Douglas M. Campbell

Physiological adjustment to postnatal growth trajectories in healthy preterm infants

Background:International guidelines suggest that growth of preterm infants should match intrauterine rates. However, the trajectory for extrauterine growth may deviate from the birth percentile due to an irreversible, physiological loss of extracellular fluid during postnatal adaptation to extrauterine conditions. To which “new” physiological growth trajectory preterm infants should adjust to after completed postnatal adaptation is unknown. This study analyzes the postnatal growth trajectories of healthy preterm infants using prospective criteria defining minimal support, as a model for physiological adaptation.Methods:International, multi-center, longitudinal, observational study at five neonatal intensive care units (NICUs). Daily weights until day of life (DoL) 21 of infants with undisturbed postnatal adaptation were analyzed (gestational ages: (i) 25–29 wk, (ii) 30–34 wk).Results:981 out of 3,703 admitted infants included. Maximum weight loss was 11% (i) and 7% (ii) by DoL 5, birth weight regained by DoL 15 (i) and 13 (ii). Infants transitioned to growth trajectories parallel to Fenton chart percentiles, 0.8 z-scores below their birth percentiles. The new trajectory after completed postnatal adaptation could be predicted for DoL 21 with R2 = 0.96.Conclusion:This study provides a robust estimate for physiological growth trajectories of infants after undisturbed postnatal adaptation. In the future, the concept of a target postnatal trajectory during NICU care may be useful.

Visual Development of Human Milk–Fed Preterm Infants Provided With Extra Energy and Nutrients After Hospital Discharge

BACKGROUND Human milk (HM) is the optimal way to nourish preterm low birth weight (LBW) infants after hospital discharge. However, there are few data on which to assess whether HM alone is sufficient to address hospital-acquired nutrition deficits, and no adequately powered studies have examined this question using neurodevelopment as an outcome. The purpose of this work was to determine whether adding extra energy and nutrients to the feedings of predominantly HM-fed LBW infants early after discharge improves their visual development. Visual development was used in this study as a surrogate marker for neurodevelopment. METHODS At discharge, 39 predominantly HM-fed LBW infants (750-1800 g, 1288 ± 288 g) were randomized to receive human milk alone (control) or around half of the HM received daily mixed with a multinutrient fortifier (intervention) for 12 weeks. Grating acuity (ie, visual acuity) and contrast sensitivity were assessed using sweep visual-evoked potential tests at 4 and 6 months corrected age. RESULTS At 4 and 6 months corrected age, intervention infants demonstrated higher grating acuity compared to those in the control group (intervention: 7.8 ± 1.3 and 9.7 ± 1.2 [cycles/degree] vs control 6.9 ± 1.2 and 8.2 ± 1.3, P = .02). Differences in contrast sensitivity did not reach statistical significance (P = .11). CONCLUSION Adding a multinutrient fortifier to a portion of the expressed breast milk provided to predominantly HM-fed LBW infants early after discharge improves their early visual development. Whether these subtle differences in visual development apply to other aspects of development or longer term neurodevelopment are worthy of future investigation.

Simulation-based medical education: Time for a pedagogical shift

The purpose of medical education at all levels is to prepare physicians with the knowledge and comprehensive skills, required to deliver safe and effective patient care. The traditional ‘apprentice’ learning model in medical education is undergoing a pedagogical shift to a ‘simulation-based’ learning model. Experiential learning, deliberate practice and the ability to provide immediate feedback are the primary advantages of simulation-based medical education. It is an effective way to develop new skills, identify knowledge gaps, reduce medical errors, and maintain infrequently used clinical skills even among experienced clinical teams, with the overall goal of improving patient care. Although simulation cannot replace clinical exposure as a form of experiential learning, it promotes learning without compromising patient safety. This new paradigm shift is revolutionizing medical education in the Western world. It is time that the developing countries embrace this new pedagogical shift.

Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST)

Introduction Errors in trauma resuscitation are common and have been attributed to breakdowns in the coordination of system elements (eg, tools/technology, physical environment and layout, individual skills/knowledge, team interaction). These breakdowns are triggered by unique circumstances and may go unrecognised by trauma team members or hospital administrators; they can be described as latent safety threats (LSTs). Retrospective approaches to identifying LSTs (ie, after they occur) are likely to be incomplete and prone to bias. To date, prospective studies have not used video review as the primary mechanism to identify any and all LSTs in trauma resuscitation. Methods and analysis A series of 12 unannounced in situ simulations (ISS) will be conducted to prospectively identify LSTs at a level 1 Canadian trauma centre (over 800 dedicated trauma team activations annually). 4 scenarios have already been designed as part of this protocol based on 5 recurring themes found in the hospitals mortality and morbidity process. The actual trauma team will be activated to participate in the study. Each simulation will be audio/video recorded from 4 different camera angles and transcribed to conduct a framework analysis. Video reviewers will code the videos deductively based on a priori themes of LSTs identified from the literature, and/or inductively based on the events occurring in the simulation. LSTs will be prioritised to target interventions in future work. Ethics and dissemination Institutional research ethics approval has been acquired (SMH REB #15-046). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will also be presented to key institutional stakeholders to inform mitigation strategies for improved patient safety.

Severe Neonatal Hyperbilirubinemia Decreased after the 2007 Canadian Guidelines

OBJECTIVES To estimate the incidence of severe neonatal hyperbilirubinemia in Canada from 2011-2013 following the implementation of the Canadian Pediatric Societys published guidelines on the management of hyperbilirubinemia in 2007. Our previously reported incidence of hyperbilirubinemia in Canada was 1 in 2480. STUDY DESIGN Term infants ≤ 60 days of age, with a peak serum total bilirubin level > 425 μmol/L or who had an exchange transfusion were followed prospectively through the Canadian Pediatric Surveillance Program from 2011-2013. Infants with rhesus isoimmunization or born < 35 weeks gestation were excluded. RESULTS Ninety-one cases of severe neonatal hyperbilirubinemia were confirmed. Sixty-nine infants (76%) were readmitted to hospital, 47 (52%) of them within 6 days of age. The remaining 22 infants (24%) were identified with severe neonatal hyperbilirubinemia before they were discharged from the hospital. The mean reported peak bilirubin level was 484 μmol/L (range 181-788; SD ± 92). An etiology was identified in 57 (63%) cases, with ABO incompatibility (n = 35) and glucose-6-phosphate dehydrogenase deficiency (n = 11) being the most common. An infant was 3.5 times more likely to be diagnosed with severe neonatal hyperbilirubinemia from 2002-2004 compared with 2011-2013 (95% CI 2.72-4.47). CONCLUSIONS The minimum estimated incidence of severe neonatal hyperbilirubinemia in Canada is 1 in 8352 live births. Introduction of the Canadian Pediatric Society guidelines and improved physician awareness of severe neonatal hyperbilirubinemia in the last 10 years likely made positive contributions to this trend.

Simulation in neonatal transport medicine

The safe transport of infants in critical condition requires highly reliable inter-professional transport teams that are equipped with the expertise to provide neonatal care in unfamiliar and resource-limited environments. Increasingly, transport teams are comprised of health professionals from various disciplines. Providing didactic and experiential learning alone is insufficient to fully prepare teams that have limited exposure to rare events. Simulation-based training supplements and reinforces knowledge, skills, and the experiences of team members. This article presents the current use of simulation in the training of neonatal transport teams and critically reviews how simulation methodologies may be further incorporated into curricula and quality improvement to achieve high-reliability teams.

A newborn infant with respiratory distress: More than meets the eye: Neonatal respiratory distress

