Christie J. Bruno

Haemorrhagic stroke in term and late preterm neonates

Objective Few data regarding causes and outcomes of haemorrhagic stroke (HS) in term neonates are available. We characterised risk factors, mechanism and short-term outcomes in term and late preterm neonates with acute HS. Design Prospective cohort. Setting Single-centre tertiary care stroke registry. Subjects Term and late preterm neonates (≥34 weeks gestation), born 2004–2010, with acute HS ≤28 days of life were identified, and clinical information was abstracted. Short-term outcomes were assessed via standardised neurological exam and rated using the Paediatric Stroke Outcome Measure (PSOM). Results Among 42 neonates, median gestational age was 39.7 weeks (IQR 38–40.7 weeks). Diagnosis occurred at a median of 1 day (IQR 0–7 days) after delivery. Twenty-seven (64%) had intraparenchymal and intraventricular haemorrhage. Mechanism was haemorrhagic transformation of venous or arterial infarction in 22 (53%). Major risk factors included congenital heart disease (CHD), fetal distress and haemostatic abnormalities. Common presentations included seizure, apnoea, and poor feeding or vomiting. Acute hydrocephalus was common. Mortality was 12%. Follow-up occurred in 36/37 survivors at a median of 1 year (IQR 0.5–2.0 years). Among 17/36 survivors evaluated in stroke clinic, 47% demonstrated neurologic deficits. Deficits were mild (PSOM 0.5–1.5) in 9/36 (25%), and moderate-to-severe (PSOM ≥2.0) in 8/36 (22%). Conclusions In our cohort with acute HS, most presented with seizures, apnoea and/or poor feeding. Fetal distress and CHD were common. Nearly two-thirds had intraparenchymal with intraventricular haemorrhage. Over half were due to haemorrhagic transformation of infarction. Short-term neurologic deficits were present in 47% of survivors.

Simulation as a tool for improving acquisition of neonatal resuscitation skills for obstetric residents

Abstract Objective: Our goal was to compare the confidence, knowledge, and performance of obstetric residents taught initial neonatal resuscitation steps in a simulation-based versus lecture-based format. Methods: Our study was a prospective randomized controlled trial of 33 obstetric residents. Baseline confidence, knowledge, and clinical skills assessments were performed. Subjects were randomized to traditional lecture (n = 14) or simulation-based (n = 19) neonatal resuscitation curriculum with a focus on initial steps. Follow-up assessments were performed at 3 and 6 months. Total confidence, knowledge, and clinical performance scores and change from baseline in these scores were calculated and compared between groups. Results: Both the lecture-based and simulated-based groups demonstrated significant improvement in confidence, knowledge, and performance over time. However, compared with the lecture group, the magnitude of the mean change from baseline in performance scores was significantly greater in the simulation group at 3 months (2.9 versus 10.1; p < 0.001), but not at 6 months (7.0 versus 9.3; p = 0.11). Conclusions: Our study demonstrates the superiority of simulation in teaching obstetric residents initial neonatal resuscitation steps compared with a traditional lecture format. Skills are retained for upwards of 3–6 months. Refresher instruction by 6 months post-instruction may be beneficial.

Screening for Critical Congenital Heart Disease in Newborns

CCHD affects more than 25% of neonates born with congenital heart disease. Patients with CCHD require timely intervention in the form of surgery or cardiac catheterization to survive. These interventions may improve survival and outcomes for these patients. There is strong evidence that performing newborn pulse oximetry screening after the first 24 hours of life may help to detect more than 1200 neonates in the United States each year with CCHD. Pulse oximetry screening for CCHD has been demonstrated to be reasonable to implement and seems to be cost-effective. There is evidence that asymptomatic patients with CCHD can be diagnosed before clinical presentation or cardiovascular collapse with this screening. Pulse oximeter screening has been endorsed by several national organizations as a valuable newborn screening tool. Implementation of pulse oximetry screening programs in a standardized manner with strong communication among all involved parties will likely improve outcomes as well. As we move forward, we as clinicians should work to have a centralized system of reporting positive CCHD results, prompt patient evaluation, and good follow-up for the families of those neonates with positive screening results. Achieving these objectives will likely help us to achieve the goal of improving outcomes of the most critical neonates with CCHD.

