Sharon S. Crandell

Team Training in the Neonatal Resuscitation Program for Interns: Teamwork and Quality of Resuscitations

OBJECTIVE: Poor communication and teamwork may contribute to errors during neonatal resuscitation. Our objective was to evaluate whether interns who received a 2-hour teamwork training intervention with the Neonatal Resuscitation Program (NRP) demonstrated more teamwork and higher quality resuscitations than control subjects. METHODS: Participants were noncertified 2007 and 2008 incoming interns for pediatrics, combined pediatrics and internal medicine, family medicine, emergency medicine, and obstetrics and gynecology (n = 98). Pediatrics and combined pediatrics/internal medicine interns were eligible for 6-month follow-up (n = 34). A randomized trial was conducted in which half of the participants in the team training arm practiced NRP skills by using high-fidelity simulators; the remaining practiced with low-fidelity simulators, as did control subjects. Blinded, trained observers viewed video recordings of high-fidelity–simulated resuscitations for teamwork and resuscitation quality. RESULTS: High-fidelity training (HFT) group had higher teamwork frequency than did control subjects (12.8 vs 9.0 behaviors per minute; P < .001). Intervention groups maintained more workload management (control subjects: 89.3%; low-fidelity training [LFT] group: 98.0% [P < .001]; HFT group: 98.8%; HFT group versus control subjects [P < .001]) and completed resuscitations faster (control subjects: 10.6 minutes; LFT group: 8.6 minutes [P = .040]; HFT group: 7.4 minutes; HFT group versus control subjects [P < .001]). Overall, intervention teams completed the resuscitation an average of 2.6 minutes faster than did control subjects, a time reduction of 24% (95% confidence interval: 12%–37%). Intervention groups demonstrated more frequent teamwork during 6-month follow-up resuscitations (11.8 vs 10.0 behaviors per minute; P = .030). CONCLUSIONS: Trained participants exhibited more frequent teamwork behaviors (especially the HFT group) and better workload management and completed the resuscitation more quickly than did control subjects. The impact on team behaviors persisted for at least 6 months. Incorporating team training into the NRP curriculum is a feasible and effective way to teach interns teamwork skills. It also improves simulated resuscitation quality by shortening the duration.

Effect of maternal serum insulin on umbilical extraction of glucose and lactate in fed and fasted sheep.

In 18 chronically instrumented pregnant ewes in late gestation, umbilical extractions of glucose and lactate were determined before and during the continuous infusion of ovine insulin, 0.25 mU/kg . min, into one uterine artery. Studies were conducted in both well-nourished and fasting ewes. Exogenous insulin increased the umbilical extraction of glucose without altering the umbilical extraction of lactate over the range of concentrations of maternal blood glucose encountered in the fed and fasted states. Moreover, the efflux of lactate into the uterine venous circulation in two additional ewes was not altered by the administration of insulin. These studies support the hypothesis that maternal circulating insulin binds to insulin receptors on the microvillous brush border of the placenta to effect an increase in the carrier-mediated transfer of glucose rather than cause an intraplacental decrease in the catabolism of glucose to lactate. The results suggest that, as maternal levels of blood glucose and serum insulin spontaneously rise in concert over the physiologic range, both factors may contribute to the increasing umbilical extraction of glucose. Furthermore, these observations raise the possibility that decreased binding of insulin by placental insulin receptors, which is reported to occur in placentas from diabetic women, may be accompanied by a relatively decreased umbilical uptake of glucose for a given maternal concentration of glucose, but not of lactate.

Efficacy of a medical genetics rotation during pediatric training.

Purpose:With the greater understanding that genetics underlies the basis of health and disease, the practice of medicine is changing such that we are now in an era of genomic medicine. However, there has been a deficiency of training in genetics and genomics among primary care residents.Methods:We describe the experience of our institution, which requires pediatric, child neurology, and medicine–pediatric residents to complete a subspecialty rotation in medical genetics. Standardized end-of-rotation evaluation results were analyzed and thematic analysis was performed.Results:The mean overall educational quality of the rotation rated on a 5-point scale ranging from 1 (poor) to 5 (excellent) was 4.49. The participation in medical genetics had three main outcomes: (i) a variety of learning opportunities were presented such that it was one of the most educational rotations that trainees experienced; (ii) both trainee competence and confidence in clinical practice improved through knowledge gained; and (iii) an increased awareness and appreciation for interprofessional relationships, especially for the genetic counseling profession, was highly valued. In addition, some residents have gone on to choose medical genetics as a profession.Conclusion:A rotation in medical genetics increases knowledge and awareness of the importance that medical genetics has in clinical practice.Genet Med 18 2, 199–202.

