Marzia Gentile

Education in neonatology by simulation: between reality and declaration of intent

An unexpected event is not rare in Neonatology and can be dramatic: the operators must act with the right skills and abilities in the shortest time. Often it is a team effort and each member must be trained adequately. According to the “Swiss cheese” model by J. Reason, an accident is never the consequence of a single error, but the very final result of a chain of misunderstandings, irregularities or negligence (cheese holes): several holes allow the final medical error. Therefore, we should avoid those holes in our work. The clinical risk is always around the corner. The legal issues are becoming more and more relevant and lead to a defensive medicine, which is definitely not the best practice. For this reason, raising the safety standards is mandatory. With this purpose, after a decade of experience in “traditional” training courses, we started testing a new strategy of continuous education in Neonatology by means of highfidelity simulation. Since 2008, we have arranged and managed a Center for Neonatal Simulation and Advanced Training in the Neonatology Unit of the University Hospital of Pisa. We have already delivered courses to pediatricians, neonatologists, anesthesiologists, gynecologists, emergency doctors, midwives and nurses, using an advanced Laerdal SimNewB simulator to teach diagnostic and therapeutic skills or communication strategies. The model has been proposed to the Italian Society of Neonatology and it has been decided to create a Task Force to discuss our model and encourage to use it in other Italian areas.

An active one-lobe pulmonary simulator with compliance control for medical training in neonatal mechanical ventilation

Mechanical ventilation is a current support therapy for newborns affected by respiratory diseases. However, several side effects have been observed after treatment, making it mandatory for physicians to determine more suitable approaches. High fidelity simulation is an efficient educational technique that recreates clinical experience. The aim of the present study is the design of an innovative and versatile neonatal respiratory simulator which could be useful in training courses for physicians and nurses as for mechanical ventilation. A single chamber prototype, reproducing a pulmonary lobe both in size and function, was designed and assembled. Volume and pressure within the chamber can be tuned by the operator through the device control system, in order to simulate both spontaneous and assisted breathing. An innovative software-based simulator for training neonatologists and nurses within the continuing medical education program on respiratory disease management was validated. Following the clinical needs, three friendly graphic user interfaces were implemented for simulating three different clinical scenarios (spontaneous breathing, controlled breathing and triggered/assisted ventilation modalities) thus providing physicians with an active experience. The proposed pulmonary simulator has the potential to be included in the range of computer-driven technologies used in medical training, adding novel functions and improving simulation results.

MEchatronic REspiratory System SImulator for Neonatal Applications (MERESSINA) project: a novel bioengineering goal

Respiratory function is mandatory for extrauterine life, but is sometimes impaired in newborns due to prematurity, congenital malformations, or acquired pathologies. Mechanical ventilation is standard care, but long-term complications, such as bronchopulmonary dysplasia, are still largely reported. Therefore, continuous medical education is mandatory to correctly manage devices for assistance. Commercially available breathing function simulators are rarely suitable for the anatomical and physiological realities. The aim of this study is to develop a high-fidelity mechatronic simulator of neonatal airways and lungs for staff training and mechanical ventilator testing. The project is divided into three different phases: (1) a review study on respiratory physiology and pathophysiology and on already available single and multi-compartment models; (2) the prototyping phase; and (3) the on-field system validation.

High-fidelity simulation in Neonatology and the Italian experience of Nina

The modern methodology of simulation was born in the aeronautical field. In medicine, anesthetists showed great attention for technological advances and simulation, closely followed by surgeons with minimally invasive surgery. In Neonatology training in simulation is actually useful in order to face unexpected dramatic events, to minimize clinical risk preventing errors and to optimize team work. Critical issues in simulation are: teachers-learners relationship, focus on technical and non-technical skills, training coordination, adequate scenarios, effective debriefing. Therefore, the quality of a simulation training center is multi-factorial and is not only related to the mannequin equipment. High-fidelity simulation is the most effective method in education. In Italy simulation for education in Medicine has been used for a few years only. In Pisa we founded Nina (that is the acronymous for the Italian name of the Center, Ce N tro di Formaz I one e Simulazio N e Neon A tale ), the first neonatal simulation center dedicated but integrated within a Hospital Unit in Italy. This paper describes how we manage education in Nina Center, in order to offer a model for other similar experiences.

A novel simulator for mechanical ventilation in newborns: MEchatronic REspiratory System SImulator for Neonatal Applications.

Respiratory problems are among the main causes of mortality for preterm newborns with pulmonary diseases; mechanical ventilation provides standard care, but long-term complications are still largely reported. In this framework, continuous medical education is mandatory to correctly manage assistance devices. However, commercially available neonatal respiratory simulators are rarely suitable for representing anatomical and physiological conditions; a step toward high-fidelity simulation, therefore, is essential for nurses and neonatologists to acquire the practice needed without any risk. An innovative multi-compartmental infant respirator simulator based on a five-lobe model was developed to reproduce different physio-pathological conditions in infants and to simulate many different kinds of clinical scenarios. The work consisted of three phases: (1) a theoretical study and modeling phase, (2) a prototyping phase, and (3) testing of the simulation software during training courses. The neonatal pulmonary simulator produced allows the replication and evaluation of different mechanical ventilation modalities in infants suffering from many different kinds of respiratory physio-pathological conditions. In particular, the system provides variable compliances for each lobe in an independent manner and different resistance levels for the airway branches; moreover, it allows the trainer to simulate both autonomous and mechanically assisted respiratory cycles in newborns. The developed and tested simulator is a significant contribution to the field of medical simulation in neonatology, as it makes it possible to choose the best ventilation strategy and to perform fully aware management of ventilation parameters.

Comparative performances analysis of neonatal ventilators

BackgroundMechanical ventilation is a therapeutic action for newborns with respiratory diseases but may have side effects. Correct equipment knowledge and training may limit human errors. We aimed to test different neonatal mechanical ventilators’ performances by an acquisition module (a commercial pressure sensor plus an isolated chamber and a dedicated software).MethodsThe differences (ΔP) between peak pressure values and end-expiration pressure were investigated for each ventilator. We focused on discrepancies among measured and imposed pressure data. A statistical analysis was performed.ResultsWe investigated the measured/imposed ΔP relation. The ΔP do not reveal univocal trends related to ventilation setting parameters and the data distributions were non-Gaussian.ConclusionsMeasured ΔP represent a significant parameter in newborns’ ventilation, due to the typical small volumes. The investigated ventilators showed different tendencies. Therefore, a deep specific knowledge of the intensive care devices is mandatory for caregivers to correctly exploit their operating principles.