Laura Haubner

Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units.

OBJECTIVE To describe neonatal tracheal intubation (TI) performance across five neonatal intensive care units. METHODS This prospective descriptive study was conducted at five level III neonatal intensive care units (NICU) between July 2010 and July 2011. TI performance data were collected using a standardized data collection instrument (provider, procedure, and patient characteristics) and analyzed using descriptive and inferential statistics. The primary outcome of interest was procedural success rate defined as a tube placed in the airway between the vocal cords that could be used to provide ventilation. RESULTS Forty-four percent of 455 TI attempts (203 patients) were successful. Attending physicians and 3rd year neonatal fellows had the highest success rates; 72.2% and 70%, respectively. Pediatric residents had the lowest success rate (20.3%). The median duration of attempts was 30s for residents, 25s for fellows, and 20s for neonatal attending physicians. The most common reasons cited for failure were inability to visualize the vocal cords (25%), patient decompensation (desaturation/bradycardia, 41%) and esophageal TI (19%). The duration of all TI attempts ranged from 5s to 180s and there was no difference between successful and failed attempts. Impending respiratory failure (46.5%) was the most common indication for TI. Patient factors (weight, gestational age, or number of previous TI attempts) were not associated with TI success. CONCLUSIONS Overall TI procedure success rates were poor. Providers with advanced training were more likely to be successful. Patient factors were not associated with TI success.

Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol

Breaking bad news (BBN) in the emergency department (ED) is a common occurrence. This is especially true for an emergency physician (EP) as there is little time to prepare for the event and likely little or no knowledge of the patients or family background information. At our institution, there is no formal training for EP residents in delivering bad news. We felt teaching emergency medicine residents these communication skills should be an important part of their educational curriculum. We describe our experience with a defined educational program designed to educate and improve physician’s confidence and competence in bad news and death notification. A regularly scheduled 5-h grand rounds conference time frame was dedicated to the education of EM residents about BBN. A multidisciplinary approach was taken to broaden the prospective of the participants. The course included lectures from different specialties, role playing for three short scenarios in different capacities, and hi-fidelity simulation cases with volatile psychosocial issues and stressors. Participants were asked to fill out a self-efficacy form and evaluation sheets. Fourteen emergency residents participated and all thought that this education is necessary. The mean score of usefulness is 4.73 on a Likert Scale from 1 to 5. The simulation part was thought to be the most useful (43%), with role play 14%, and lecture 7%. We believe that teaching physicians to BBN in a controlled environment is a good use of educational time and an important procedure that EP must learn.

Interns' Success With Clinical Procedures in Infants After Simulation Training

BACKGROUND AND OBJECTIVE: Simulation-based medical education (SBME) is used to teach residents. However, few studies have evaluated its clinical impact. The goal of this study was to evaluate the impact of an SBME session on pediatric interns’ clinical procedural success. METHODS: This randomized trial was conducted at 10 academic medical centers. Interns were surveyed on infant lumbar puncture (ILP) and child intravenous line placement (CIV) knowledge and watched audiovisual expert modeling of both procedures. Participants were randomized to SBME mastery learning for ILP or CIV and for 6 succeeding months reported clinical performance for both procedures. ILP success was defined as obtaining a sample on the first attempt with <1000 red blood cells per high-power field or fluid described as clear. CIV success was defined as placement of a functioning catheter on the first try. Each group served as the control group for the procedure for which they did not receive the intervention. RESULTS: Two-hundred interns participated (104 in the ILP group and 96 in the CIV group). Together, they reported 409 procedures. ILP success rates were 34% (31 of 91) for interns who received ILP mastery learning and 34% (25 of 73) for controls (difference: 0.2% [95% confidence interval: –0.1 to 0.1]). The CIV success rate was 54% (62 of 115) for interns who received CIV mastery learning compared with 50% (58 of 115) for controls (difference: 3% [95% confidence interval: –10 to 17]). CONCLUSIONS: Participation in a single SBME mastery learning session was insufficient to affect pediatric interns’ subsequent procedural success.

Impact of Just-in-Time and Just-in-Place Simulation on Intern Success With Infant Lumbar Puncture.

BACKGROUND AND OBJECTIVE: Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns’ infant lumbar puncture (LP) success. METHODS: This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009–2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010–2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts. RESULTS: A total of 436 first infant LPs were analyzed. The LP success rate in cohort A was 35% (13/37), compared with 38% (152/399) in cohort B (95% confidence interval for difference [CI diff], −15% to +18%). Cohort B exhibited greater analgesia use (68% vs 19%; 95% CI diff, 33% to 59%), early stylet removal (69% vs 54%; 95% CI diff, 0% to 32%), and lower mean number of attempts (1.4 ± 0.6 vs 2.1 ± 1.6, P < .01) compared with cohort A. CONCLUSIONS: Across multiple institutions, intern success rates with infant LP are poor. Despite improving process measures, adding JIPT to training bundles did not improve success rate. More research is needed on optimal instructional design strategies for infant LP.