Expanded newborn screening in Texas: A survey and educational module addressing the knowledge of pediatric residents

Purpose: To assess the effectiveness of an educational module as a tool for improving the knowledge of pediatric residents about newborn screening and its expansion in Texas.Methods: The study population consisted of 63 pediatric residents from the University of Texas at Houston, Baylor College of Medicine in Houston, and the University of Texas Medical Branch in Galveston. Residents were invited to participate in the study during daily scheduled didactic lectures in their respective residency programs. Questionnaires were distributed to the residents both before and after the presentation of an educational module about newborn screening in Texas to assess whether knowledge was gained from the presentation.Results: Analysis of questionnaires from the full group of participants showed a substantial increase in knowledge about newborn screening in Texas after the presentation of the educational module. This included a 45.4% increase in knowledge about pre-expansion newborn screening conditions and a 308.4% increase in knowledge about expanded newborn screening conditions (P ≤ 0.001).Conclusions: Our results suggest that an educational module about newborn screening like the one we created for this study would be an effective tool for improving the knowledge of pediatric residents on a larger scale.

A Vertically Integrated Core Pediatric Education

The objective of this study was to implement and evaluate a vertically integrated general pediatrics rotation that includes inpatient ward, newborn nursery, and ambulatory components in a format intended to mimic real-world pediatric practice. Separate ward, well-baby nursery, and ambulatory rotations were combined into a 4-month block rotation. Two parallel teams staff the inpatient ward and newborn nursery; on alternating days, the admitting team staffs an afternoon clinic, seeing ward and nursery patients in follow-up as well as regular clinic and referral patients. Two group meetings were held during each rotation for 2 years, and questionnaires were distributed to participating residents. All 90 residents who rotated through the combined service participated in at least 1 group meeting, only 26 returned questionnaires that limited evaluation of the program. The most important positive feature of the rotation was the continuity of patient care allowed by combining the venues into 1 rotation and by the longer duration of the rotation. Concerns included the challenges of time management and fluctuations in workload across the 3 patient care venues. Upper level residents reported that the rotation confirmed career decisions for primary care. These preliminary observations suggest that a vertically integrated rotation provides improvement in perceived continuity of care and introduces residents to the time management challenges of primary care pediatrics.

Contraplacental Hypogastrinemic Effect of Gastrin Infusion in Sheep

Summary: Infusion of gastrin, G-171, at 0.4 μg/min into either the maternal or fetal venous circulation of six late gestation sheep was associated with increases in serum gastrin concentration in the infused circulation and reciprocal decreases in the serum gastrin concentration in the other circulation (contraplacental) that perfused the placenta. Pentagastrin infusion at 0.4 μg/min was associated with an increase in C-terminal specific gastrin immunoreactivity in both the infused and the contraplacental circulations. These observations suggest that biologically active fragments of gastrin, but not the intact molecule, may cross the ovine placenta. An alternative explanation for our results is that gastrin infusion into either the maternal or fetal circulation which perfuses the placenta may result in the release of an inhibitor (ie., somatostatin) into the other circulation. Of broad importance, these observations indicate that although intact polypeptide hormones may not traverse the placenta, their concentrations in maternal and fetal sera may not be as independent as previously believed. Serum gastrin half-life values in late gestation sheep fetuses, lambs, and ewes were determined to be 13.7 ± 1.9, 16.7 ± 2.6, and 15.2 ± 2.8 min, respectively. These similar values indicate that the relatively high serum gastrin concentrations observed in near-term sheep fetuses are not the result of pro-longed half-life in the fetus.

Teaching neonatal resuscitation using an advanced life support course and laboratory experience.

No abstract available.