital literacy, both recognized barriers to telehealth use.54–57 Future research should test implementation strategies to support equitable reach of virtual FCR, such as use of digital navigators to disseminate devices, improve digital literacy, and provide real-time support.58,59
Limitations
Findings may not be generalizable to other hospitals, as the setting was a single Level IV NICU. This institution has robust telehealth infrastructure to facilitate successful implementation of virtual FCR; such support might not be available elsewhere. We only gathered data on weekdays; attendance and virtual FCR use on weekends are not known. Most parent characteristics data were collected via survey, with responses from 84.5% of birthing parents and 77.6% of secondary parents, leaving some missing data. We prespecified subgroups but did not design the trial to analyze heterogeneity of intervention effects with sufficient power to detect modest effects. Future trials designed to assess heterogeneity of treatment effects are needed to confirm whether this intervention has greater benefits in increasing attendance among socially disadvantaged groups. Additionally, the trial was limited to families with at least one parent with English proficiency. A feasibility trial with families with preferred languages other than English was recently completed and will be reported separately.60 We also conducted a mixed-methods implementation evaluation, which will be disseminated separately to allow detailed reporting.
CONCLUSION
Providing the option to participate in virtual FCR improved FCR parent attendance and reduced 30-day ED revisits. Future research should test the potential of virtual FCR in addressing FCR attendance disparities as well as address the lack of intervention benefit among those with limited digital literacy or device access. Virtual FCR is a scalable approach to enhance parental engagement and reduce post-discharge utilization, though further work is needed to ensure equitable access and optimize family-centeredness.
Supplementary Material
Article Summary:
This cluster randomized trial evaluates the impact of offering families of infants hospitalized in the NICU the use of telehealth to attend family-centered rounds virtually.
What’s Known on This Subject:
Standard family-centered rounds (FCR) requires families to be physically at the bedside, which is difficult for many families. The use of telehealth to bring family members virtually to the bedside is a promising strategy to increase access to FCR.
What This Study Adds:
The option to use virtual FCR can achieve positive effects on FCR parent attendance and 30-day emergency department revisits, with greater benefits for certain subgroups.
ACKNOWLEDGMENTS
We thank the members of our parent and provider engagement team for their contributions to this trial. Members of this engagement team met in the planning stage to refine intervention procedures and refine trial documents (e.g., training materials). During the trial, the team met quarterly to review intervention adherence and survey response rates, address potential challenges, and discuss perceptions and experiences.
Funding/Sponsor:
This work was supported by the National Institute of Nursing Research, National Institutes of Health (NIH) (R21NR020330 to Dr. Rosenthal). This work was also supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH) (K23HD101550 to Dr. Rosenthal). Additional support was provided by the Doris Duke Charitable Foundation COVID-19 Fund to Retain Clinical Scientists awarded to UC Davis School of Medicine by the Burroughs Wellcome Fund.
Role of Funder/Sponsor:
The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Doris Duke Charitable Foundation.
Abbreviations:
- FCR
family-centered rounds
- NICU
neonatal intensive care unit
- RCT
randomized controlled trial
- HRQOL
health-related quality of life
- EHR
electronic health record
- HCAHPS
Hospital Consumer Assessment of Healthcare Providers and Systems
- FACCE
Family-Centered Care Experience
- ED
emergency department
- SD
standard deviations
Footnotes
Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT05762835. Status: Completed. First Posted: 3/10/2023; Last Update Posted: 8/7/2024.
Conflict of interest disclosures: The authors have no conflicts of interest relevant to this article to disclose.
Data Sharing Statement:
Deidentified individual participant data will not be made available.
