Video performance-debriefings and ventilation-refreshers improve quality of neonatal resuscitation

Advancing newborn care: Precise time of birth detection using ai-driven thermal imaging with adaptive normalization

Around 5%-10% of newborns need assistance to start breathing. Currently, there is a lack of evidence-based research, objective data collection, and opportunities for learning from real newborn resuscitation emergency events. Generating and evaluating automated newborn resuscitation algorithm activity timelines relative to the Time of Birth (ToB) offers a promising opportunity to enhance newborn care practices. Given the importance of prompt resuscitation interventions within the "golden minute" after birth, having an accurate ToB with second precision is essential for effective subsequent analysis of newborn resuscitation episodes. Instead, ToB is generally registered manually, often with minute precision, making the process inefficient and susceptible to error and imprecision. In this work, we explore the fusion of Artificial Intelligence (AI) and thermal imaging to develop the first AI-driven ToB detector. The use of temperature information offers a promising alternative to detect the newborn while respecting the privacy of healthcare providers and mothers. However, the frequent inconsistencies in measurements when using uncooled thermal sensors make normalization strategies critical. Our methodology involves a three-step process: first, we propose an adaptive normalization method based on Gaussian mixture models (GMM) to mitigate issues related to temperature variations; second, we implement an AI model to detect the presence of the newborn within the thermal video frames; and third, we evaluate and post-process the model's predictions to estimate the ToB. A precision of 88.1% and a recall of 89.3% are reported in the detection of the newborn within thermal frames during performance evaluation. Our approach achieves an absolute median deviation of 2.7 s in estimating the ToB relative to the manual annotations.

Impact of the Neonatal Resuscitation Video Review program for neonatal staff: a qualitative analysis

BACKGROUND

Neonatal resuscitation video review (NRVR) involves recording and reviewing resuscitations for education and quality assurance. Though NRVR has been shown to improve teamwork and skill retention, it is not widely used. We evaluated clinicians' experiences of NRVR to understand how NRVR impacts learning and can be improved.

METHODS

Neonatal Intensive Care Unit (NICU) clinicians with previous NRVR experience were recruited for individual semi-structured interviews. Using a social constructivist viewpoint, five researchers used thematic analysis to analyze participant responses.

RESULTS

Twenty-two clinicians (11 nurses, 11 doctors) were interviewed. All participants expressed positive attitudes towards NRVR. Four themes were identified: (1) Learning from reality-exposure to real-life resuscitations was highly clinically relevant. (2) Immersive self-regulation-watching videos aided recall and reflection. (3) Complexities in learner psychological safety-all participants acknowledged viewing NRVR videos could be confronting. Some expressed fear of judgment from colleagues, though the educational benefit of NRVR superseded this. (4) Accessing and learning from diverse vantage points-NRVR promoted group discussion, which prompted participant learning from colleagues' viewpoints.

CONCLUSION

Neonatal clinicians reported NRVR to be an effective and safe method for learning and refining skills required during neonatal resuscitation, such as situational awareness and communication.

IMPACT

Neonatal resuscitation video review is not known to be widely used in neonatal resuscitation teaching, and published research in this area is limited. Our study examined clinician attitudes towards an established neonatal resuscitation video review program. We found strong support for teaching using neonatal resuscitation video review among neonatal doctors and nurses, with key benefits including increased situational awareness and increased clinical exposure to resuscitations, while maintaining psychological safety for participants. The results of this study add evidence to support the addition of video review to neonatal resuscitation training.

The evaluation of video-assisted debriefing for improving performance in simulated medical student resuscitations

Objectives

Simulation-based training is commonly used in medical education. However, there is a gap in knowledge regarding best practices in debriefing. We aimed to identify novel solutions to this by adapting video-assisted debriefing (VAD) methodologies used in athletic training. We hypothesized that utilizing VAD would lead to improvements in performance during advanced cardiac life support (ACLS)-based simulations compared to traditional verbal debriefing (VD).

Methods

The study was conducted at a single medical school. Participants were fourth-year medical students engaging in ACLS simulation-based training as part of their emergency medicine rotation. After completing an ACLS-based simulation, participants received either VD or VAD and then completed a second simulation scenario. Our primary outcome was ACLS performance, graded by blinded reviewers utilizing a previously developed modified checklist. Secondary outcomes included time from cardiac arrest to initiation of cardiopulmonary resuscitation (CPR) and first defibrillation. Measurements were made before and after the interventional debrief, referred to as pre- and postdebrief. A modified Likert-scale survey was used to subjectively assess the student's overall experience.

Results

Forty-six groups of 275 students were included in the study. Mean ACLS performance score for VD and VAD postdebrief were 85% and 82%, respectively (p = 0.27). Mean time from arrest to CPR initiation for VD and VAD postdebrief groups were 20 and 24 s, respectively (p = 0.46). Mean time from arrest to defibrillation for VD and VAD postdebrief groups were 50 and 59 s, respectively (p = 0.39). For the Likert surveys, 85% or more of participants in both groups indicated that the session was "very helpful" in all survey categories.

Conclusions

VD and VAD both led to improvements in ACLS performance, time to initiation of CPR, and defibrillation among fourth-year medical students. Though postdebrief results were not statistically significantly different by comparison, overall VD led to greater improvement overall across all outcomes.

