Family Use of Remote Infant Viewing in the Neonatal Intensive Care Unit: Impact of the COVID-19 Pandemic and Patient Room Type
Introduction
The technical innovation of remote infant viewing (RIV) has significantly impacted how parents can connect with their newborn in the neonatal intensive care unit (NICU).1 Using a camera placed near the infant’s bed, parents can connect to a 24/7 livestream video of their infant from anywhere with internet access. While a relatively new technology, RIV has been shown to have many positive impacts on families,2,3 including enhanced parent bonding,4 increased involvement in infant care,5 and reduced parental stress.6,7
In March 2020, the World Health Organization declared the COVID-19 global pandemic due to the SARS-CoV-2 virus.8 With the onset of the pandemic, many health care organizations implemented stricter visitor guidelines, which often limited the number of visitors per patient.9 State-mandated stay-at-home orders10 further impacted the ability of families and caregivers to be present in person with hospitalized patients. In addition, physical distancing was recommended to prevent virus transmission, which could be challenging in open-bay rooms where multiple patients were bedded in one continuous space.11
Pandemic-associated visitor restrictions, stay-at-home orders, and physical distancing limited the ability of family members to be present in person with infants in the NICU,11 which inhibited family-centered care and left parents feeling emotionally isolated from their newborns.12 Telehealth technologies such as RIV provided additional opportunities for families, caregivers, and friends to observe hospitalized infants virtually.
However, it is unknown how the pandemic impacted family use of RIV. Our study aimed to assess family use of RIV in the NICU during the COVID-19 pandemic and to evaluate whether RIV use varied by patient room type. We hypothesized that RIV use increased during the pandemic and that RIV was used more frequently for neonates in open-bay versus single-family rooms.
Methods
STUDY SETTING
The Mayo Clinic Hospital in Rochester, MN, has a 24-bed Level III NICU and a 34-bed Level IV NICU.13 Approximately 800 patients are admitted to the NICUs annually, of which about 25% of neonates are admitted from surrounding community hospitals (outborn). In the Level III NICU, all beds are in single-family rooms. Before December 2020, the Level IV NICU included 26 patient beds in open-bay rooms and 8 beds in single-family rooms. On December 1, 2020, the Level IV NICU was relocated within the hospital to a unit where all beds were in single-family rooms. This relocation occurred to enable physical distancing in the setting of a pandemic.
Before the COVID-19 pandemic, the NICUs had seasonal visitor restrictions when influenza and respiratory syncytial virus (RSV) rates were highest, generally lasting from mid-November to mid-April. Seasonal visitor restrictions limited the number of visitors for each neonate to two designated adults, which remained the same for the duration of the hospitalization.
With onset of the COVID-19 pandemic in March 2020, seasonal restrictions were continued with additional protections that included no visitation by persons infected with or under investigation for SARS-CoV-2. These visitor restrictions remained in place for the remainder of the time period evaluated in this study.
REMOTE INFANT VIEWING
RIV was installed in the two NICUs on September 16, 2019. The RIV system was a Health Insurance Portability and Accountability Act (HIPAA)-compliant product of AngelEye Health® and used a camera placed at the newborn’s bedside (Fig. 1A). Family members could view the livestream video 24/7 from anywhere with internet access (Fig. 1B). When a patient was admitted to the NICU, parents were asked if they wanted to use the RIV system.
Fig. 1. (A) RIV camera set up at the patient’s bedside. (B) Family view of the infant using a wireless tablet to access the RIV system. RIV, remote infant viewing.
If parents indicated they were interested in using the system, they received an e-mail from AngelEye Health and created an account password. Once the password was created, parents could download the application (app) and begin viewing their infant(s). Parents could invite other family members or friends to use RIV by sending an invitation from the app or the website.
STUDY DESIGN AND DATA COLLECTION
The Mayo Clinic Institutional Review Board (IRB) deemed this study exempt from its review (IRB 21-005917). Patients with research authorization at the time of data curation were included in the analysis. For each patient where RIV was used, AngelEye Health recorded the number of remote infant views as well as the date, time (hh:mm:ss), and duration of each view. View duration was only available if the app or browser was closed correctly. RIV use data were exported from the AngelEye Health database for patients in the NICUs between October 1, 2019, and March 31, 2021.
NICU patient data were obtained from the ICU database for the same study period and included gestational age, birth weight, sibling in the NICU, inborn/outborn status, bed assignment, and the date/time of each location. For infants in the NICU before October 1, 2019, the beginning of their NICU stay was recorded as October 1, 2019, 00:00. For infants who were not yet discharged from the NICU on March 31, 2021, the end of their NICU stay was recorded as March 31, 2021, 23:59.
