The lost art of intubation: assessing opportunities for residents to perform neonatal intubation

Neonatal intubation with direct laryngoscopy vs videolaryngoscopy: an extremely premature baboon model

OBJECTIVE

To compare the ability to successfully intubate extremely preterm baboons using conventional direct laryngoscopy (DL) vs videolaryngoscopy.

METHODS

A prospective randomized crossover study using experienced and inexperienced neonatal intubators. All participants were shown an educational video on intubation with each device, followed by attempt of the procedure. The time for successful intubation was the primary outcome.

RESULTS

Seven subjects comprised the experienced group, while 10 individuals were in the inexperienced group. The overall intubation success rate was comparable between both devices (53% vs 26%, P = 0.09); however, mean time to intubate with the conventional laryngoscope was faster (25.5 vs 39.4 s, P = 0.02). Although both groups intubated faster with DL, it only reached statistical significance in the inexperienced group (27.0 vs 48.7 s, P < 0.05).

CONCLUSION

Conventional DL and videolaryngoscopy are suitable modes for intubating extremely preterm baboons. Although experienced intubators prefer DL, intubation success rate and time to intubate with both devices were comparable. In inexperienced intubators, participants preferred and intubated faster with DL.

Weekly and consecutive day neonatal intubation training: comparable on a pediatrics clerkship

PURPOSE

To determine whether medical student intubation proficiency with a neonatal mannequin differs according to weekly or consecutive day practice sessions during a six-week pediatric clerkship.

METHOD

From July 2010 through June 2011, the authors prospectively randomized 110 third-year medical students into three neonatal intubation practice groups: standard (control; no practice sessions), weekly (practice once/week for four consecutive weeks), or consecutive day (practice once/day for four consecutive days). At baseline, students performed intubation during individual sessions using a neonatal mannequin (SimNewB). Two reviewers, blinded to practice group, viewed videotapes of intubations and independently scored students on equipment selection, procedural skill steps, length of intubation attempts (in seconds), and the number of attempts (up to three) needed for a successful intubation. Videotaped individual final assessment intubation sessions during week six were evaluated in the same manner.

RESULTS

Students in the weekly and consecutive day practice groups performed better at the final assessment on all variables than students in the standard group (P < .001), but over six weeks, the authors detected no differences between the two distributed practice formats for any outcomes of interest.

CONCLUSIONS

Practice improved all aspects of neonatal intubation performance, including choosing the correct equipment, properly performing the skill steps, length of time to successful intubation, and success rate, for novice health care providers in a simulation setting. Over six weeks, neither practice format proved superior, but it remains unclear whether one format is superior for learning and skill retention over the long term or in actual practice.

The new 6-unit individualized curriculum for pediatric residents: the perspective of neonatology fellowship program directors

OBJECTIVE

Starting in 2013, all pediatric residents entering fellowship must be provided six educational units whose structure is to be determined by their individual career plans. We sought to determine whether (1) neonatology fellowship program directors (PDs) consistently identify certain weaknesses among incoming fellows and (2) neonatology fellowship PDs agree on the most beneficial activities in which pediatric residents should participate to improve preparation for entry into neonatology fellowships.

STUDY DESIGN

We sent a 21-question survey focused on the structure and implementation of the 6-unit curriculum to all members of the Organization of Neonatology Training Program Directors.

RESULTS

Sixty-seven percent of PDs responded. Seventy-five percent cited insufficient procedural skills as the primary weakness of incoming fellows. More than 80% rated additional training in clinical neonatology, including procedural and resuscitation training, as 'beneficial' or 'highly beneficial'. In contrast, fewer than 40% of PDs gave the same positive ratings to activities broadly focused on scholarship.

CONCLUSIONS

The results of the survey may help guide pediatric residency programs as they undertake development of these new curricular initiatives for individual residents entering neonatology.

Deliberate practice improves pediatric residents' skills and team behaviors during simulated neonatal resuscitation

OBJECTIVE

To evaluate the skills and team behavior of pediatric residents during resuscitation with a high-fidelity mannequin before and after a deliberate practice intervention.

METHODS

Each month residents participate in two 90-minute videorecorded sessions (2-3 weeks apart) in an "off-site" delivery room during their neonatal ICU rotation. Teams responded to a scenario that required 5 skills (positive pressure ventilation, chest compressions, endotracheal intubation, umbilical vein catheterization, and epinephrine administration). Skills were scored for technique and timeliness and team behaviors for communication, management, and leadership. A 2-hour focused intervention was given between sessions.

RESULTS

In all, 33 residents (11 teams) completed the sessions. Gaps in procedural skills noted during the first session were corrected. Timeliness for completion of skills remained below expectations. Improvements in team behaviors were noted.

CONCLUSIONS

Deliberate practice improved procedural skills and team performance. Lack of improvement in timeliness suggests that a different educational paradigm is required.