REFERENCES
- 1.Sisterhen LL, Blaszak RT, Woods MB, Smith CE. Defining family-centered rounds. Teaching and learning in medicine. 2007;19(3):319–322. [DOI] [PubMed] [Google Scholar]
- 2.Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Family-centered care and the pediatrician’s role. Pediatrics. 2003;112(3 Pt 1):691. [PubMed] [Google Scholar]
- 3.Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient-and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394. [DOI] [PubMed] [Google Scholar]
- 4.Landry M-A, Lafrenaye S, Roy M-C, Cyr C. A randomized, controlled trial of bedside versus conference-room case presentation in a pediatric intensive care unit. Pediatrics. 2007;120(2):275–280. [DOI] [PubMed] [Google Scholar]
- 5.Rosen P, Stenger E, Bochkoris M, Hannon MJ, Kwoh CK. Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics. 2009;123(4):e603–e608. [DOI] [PubMed] [Google Scholar]
- 6.Kuo DZ, Sisterhen LL, Sigrest TE, Biazo JM, Aitken ME, Smith CE. Family experiences and pediatric health services use associated with family-centered rounds. Pediatrics. 2012;130(2):299–305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Khan A, Spector ND, Baird JD, et al. Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. bmj. 2018;363. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Wrobleski DMS, Joswiak ME, Dunn DF, Maxson PM, Holland DE. Discharge planning rounds to the bedside: A patient-and family-centered approach. Medsurg Nursing. 2014;23(2):111. [PubMed] [Google Scholar]
- 9.Oshimura JM, Downs SM, Saysana M. Family-centered rounding: can it impact the time of discharge and time of completion of studies at an academic children’s hospital? Hospital Pediatrics. 2014;4(4):228–232. [DOI] [PubMed] [Google Scholar]
- 10.Mittal VS, Sigrest T, Ottolini MC, et al. Family-centered rounds on pediatric wards: a PRIS network survey of US and Canadian hospitalists. Pediatrics. 2010:peds. 2009–2364. [DOI] [PubMed] [Google Scholar]
- 11.Lee HC, Bennett MV, Schulman J, Gould JB, Profit J. Estimating length of stay by patient type in the neonatal intensive care unit. American journal of perinatology. 2016;33(08):751–757. [DOI] [PubMed] [Google Scholar]
- 12.Ray JG, Urquia ML, Berger H, Vermeulen MJ. Maternal and neonatal separation and mortality associated with concurrent admissions to intensive care units. CMAJ. 2012;184(18):E956–E962. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Safran C. The collaborative edge: patient empowerment for vulnerable populations. International journal of medical informatics. 2003;69(2–3):185–190. [DOI] [PubMed] [Google Scholar]
- 14.Hall EM, Shahidullah JD, Lassen SR. Development of postpartum depression interventions for mothers of premature infants: a call to target low-SES NICU families. Journal of Perinatology. 2020;40(1):1–9. [DOI] [PubMed] [Google Scholar]
- 15.Center for Connected Health Policy. About Telehealth: Live Video (synchronous) or Real-Time Interaction. Available at: https://www.cchpca.org/about/about-telehealth/live-video-synchronous-or-real-time-interaction. Accessed December 20, 2021.
- 16.Rosenthal J, Sauers-Ford H, Williams J, Ranu J, Tancredi D, Hoffman K. Virtual Family-Centered Rounds in the Neonatal Intensive Care Unit: A Randomized Controlled Pilot Trial. Academic Pediatrics. 2021;21(7):1244–1252. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Rosenthal JL, Tancredi DJ, Marcin JP, et al. Virtual family-centered hospital rounds in the neonatal intensive care unit: protocol for a cluster randomized controlled trial. Trials. 2023;24(1):331. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Khan A, Patel SJ, Anderson M, et al. Implementing a family-centered rounds intervention using novel mentor-trios. Pediatrics. 2024;153(2):e2023062666. [DOI] [PubMed] [Google Scholar]
- 19.Toomey SL, Zaslavsky AM, Elliott MN, et al. The Development of a Pediatric Inpatient Experience of Care Measure: Child HCAHPS. Pediatrics. Aug 2015;136(2):360–9. doi: 10.1542/peds.2015-0966 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Giordano LA, Elliott MN, Goldstein E, Lehrman WG, Spencer PA. Development, implementation, and public reporting of the HCAHPS survey. Medical Care Research and Review. 2010;67(1):27–37. [DOI] [PubMed] [Google Scholar]