The statistician merged the two aforementioned data sources to identify the room type (open-bay vs. single-family room) at the time of each camera view.
STATISTICAL ANALYSIS
Patient characteristics were compared between the two groups, patients whose families did use RIV versus those who did not. Comparisons were evaluated using the two-sample t test for continuously scaled characteristics and the chi-square for dichotomous characteristics.
For analysis of RIV use before and during the COVID-19 pandemic, data were separated into two periods: period 1 was before the COVID-19 pandemic (October 1, 2019, to February 29, 2020) and period 2 was during the COVID-19 pandemic (April 1, 2020, to March 31, 2021). March 2020 was considered a washout period to account for onset of the pandemic and was therefore excluded. The number of patients with at least one camera view was determined for each month during the study timeline and reported as a proportion of all infants in the NICU each month. The total number of camera views and the total camera view duration were aggregated for each month during the study timeline.
These measures were standardized relative to the total number of patient-days for all infants in the NICU each month to account for the duration of RIV opportunities. For each of these two measures, a simple linear regression model was fit to test whether the slope over time during the pandemic period was significantly different from zero.
To evaluate for differences in RIV use according to patient room type, patient-level data from the entire study period, including March 2020, were utilized. Data for each patient were aggregated by room type to calculate the number of camera views per patient and the duration of camera views, in minutes, per patient in each setting. These data were standardized to the length of stay, in days, per patient in each setting.
Generalized linear regression models were fit to compare each standardized measure between room types (open-bay vs. single-family room) using the generalized estimating equation methodology to account for the correlation induced when patients have data for both room types. Separate models were fit with and without adjusting for the patient’s gestational age at birth.
Statistical analysis was performed using the SAS, version 9.4, software package (SAS Institute, Inc., Cary, NC). All calculated p-values were two-sided, and p-values <0.05 were considered statistically significant.
Results
Among the 980 infants in the NICU during the study period with research authorization, 721 (73.6%) had families who used RIV. Infant characteristics, room type during NICU hospitalization, and length of NICU stay, according to whether the infant was viewed using RIV, are summarized in Table 1. The mean gestational age and mean birth weight were significantly lower for infants viewed using RIV compared with those who were not viewed. The proportion of infants who were outborn did not vary between those who were viewed and not viewed using RIV (26.1% vs. 23.2%, p = 0.36).
| INFANT CHARACTERISTIC | VIEWED USING RIV | pa | |
|---|---|---|---|
| YES (N = 721) | NO (N = 259) | ||
| At NICU admission | |||
| Gestational age (weeks), mean (SD) | 34.8 (3.7) | 35.4 (3.9) | 0.019 |
| Gestational age category, n (%) | |||
| 22–31 Weeks | 120 (16.6) | 38 (14.7) | |
| 32–33 Weeks | 93 (12.9) | 21 (8.1) | |
| 34–36 Weeks | 263 (36.5) | 78 (30.1) | |
| 37–42 Weeks | 245 (34.0) | 122 (47.1) | |
| Birth weight (g), mean (SD) | 2,522.6 (924.4) | 2,709.3 (923.6) | 0.005 |
| Birth weight category, n (%) | |||
| <1,000 g (Extremely low) | 41 (5.7) | 15 (5.8) | |
| 1,000 to <1,500 g (Very low) | 54 (7.5) | 10 (3.9) | |
| 1,500 to <2,500 g (Low) | 276 (38.3) | 73 (28.2) | |
| ≥2,500 g | 350 (48.5) | 161 (62.2) | |
| Family had multiples in the NICU, n (%) | 103 (14.3) | 33 (12.7) | 0.54 |
| Outborn (vs. inborn), n (%) | 188 (26.1) | 60 (23.2) | 0.36 |
| Open-bay room (vs. single-family room) at NICU admission, n (%) | 242 (33.6) | 81 (31.3) | 0.50 |
| During NICU hospitalization | |||
| Room type, n (%) | —b | ||
| Open-bay room only | 53 (7.4) | 25 (9.7) | |
| Single-family room only | 451 (62.5) | 172 (66.4) | |
| Open-bay and single-family rooms | 217 (30.1) | 62 (23.9) | |
| Length of NICU stay (days), median (IQR) | 9.4 (4.4–19.6) | 6.0 (12.9–12.9) | —b |
Of the 721 infants who were viewed, family members produced a total of 232,955 camera views. Of these camera views, 62.9% had a measurable duration associated with the RIV use. The median number of views per patient-days was 12.5 (interquartile range [IQR], 5.4–26.0), with a single camera view lasting a median of 64.5 s (IQR, 16.7 s to 4.5 min).