Do you see what I see? A randomised pilot study to evaluate the effectiveness and efficiency of simulation-based training with videolaryngoscopy for neonatal intubation

Introduction Direct laryngoscopy (DL) and airway intubation are critical for neonatal resuscitation. A challenge in teaching DL is that the instructor cannot assess the learners’ airway view. Videolaryngoscopy (VL), which allows display of a patients airway on a monitor, enables the instructor to view the airway during the procedure. This pilot study compared deliberate practice using either VL with instruction (I-VL) or traditional DL. We hypothesised that I-VL would improve the efficiency and effectiveness of neonatal intubation (NI) training. Methods Participants (students, paediatric interns and neonatal fellows) were randomised to I-VL or DL. Baseline technical skills were assessed using a skills checklist and global skills assessment. Following educational sessions, deliberate practice was performed on mannequins using the Storz C-MAC. With I-VL, the instructor could guide training using a real-time airway monitor view. With DL, feedback was based solely on technique or direct visual confirmation, but the instructor and learner views were not concurrent. During summative assessment, procedural skills checklists were used to evaluate intubation ability on a neonatal airway trainer. The duration of attempts was recorded, and recorded airway views were blindly reviewed for airway grade. ‘Effectiveness’ reflected achievement of the minimum passing score (MPS). ‘Efficiency’ was the duration of training for learners achieving the MPS. Results 58 learners were randomised. Baseline demographics were similar. All participants had a significant improvement in knowledge, skills and comfort/confidence following training. There were no significant differences between randomised groups in efficiency or effectiveness, but trends towards improvement in each were noted. Fellows were more likely to achieve ‘competency’ postinstruction compared to non-fellows (p<0.001). Conclusions This educational intervention to teach NI increased the learners knowledge, technical skills and confidence in procedural performance in both groups. I-VL did not improve training effectiveness. The small sample size and participant diversity may have limited findings, and future work is indicated.

Opinions regarding neonatal resuscitation training for the obstetric physician: a survey of neonatal and obstetric training program directors

Abstract Purpose: Our goal was to garner opinions regarding neonatal resuscitation training for obstetric physicians. We sought to evaluate obstacles to neonatal resuscitation training for obstetric physicians and possible solutions for implementation challenges. Materials and methods: We distributed a national survey via email to all neonatal-perinatal medicine fellowship directors and obstetrics & gynecology residency program directors in the United States. This survey was designed by a consensus method. Results: Ninety-eight (53%) obstetric and fifty-seven (51%) neonatal program directors responded to our surveys. Eighty-eight percent of neonatologists surveyed believe that obstetricians should be neonatal resuscitation program (NRP) certified. The majority of surveyed obstetricians (>89%) believe that obstetricians should have some neonatal resuscitation training. Eighty-six percent of obstetric residents have completed training in NRP, but only 19% of obstetric attendings are NRP certified. Major barriers to NRP training that were identified include time, lack of national requirement, lack of belief it is helpful, and cost. Conclusions: Most obstetric attendings are not NRP certified, but the majority of respondents believe that obstetric providers should have some neonatal resuscitation training. Our study demonstrates that most respondents support a modified neonatal resuscitation course for obstetric physicians.

Neonatal Intubation Competency Assessment Tool: Development and Validation

BACKGROUND Neonatal tracheal intubation (NTI) is an important clinical skill. Suboptimal performance is associated with patient harm. Simulation training can improve NTI performance. Improving performance requires an objective assessment of competency. Competency assessment tools need strong evidence of validity. We hypothesized that an NTI competency assessment tool with multisource validity evidence could be developed and be used for formative and summative assessment during simulation-based training. METHODS An NTI assessment tool was developed based on a literature review. The tool was refined through 2 rounds of a modified Delphi process involving 12 subject-matter experts. The final tool included a 22-item checklist, a global skills assessment, and an entrustable professional activity (EPA) level. The validity of the checklist was assessed by having 4 blinded reviewers score 23 videos of health care providers intubating a neonatal simulator. RESULTS The checklist items had good internal consistency (overall α = 0.79). Checklist scores were greater for providers at greater training levels and with more NTI experience. Checklist scores correlated with global skills assessment (ρ = 0.85; P < .05), EPA levels (ρ = 0.87; P < .05), percent glottic exposure (r = 0.59; P < .05), and Cormack-Lehane scores (ρ = 0.95; P < .05). Checklist scores reliably predicted EPA levels. CONCLUSIONS We developed an NTI competency assessment tool with multisource validity evidence. The tool was able to discriminate NTI performance based on experience. The tool can be used during simulation-based NTI training to provide formative and summative assessment and can aid with entrustment decisions.

Shoulder Dystocia and Neonatal Resuscitation: An Integrated Obstetrics and Neonatology Simulation Case for Medical Students

Introduction The new model in medical education of longitudinal clinical clerkships can be complemented by high-technology simulation, which provides a safe space for learners to consolidate clinical knowledge and practice decision-making skills, teamwork, and communication. We developed an interdisciplinary training intervention including a simulation case and structured debriefing to link clinical content between pediatrics and obstetrics at a major academic medical center. Methods In this case, a 38-year-old female at 38 weeks gestation presents with onset of labor complicated by shoulder dystocia. After the appropriate maneuvers, a depressed neonate is delivered and requires resuscitation. Major equipment needed includes a high- or low-technology birthing mannequin and an infant mannequin. Results Fifty-four third-year medical students participated in this simulation-based intervention at the completion of their integrated pediatrics and obstetrics clerkship. Ninety-one percent of students agreed that the shoulder dystocia simulation was designed appropriately for their learning level and enhanced their ability to handle a risky delivery. Ninety-four percent agreed that the neonatal resuscitation simulation was designed appropriately for their learning level, and 89% reported an enhanced ability to handle a similar situation in the clinic following the intervention. The average overall ratings were 4.24 (SD = 0.61) and 4.06 (SD = 0.89) on a 5-point scale (1 = poor, 5 = excellent) for the obstetrics and pediatrics simulations, respectively. Discussion The integrated obstetrics and pediatrics scenario is feasible to run and clinically accurate. Two distinct areas of medicine in the third-year curriculum are logically incorporated into one cohesive simulation-based training intervention that students found positive and realistic.