- 21.Rosenthal JL, Albano AD, Tancredi DJ, Perez SL, Young HM, Romano PS. Development and Psychometric Evaluation of a Caregiver Survey to Assess Family-Centered Care in the Emergency Department. Academic Pediatrics. 2022; [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hibbard JH, Mahoney ER, Stockard J, Tusler M. Development and testing of a short form of the patient activation measure. Health services research. 2005;40(6p1):1918–1930. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Pennarola BW, Rodday AM, Mayer DK, et al. Factors associated with parental activation in pediatric hematopoietic stem cell transplant. Medical Care Research and Review. 2012;69(2):194–214. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Varni JW, Sherman SA, Burwinkle TM, Dickinson PE, Dixon P. The PedsQL™ family impact module: preliminary reliability and validity. Health and quality of life outcomes. 2004;2(1):1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. Journal of general internal medicine. 1995;10(4):199–205. [DOI] [PubMed] [Google Scholar]
- 26.Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. Nov 2014;371(19):1803–12. doi: 10.1056/NEJMsa1405556 [DOI] [PubMed] [Google Scholar]
- 27.Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC pediatrics. 2013;13(1):1–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Horbar JD, Ehrenkranz RA, Badger GJ, et al. Weight growth velocity and postnatal growth failure in infants 501 to 1500 grams: 2000–2013. Pediatrics. 2015;136(1):e84–e92. [DOI] [PubMed] [Google Scholar]
- 29.Ranu J, Hoffman KR, Sauers-Ford HS, Williams J, Rosenthal JL. A Qualitative Intervention Evaluation of Neonatal Virtual Family-Centered Rounds. Hospital Pediatrics. 2024;14(6):463–473. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.LaVange L, Koch G, Schwartz T. Applying sample survey methods to clinical trials data. Statistics in medicine. 2001;20(17–18):2609–2623. [DOI] [PubMed] [Google Scholar]
- 31.Pirondini L, Gregson J, Owen R, Collier T, Pocock S. Covariate adjustment in cardiovascular randomized controlled trials: its value, current practice, and need for improvement. Heart Failure. 2022;10(5):297–305. [DOI] [PubMed] [Google Scholar]
- 32.Rosenthal JL, Hoffman KR, Sauers-Ford HS, Stein D, Haynes SC, Tancredi DJ. Differential Impact of Virtual Family-Centered Rounds in the Neonatal Intensive Care Unit by Social Factors: A Post Hoc Subgroup Analysis. Telemed J E Health. Aug 9 2024;doi: 10.1089/tmj.2024.0176 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Public Health Alliance of Southern California. Healthy Places Index. Available at: https://www.healthyplacesindex.org. Accessed November 3, 2022.
- 34.Nelson LA, Pennings JS, Sommer EC, Popescu F, Barkin SL. A 3-Item Measure of Digital Health Care Literacy: Development and Validation Study. JMIR Formative Research. 2022;6(4):e36043. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Yager PH, Clark M, Cummings BM, Noviski N. Parent participation in pediatric intensive care unit rounds via telemedicine: feasibility and impact. The journal of pediatrics. 2017;185:181–186. e3. [DOI] [PubMed] [Google Scholar]
- 36.Østervang C, Vestergaard LV, Dieperink KB, Danbjørg DB. Patient rounds with video-consulted relatives: qualitative study on possibilities and barriers from the perspective of healthcare providers. Journal of medical Internet research. 2019;21(3):e12584. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Mercadante S, Adile C, Ferrera P, Giuliana F, Terruso L, Piccione T. Palliative Care in the Time of COVID-19. J Pain Symptom Manage. Aug 2020;60(2):e79–e80. doi: 10.1016/j.jpainsymman.2020.04.025 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Rising K, Ricco J, Printz A, Hoon Woo S, Hollander J. Virtual rounds: observational study of a new service connecting family members remotely to inpatient rounds. Gen Int Med Clin Innov. 2016;1(3):44–47. [Google Scholar]
- 39.Petersson NB, Jørgensen AL, Danbjørg DB, Dieperink KB. Video-consulted rounds with caregivers: The experience of patients with cancer. Eur J Oncol Nurs. Apr 21 2020;46:101763. doi: 10.1016/j.ejon.2020.101763 [DOI] [PubMed] [Google Scholar]
- 40.Vedel Vestergaard L, Østervang C, Boe Danbjørg D, Brochstedt Dieperink K. Video-Based Patient Rounds for Caregivers of Patients With Cancer. 2019: [DOI] [PubMed]
- 41.Tallent S, Turi JL, Thompson J, Allareddy V, Hueckel R. Extending the radius of family-centered care in the pediatric cardiac intensive care unit through virtual rounding. J Am Assoc Nurse Pract. May 18 2021;doi: 10.1097/jxx.0000000000000610 [DOI] [PubMed] [Google Scholar]
- 42.Ramirez P, Mueller A, Shelton K, et al. Family Perceptions of Virtual Family-Centered Rounds in a Quaternary Cardiac Intensive Care Unit. Journal of intensive care medicine. 2024:08850666241233495. [DOI] [PubMed] [Google Scholar]