During the 5 months before the pandemic, the average proportion of infants in the NICU with at least one RIV per month was 57.5%. During the pandemic period, this increased from 71.6% in April 2020 to 94.3% in March 2021 (Fig. 2, p < 0.001). The standardized monthly number of camera views increased during the pandemic (p = 0.003, Fig. 3A), as did the standardized monthly view duration (in minutes; p = 0.029, Fig. 3B).
Fig. 2. Impact of the COVID-19 pandemic on the proportion of NICU patients with at least one RIV. The vertical reference lines denote the (A) onset of the COVID-19 pandemic and (B) Level IV NICU relocation to a unit with all single-family rooms. The reported p-value is based on assessing whether the slope of the simple linear regression line during the pandemic period is significantly different from zero. NICU, neonatal intensive care unit.
Fig. 3. Impact of the COVID-19 pandemic on the (A) number of camera views per total patient-days and (B) duration of camera views (in minutes) per total patient-days. Each reported p-value is based on assessing whether the slope of the simple linear regression line during the pandemic period is significantly different from zero.
When the aggregated monthly data were stratified by room type, both the standardized monthly number of views and view duration increased during the pandemic for patients in single-family rooms (p = 0.005 and p = 0.024, respectively, Fig. 4A). For those in open-bay rooms, the increase in these two measures was less pronounced and was not statistically significant; however, there were fewer data points due to the transition to all single-family rooms on December 1, 2020 (p = 0.35 and p = 0.75, respectively, Fig. 4B).
Fig. 4. Impact of the COVID-19 pandemic on the (A) number of camera views and view duration (in minutes) per total patient-days for infants in single-family rooms and (B) number of camera views and view duration (minutes) per total patient-days for infants in open-bay rooms. Each reported p-value is based on assessing whether the slope of the simple linear regression line during the pandemic period is significantly different from zero.
Of the 721 patients whose families used RIV during the entire study period, patient-level data showed that 53 patients were only in an open-bay room, 451 were only in a single-family room, and 217 had stayed in both an open-bay room and a single-family room during their NICU hospitalization. The median number of camera views per patient-days was higher for open-bay than single-family rooms (13.5 vs. 10.5; p < 0.001; Table 2).
| MEASURE, MEDIAN (IQR) | ROOM TYPE | p | ||
|---|---|---|---|---|
| OPEN-BAY | SINGLE-FAMILY | UNADJUSTED ANALYSIS | ADJUSTED FOR GA | |
| Number of patients with camera viewsa | 270 | 668 | ||
| Room type-specific patient days | 6.1 (3.2–16.9) | 8.8 (3.7–15.8) | —b | —b |
| Number of camera views per room type-specific patient-days | 13.5 (5.3–32.0) | 10.5 (4.1–24.1) | <0.001 | <0.001 |
| Duration of camera views (minutes) per room type-specific patient-daysc | 21.8 (8.4–53.9) | 12.1 (4.4–33.6) | <0.001 | <0.001 |
| Subset of patients who had stayed in both room types | 217 | 217 | ||
| Room type-specific patient days | 7.0 (3.2–19.5) | 11.9 (3.5–23.8) | —b | —b |
| Number of camera views per room type-specific patient-days | 12.7 (4.1–30.0) | 7.0 (1.8–17.1) | <0.001 | <0.001 |
| Duration of camera views (minutes) per room type-specific patient-daysd | 23.7 (10.0–64.9) | 11.1 (4.2–32.1) | <0.001 | <0.001 |
Moreover, the median view duration (minutes) per patient-days was longer for patients in an open-bay room (21.8 vs. 12.1; p < 0.001; Table 2). Both comparisons retained statistical significance after adjusting for gestational age. These differences were also observed, with a more pronounced difference, when the results were restricted to the subset of patients who stayed in both room types (Table 2).
Discussion
Family use of RIV increased significantly during the COVID-19 pandemic, including the proportion of families using RIV as well as the number of views and view duration by family members. In addition, families whose infants were bedded in an open-bay room used RIV more frequently and for longer duration than those whose infants were in a single-family room. Utilization of RIV was higher when families’ ability to be present in person at the infant’s bedside was limited by various factors, such as visitor restrictions and shared physical space.
Our finding of increased RIV use during the pandemic is consistent with observations across many fields of medicine where various telehealth platforms were used to continue health care delivery amid the pandemic. Studies demonstrated that use of telehealth increased by anywhere from 200% to 2,000% after the onset of the COVID-19 pandemic, depending on the specialty and health care setting.14–16
Following this rapid rise in telehealth, many organizations observed a subsequent drop in telehealth visits as organizations reopened to in-person outpatient care,14,17 although the percentage of visits conducted through telehealth remained higher than before the pandemic. In our study, family use of RIV did not appear to wane during the ongoing pandemic, which may reflect the inpatient visitor restrictions that continued to be in place for hospitalized patients.