The Effects of Maternal Dietary Docosahexaenoic Acid Intake on Rat Pup Myelin and the Auditory Startle Response

We investigated the effects of maternal docosahexanoic acid (DHA) supplementation on pups’ auditory startle responses and the composition of brain myelin. Methods: Timed-pregnant rats were fed throughout pregnancy and lactation diets that contained 0, 0.3, 0.7 or 3% of total fatty acids as DHA. Milk was collected from culled pups’ stomachs on postnatal day (PND) 3, latency of the auditory startle reflex was measured on PND 15, and pups were killed and brains collected on PND 24. Results: Higher levels of DHA in maternal diet were reflected in milk and in pups’ myelin. The latency of the auditory startle response was significantly longer in offspring of dams fed higher levels of DHA. There was a positive correlation between the myelin content of DHA and the latency of the startle response (p = 0.044), and a negative correlation between the myelin content of DHA and the myelin content of cholesterol (p = 0.005). Conclusion: High levels of maternal DHA intake alter the lipid composition of rat pup myelin, and are associated with longer latencies of the auditory startle response – a myelin-dependent electrophysiologic response.

Maternal and neonatal outcomes based on the gestational age of midtrimester preterm premature rupture of membranes

Objectives. Determine neonatal and maternal outcomes based on the gestational age (GA) that midtrimester preterm premature rupture of membranes (mtPPROM) occurs. Study design. A retrospective chart review was conducted on pregnancies with mtPPROM between 180/7 and 236/7 weeks gestation from January 2000 to December 2007. Antenatal complications, maternal morbidity, and neonatal survival and morbidity were analysed by the specific GA of mtPPROM. Statistical analysis was performed using Chi-square, Fishers Exact, and Kruskal–Wallis tests. Results. A total of 105 patients met inclusion criteria. There was a trend for longer latency with earlier GA of mtPPROM (p = 0.05). Neonatal survival to discharge was 26.6%, with an overall morbidity of 86%. Survival was significantly higher with mtPPROM at 22 0/7–23 6/7 weeks compared to 18 0/7–19 6/7 (p = 0.01) and 20 0/7–21 6/7 weeks (p = 0.01). There was no difference in neonatal morbidity based on the GA of mtPPROM. Conclusions. While neonatal survival improves at later GAs of mtPPROM, morbidity continues to be high.

Outcomes of a Neonatal Golden Hour Implementation Project

The objective of this study was to implement and evaluate a quality improvement project (the golden hour pathway [GHP]) aimed at improving the quality and efficiency of care delivered to extremely low birth weight (ELBW) infants <28 weeks gestation and/or <1000 g birth weight during the first hour of life. Process improvement and patient data collected during the quality improvement cycles were compared with retrospective data for ELBW infants admitted to the study neonatal intensive care unit during the 2 years prior to GHP implementation. GHP implementation resulted in improvements compared with past internal performance in time to surfactant administration, time to administration of dextrose and amino acids, body temperature at admission, odds of developing chronic lung disease, and odds of developing retinopathy of prematurity. A standardized interdisciplinary approach to the care of ELBW infants in the first hour of life can lead to more efficient care delivery and contribute to improved outcomes.

Dietary Docosahexanoic Acid (DHA) Effects upon the Rat Pup Auditory System|[bull]| 1526

Rats fed diets high in n3 fatty acids have lower whole brain levels of myelin basic protein, lower activities of 2′-3′cyclic nucleotide 3′-phosphodiesterase(an indicator of myelination) (DiBiase & Salvati, 1997), and longer auditory brainstem conduction times (ABCTs) (Saste et al., in press). We investigated the effects of varying levels of the n3 fatty acid DHA upon development of the rat pup auditory system.Methods: Dams were fed, from day 2 of gestation and throughout lactation, a purified diet whose fat source (22% of cals) was a vegetable oil blend supplemented with an algae oil containing 0% or 3% DHA. On postnatal day(pnd) 3, pups were culled to 10 per dam and were randomly cross fostered among dams of the same diet group to minimize litter effects (n=6 dams per diet group, 60 pups per diet group). Milk from culled pup stomachs was used for fatty acid analysis. On pnd 15, auditory electromyelographic reflexes (AEMR) to 130 db peak sound pressure level clicks were recorded from needle electrodes placed in the muscle of the thigh of 20 pups per diet group; pups were then sacrificed and brainstems removed for fatty acid analysis. For the remaining 40 pups per diet group, ABCTs were measured on pnd 24 and 31, and the postnatal day of appearance of the auditory startle reflex was determined. An additional group of dams fed 1% DHA diet had pups whose weight gains were 2/3 that of dams fed the 0% or 3% DHA diets; data from these pups are not presented. Results: Length of gestation, maternal weight gains and pup weights on pnd 3 did not differ between diet groups. Weight gains to pnd 12 were slightly lower among pups of dams fed the 3% DHA diet. The fatty acid composition of dam milk and pup brainstems reflected maternal diet. AEMRs were not different, however, ABCTs on pnd 24 were longer and the time of appearance of the auditory startle reflex was later in pups of dams fed 3% DHA.Conclusion: High levels of dietary DHA during development may be associated with delays in myelination of the central nervous system as suggested by longer ABCTs and a delay in appearance of the auditory startle reflex. Similar AEMRs between diet groups suggest minimal effects upon the peripheral nervous system. Table