- 43.Blagdon A, Smith D, Bramfield T, Soraisham A, Mehrem AA. Evaluation of family and staff experiences with virtual rounding and bedside presence in a tertiary neonatal intensive care unit during the COVID-19 pandemic. Journal of Telemedicine and Telecare. 2022:1357633X221081294. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Grzyb M, Coo H, Rühland L, Dow K. Views of parents and health-care providers regarding parental presence at bedside rounds in a neonatal intensive care unit. Journal of Perinatology. 2014;34(2):143–148. [DOI] [PubMed] [Google Scholar]
- 45.Au SS, des Ordons ALR, Leigh JP, et al. A Multicenter Observational Study of Family Participation in ICU Rounds. Critical care medicine. 2018;46(8):1255–1262. [DOI] [PubMed] [Google Scholar]
- 46.Ju A, Sedano S, Mackin K, Koh J, Lakshmanan A, Wu S. Variation in Family Involvement on Rounds Between English-Speaking and Spanish-Speaking Families. Hospital Pediatrics. 2022; [DOI] [PubMed] [Google Scholar]
- 47.Cheng JH, Wang C, Jhaveri V, Morrow E, Li S-TT, Rosenthal JL. Health care provider practices and perceptions during family-centered rounds with limited English-proficient families. Academic Pediatrics. 2021;21(7):1223–1229. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Glick AF, Goonan M, Kim C, Sandmeyer D, Londoño K, Gold-von Simson G. Factors Associated With Parental Participation in Family-Centered Rounds. Hospital Pediatrics. 2021;11(1):61–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Levin AB, Fisher KR, Cato KD, Zurca AD, October TW. An evaluation of family-centered rounds in the PICU: room for improvement suggested by families and providers. Pediatric Critical Care Medicine. 2015;16(9):801–807. [DOI] [PubMed] [Google Scholar]
- 50.Aija A, Toome L, Axelin A, Raiskila S, Lehtonen L. Parents’ presence and participation in medical rounds in 11 European neonatal units. Early Human Development. 2019;130:10–16. [DOI] [PubMed] [Google Scholar]
- 51.Parente VM, Reid HW, Robles J, et al. Racial and ethnic differences in communication quality during family-centered rounds. Pediatrics. 2022;150(6) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Azuine RE, Singh GK, Ghandour RM, Kogan MD. Geographic, racial/ethnic, and sociodemographic disparities in parent-reported receipt of family-centered care among US children. International journal of family medicine. 2015;2015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.DeLemos D, Chen M, Romer A, et al. Building trust through communication in the intensive care unit: HICCC. Pediatric Critical Care Medicine. 2010;11(3):378–384. [DOI] [PubMed] [Google Scholar]
- 54.Rosenthal JL, O’Neal C, Sanders A, Fernandez y Garcia E. Differential Use of Pediatric Video Visits by a Diverse Population During the COVID-19 Pandemic: A Mixed-Methods Study. Frontiers in pediatrics. 2021;9:516. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Ukoha EP, Davis K, Yinger M, et al. Ensuring equitable implementation of telemedicine in perinatal care. Obstetrics & Gynecology. 2021;137(3):487–492. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Anaya YB-M, Mota AB, Hernandez GD, Osorio A, Hayes-Bautista DE. Post-pandemic telehealth policy for primary care: an equity perspective. The Journal of the American Board of Family Medicine. 2022;35(3):588–592. [DOI] [PubMed] [Google Scholar]
- 57.Katzow MW, Steinway C, Jan S. Telemedicine and Health Disparities During COVID-19. Pediatrics. 2020;146(2) [DOI] [PubMed] [Google Scholar]
- 58.Perret S, Alon N, Carpenter-Song E, et al. Standardising the role of a digital navigator in behavioural health: a systematic review. The Lancet Digital Health. 2023;5(12):e925–e932. [DOI] [PubMed] [Google Scholar]
- 59.Saiyed S, Ng WL, Cherry M, Khattab S, Pathan H. Implementing A Digital Health Navigator: Strategies & Experience in The Hospital Setting to alleviate Digital Equity: Implementing a Digital Health Navigator program. Telehealth and Medicine Today. 2024;9(1) [Google Scholar]
- 60.Hoyt-Austin AE, Zerda EN, Tancredi DJ, et al. Protocol for a single-arm feasibility trial of virtual family-centered rounds: increasing opportunities for family engagement among caregivers with language preference other than English. Pilot Feasibility Stud. Feb 12 2025;11(1):16. doi: 10.1186/s40814-025-01599-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
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Data Availability Statement
Deidentified individual participant data will not be made available.