RIV allows families to connect with their hospitalized infant and increases perceived involvement in their newborn’s care.5 Parents of infants in the NICU feel RIV is an important mechanism for enhancing their ability to bond with their infant and easing the transition to parenthood.4 These positive impacts of RIV may have been even more relevant during the pandemic when family members needed to stay at home and in-person visits were restricted—explaining our observed increase in RIV use.
Furthermore, a previous study demonstrated that utilization of RIV was associated with lower (better) scores on the NICU Parental Stress Scale.6,7 Family members may have used RIV more frequently and for longer duration to mitigate the stress of having an infant in the NICU during a pandemic. Increased use of RIV during the pandemic may reflect family members’ efforts to amplify infant bonding and family-centered care when experiencing limitations to in-person visits.
In a study conducted before the COVID-19 pandemic, Pineda et al found that parents whose infants were in open-bay rooms were at the bedside for shorter duration than those of infants in single-family rooms.18 This reduced parental presence may explain our findings that families of infants in open-bay rooms used RIV at a higher frequency and for longer duration as it offered an alternative way to be present at the infant’s bedside. This was especially evident in our subset of patients who had stayed in both room types while in the NICU, where family use of RIV was substantially higher when the infant was in an open-bay room.
The difference in parental presence based on room type may have been exacerbated by the COVID-19 pandemic. Darcy Mahoney et al found that during the pandemic, in-person parental presence for infants in open-bay rooms decreased at a significantly greater rate than for infants in single-family rooms.11 In our study, family use of RIV increased during the pandemic for infants in single-family rooms; however, we did not observe this same finding for families whose infants were in open-bay rooms. This could be explained by their higher use of RIV before the pandemic.
Families with infants in open-bay rooms may have experienced factors that reduced in-person presence and increased RIV use at baseline, for example, crowding and perceived lack of privacy. Thus, the pandemic had less of an incremental influence on their use of RIV. Conversely, before the pandemic, parents whose infants were in single-family rooms may have spent more time at the bedside as it was a comfortable, private care setting and their need to use RIV was low. However, during the pandemic, parents’ ability to be in the infant’s room was limited by stay-at-home orders and visitor restrictions; hence, their use of RIV was higher.
This study had limitations. First, because of its observational nature, our study did not allow for conclusions about causality, but instead demonstrated an association between RIV use and the COVID-19 pandemic and between RIV use and patient room type. Second, there was risk of confounding bias by other unmeasured factors that could impact RIV use, for example, family access to internet and comfort with technology.
Third, study results were also limited by the percent of views that had a view duration. We postulate that the risk of bias due to missing data is low as there was no strong correlation between total views for each patient and the percent of each patient’s views with a measured duration (Spearman correlation = −0.18).
Last, due to the transition from the NICU to all single-family rooms on 12/1/2020, there were fewer monthly data points, resulting in less statistical power to assess changes over time during the pandemic for open-bay patient-days.
Conclusions
Use of RIV in the NICU increased during the COVID-19 pandemic. Families with newborns in an open-bay room used RIV more frequently and for longer duration than families with newborns in a single-family room. RIV allows families to observe their newborn when hospital visitor restrictions are in place or when in-person bedside visits may be less private or do not allow for physical distancing.
These findings underscore the importance of telehealth platforms in the NICU, especially given the positive impact of RIV for families. Hospitals should consider implementing the RIV system to facilitate virtual family presence. Future research should aim to better understand why RIV use has increased, perhaps through surveys and interviews with family members to understand their perspectives on RIV in the NICU.
Acknowledgment
The authors thank Ruxin Dai, MS, for abstracting patient data from the ICU database.
Authors’ Contributions
R.K.P. conducted data collection, drafted the initial manuscript, and reviewed and revised the manuscript. B.L.K. conducted data collection, provided input on study design, and critically reviewed and revised the manuscript. K.M.M. provided input on study design and critically reviewed and revised the manuscript. A.L.W. provided input on study design, carried out analyses, and reviewed and revised the manuscript. J.E.B. provided input on study design, conducted data collection, and reviewed and revised the manuscript. J.L.F. conceptualized and designed the study; conducted, coordinated, and supervised data collection; drafted the initial manuscript; and reviewed and revised the manuscript.
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Disclosure Statement
The authors have no conflicts of interest relevant to this article to disclose.
Funding Information
No funding was secured for this study.
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