Cost-effective and low-technology options for simulation and training in neonatology

The purpose of this review is to explore low-cost options for simulation and training in neonatology. Numerous cost-effective options exist for simulation and training in neonatology. Lower cost options are available for teaching clinical skills and procedural training in neonatal intubation, chest tube insertion, and pericardiocentesis, among others. Cost-effective, low-cost options for simulation-based education can be developed and shared in order to optimize the neonatal simulation training experience.

Board 314 - Research Abstract Simulation as a Tool for Improving Acquisition of Neonatal Resuscitation Skills (Submission #946)

Introduction/Background The first few minutes after birth are most critical for a newborn. Although most infants transition with ease, some require delivery room resuscitation.1 The quality of initial resuscitation may impact the infant’s short- and long-term outcome.2 Traditionally, neonatal providers are present at deliveries as soon as the need is recognized and delivery of the infant is imminent. However, in the event that the neonatal resuscitation team is not present, the obstetric team must initiate resuscitation. While obstetric nurses complete resuscitation training, obstetric physicians are often not required to complete neonatal resuscitation training. In order to fulfill this educational need we hypothesize that a short instructional session that teaches initial neonatal resuscitation steps with a simulation based curriculum will increase obstetric physician confidence, knowledge, performance and retention of neonatal resuscitation skills. Methods This was a prospective randomized, controlled trial of 33 obstetric residents. Subjects received baseline confidence, knowledge and clinical skills assessments. Subjects were then randomized to traditional lecture (n=14) or simulation-based (n=19) neonatal resuscitation education with a focus on initial steps. All instructional sessions were less than one hour in duration and both lecture and simulation interventions contained the same content. The simulation session required that the subject learn how to resuscitate a depressed neonate “hands on” with expert coaching. Follow-up assessments of confidence, knowledge and clinical skills occurred at intervals of three and six months post initial instruction. Confidence was reported based on a Likert scale of 1 (least confident) to 5 (most confident). Knowledge was assessed using seven multiple choice questions at the three intervals. Clinical assessments were performed in a simulated environment and were graded as yes/no if the subject completed individual tasks successfully in the following areas: preparation, initial resuscitation, ventilation, cardiovascular resuscitation. Total knowledge and clinical assessment scores were calculated. Statistical analysis was performed with paired T-tests to test individuals improvement and Student T-test for comparisons between groups. Results For both the lecture and simulation-based groups, confidence increased significantly at three and six months post instruction when compared to baseline (p<0.01). This increase in confidence was sustained as there were no significant differences between confidence at three and six months in both groups. Performance on knowledge assessment questions also improved significantly from baseline at three and six months post instruction for both groups when compared to baseline (p<0.01). Knowledge was maintained as there were no significant differences between knowledge scores at three and six months in both groups. Clinical assessments for the lecture group revealed no significant difference in successfully completed tasks between baseline and three months. However, significant improvement was demonstrated when six month performance was compared to baseline and 3 months (P<0.01). For the simulation group, clinical assessment performance was significantly improved at three and six months versus baseline (p<0.01) and this improvement was sustained with no significant difference between three and six month scores. Although there was an overall improvement in both groups, analysis with Student T-tests demonstrated that simulation performance scores were significantly higher than the lecture group at both three months (19.8 vs. 13.4) (p<0.01) and 6 months (19.1 vs. 17.2) (p<0.05). Conclusion A short, focused curriculum that teaches initial neonatal resuscitation steps via lecture or simulation enhances subject confidence, knowledge and skills. However, education that incorporates simulation is superior to lecture, resulting in more rapid acquisition of clinical skills and sustained improvements in overall clinical performance. Fortunately, an unanticipated depressed neonate is a relatively infrequent event; however, improved ability for obstetric providers to initiate a prompt and effective neonatal resuscitation after a brief simulation intervention, has the potential to greatly impact outcomes for these vulnerable newborns. References 1. Perlman JM, Risser R: Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med 1995; 149:20-25. 2. Casalaz DM, Marlow N, Speidel BD: Outcome of resuscitation following unexpected apparent stillbirth. Arch Dis Child Fetal Neonatal Ed 1998;78:F112-F115. Disclosures None.