A term newborn baby born via elective c-section at 37 weeks gestational age for placenta praevia was noted to have a gradual onset of tachypnoea, subcostal indrawing, nasal flaring and grunting at 5 min of life. Oxygen saturation via pulse oximeter was 85%. Continuous positive airway pressure (CPAP) of 6 cm H2O was initiated via bag and mask in room air, with improvement in symptoms. Maternal history revealed a healthy 32-year-old G6P1A4 (4xTA) mother with a spontaneous pregnancy. There was a single episode of vaginal bleeding and cramping at 27 weeks requiring one dose of betamethasone and anti-D intramuscularly. Serologies were protective (i.e. HIV negative, Syphilis non-reactive, Hepatitis B surface antigen non-reactive and Rubella immune), fetal anatomy ultrasound scan at 18 weeks gestational age was normal, and integrated prenatal screening was declined. There was a maternal history of depression and attempted suicide, but at present, the mother was well. Only medications were prenatal vitamins. Due to ongoing respiratory effort and ‘CPAP requirement’, the infant was admitted to the neonatal intensive care unit (NICU) for initiation of nasal CPAP. On admission, his heart rate was 149 beats/min, respiratory rate 54 breaths/min, oxygen saturation 100% in room air, blood pressure 76/32 mmHg and temperature 36.1 C. Blood glucose was 4.7 mmol/L, white blood cell count 12.38 (×10/L), haemoglobin 150 g/L, platelets 223 (×10/ L) and absolute neutrophils 4.33 (×10/L). Chest X-ray at 1 h of life confirmed the diagnosis of pulmonary air leak, with bilateral pneumothoraces, pneumomediastinum and the classic sail sign (Fig. 1). CPAP was discontinued at 90 min. The baby remained haemodynamically stable on room air with no evidence of respiratory distress. As there were no septic risk factors, and the baby was delivered via an elective c-section, a blood culture was not sent, and antibiotics were not started. Chest X-ray repeated 7 h later showed minimal resolution of the air leak (Fig. 2). The baby continued to remain asymptomatic, and no further intervention was indicated. After a further period of observation, the baby was discharged from the NICU to the post-partum floor with no further respiratory symptoms.

Adapting form to function: can simulation serve our healthcare system and educational needs?

In artistic fields, like graphic design and architecture, designers often experience tension between highlighting a product’s appearance (form) and creating a product that meets the intended purpose (function). Traditionally, simulation educators and champions have valued form: the expensive “high-fidelity” manikin or standardized patient is discussed more often than the “low-fidelity” task trainer. That preoccupation has jeopardized and de-emphasized the importance of the functions (i.e., educational objectives) the simulation is supposed to address [1–3]. With the availability today of a vast array of simulation techniques and innovations, there is clearly an obligation to use simulation resources wisely and to develop an evidence-base that meaningfully connects simulation form (i.e., simulator, simulation actors/confederates, simulation technique, and location) and simulation function (e.g., for education, for assessment, for evaluating systems). As an analogy, high-quality research arises first from a focused research question and second from methods chosen to best answer that question. Similarly, we suggest a simulation session must begin with a clear statement of the session’s objective, which ultimately dictates the session’s form. We believe this principle applies to any form of simulation, be it a task trainer in the simulation center or a large-scale multi-disciplinary team-based event in the clinical environment. Considering the latter, while our community has made strides in de-emphasizing “fidelity” and is focusing on educational objectives in the simulation center, we wonder if the same thinking applies when conducting simulations in the workplace, commonly referred to as in situ simulation (ISS). A recent paper proposes shifting away from typical simulation descriptors (e.g., high-fidelity) to using a more applicable term, translational simulation, to highlight the importance of a functional connection with healthcare priorities and patient outcomes [4]. We agree with Posner et al. [5] that the hallmark of ISS is that it enables the study of “how the clinical environment responds in its natural state, including the personnel, equipment, and systems responsible for care in that environment.” Observing team members in their typical role using their actual equipment and following their processes likely supports a systems-thinking approach not entirely realized with simulation at off-site centers [6]. Numerous studies support applying ISS to identify latent safety threats (LSTs) [7], to test newly designed clinical environments [8], and to teach and practice communication and teamwork skills [9]. Educators often use ISS as a crash test for personnel, equipment, and systems, offering important insights into patient safety threats and potential mitigation strategies. Here, the function is to improve patient safety, and the form making it possible is ISS. Despite this potential, however, the literature still lacks evidence to help educators and administrators decide which forms of ISS to implement and which functions ISS best serves [10]. As we strive to support healthcare professionals in continuous, lifelong learning, we need evidence to clarify which simulation environment allows us to achieve our specific objectives effectively and efficiently. In producing that evidence, we discourage comparing ISS to a center-based simulation, as the two represent different * Correspondence: ryan.brydges@utoronto.ca Department of Medicine, University of Toronto, Toronto, ON, Canada Allan Waters Family Simulation Centre, St. Michael’s Hospital, Toronto, Canada Full list of author information is available at the end of the article

Simulation for Neonatal Care

Neonatal staff and trainees benefit from the cognitive, technical, and behavioral skills enhanced via simulation-based training. Simulation-based education can be used for initial training (e.g., nurse orientation, resident boot camp), maintenance of skills, course certification (e.g., neonatal resuscitation program course), development of clinical competence, and improvement of the neonatal workplace environment.