Impact of virtual simulation vs. Video refresher training on NRP simulation performance: a randomized controlled trial

OBJECTIVE

To assess the impact of NRP virtual simulations (eSim™), video or no refresher training, on simulation performance, six months after a provider course; and to evaluate eSim™ acceptability.

STUDY DESIGN

In this multi-site randomized controlled trial, NRP providers from four U.S. institutions were randomized to receive refreshers every two months with NRP eSim™, NRP resuscitation video, or no refresher (control). Simulation performance was assessed immediately after an NRP course and six months later.

RESULT

248 participants completed the baseline simulation and 148 completed the six-month follow-up simulation. The majority (71%) of subjects had a decline in resuscitation skills at 6 months. There were no differences in performance between the study groups, but participants who reported using either the video or eSim™ had less decline in performance at the 6-month follow-up (p < 0.05).

CONCLUSION

NRP refreshers with either eSim™ or NRP video may mitigate the decline in resuscitation skills after training.

Using the providers' perspective on video review of neonatal procedures to create a roadmap: a qualitative study

OBJECTIVE

To examine the providers' perceptions and experiences on implementation of video review (VR) of procedures in the neonatal intensive care unit (NICU).

DESIGN

Qualitative study using semi-structured interviews with neonatal care providers about their experiences with VR. Interviews were audio-recorded, transcribed and thematically analysed using the data analysis software Atlas.ti V.22.2.

SETTING

Providers working in the NICU of the Leiden University Medical Center were interviewed during implementation of VR.

RESULTS

In total, 28 NICU staff members were interviewed. The interviewed providers appreciated VR and valued the focus on a safe learning environment. Five overarching themes were identified: (1) added value: providers reported that VR is a powerful tool for reflection on daily practice and serves as a magnifying glass on practice, provides a helicopter view and VR with nursing and medical staff together led to new insights and was seen as highly valuable; (2) preconditions and considerations: the existing culture of trust on the NICU positively influenced providers' perception; (3) adjustment: it was recommended to first let providers attend a VR session, before being recorded; (4) experiences with VR: suggestions were made by the providers regarding the preparation and organisation of VR and the role of the chair; (5) embedding VR: providers considered how to embed VR on the long-term while maintaining a safe learning environment and provided suggestions for expanding.

CONCLUSION

Neonatal care providers appreciated the use of VR and provided viewpoints on how to implement VR successfully, which were used to develop a roadmap with recommendations.

The newborn delivery room of tomorrow: emerging and future technologies

Advances in neonatal care have resulted in improved outcomes for high-risk newborns with technologies playing a significant part although many were developed for the neonatal intensive care unit. The care provided in the delivery room (DR) during the first few minutes of life can impact short- and long-term neonatal outcomes. Increasingly, technologies have a critical role to play in the DR particularly with monitoring and information provision. However, the DR is a unique environment and has major challenges around the period of foetal to neonatal transition that need to be overcome when developing new technologies. This review focuses on current DR technologies as well as those just emerging and further over the horizon. We identify what key opinion leaders in DR care think of current technologies, what the important DR measures are to them, and which technologies might be useful in the future. We link these with key technologies including respiratory function monitors, electoral impedance tomography, videolaryngoscopy, augmented reality, video recording, eye tracking, artificial intelligence, and contactless monitoring. Encouraging funders and industry to address the unique technological challenges of newborn care in the DR will allow the continued improvement of outcomes of high-risk infants from the moment of birth. IMPACT: Technological advances for newborn delivery room care require consideration of the unique environment, the variable patient characteristics, and disease states, as well as human factor challenges. Neonatology as a speciality has embraced technology, allowing its rapid progression and improved outcomes for infants, although innovation in the delivery room often lags behind that in the intensive care unit. Investing in new and emerging technologies can support healthcare providers when optimising care and could improve training, safety, and neonatal outcomes.

Three-Phase Video-Assisted Multidisciplinary Team Debriefing in High-Fidelity Blast Simulation through the Advocacy and Inquiry Method

BACKGROUND

Video-assisted debriefing (VAD) combined with the advocacy and inquiry (A&I) technique is a tool that allows video playback of selected segments of a simulation, thereby helping the debriefers structure the session. However, no consensus exists on how to optimally perform a team debriefing. The authors demonstrate and describe the methodology of A&I debriefing in an instructional simulated blast scenario and assess the impact of VAD on residents' technical and nontechnical skills.

METHODS

After institutional review board approval, the authors performed a study with 50 residents who were randomly assigned to 2 groups. Group 1 (control, or no VAD; n = 25) consisted of residents who received oral debriefing by 1 independent faculty member without the recorded video of the simulation. Group 2 (intervention, or VAD; n = 25) consisted of residents who received VAD from the second independent faculty member. These residents repeated the same simulation scenario 1 week after their debrief. Every resident was assessed on the primary and secondary survey, as well as the nontechnical skills, based on the integrated skills score.

RESULTS

The VAD group presented significantly higher values for the integrated skills score ( P < 0.001) compared with the no-VAD group.

CONCLUSIONS

This demonstration of 3-phase VAD emphasizes important aspects of coherent simulation-based training: psychologic safety, A&I, reflection, cognitive frames, prebrief, main debrief, summary, and translation of new discoveries to real-life patient care. The unique audiovisual aspect of the VAD enhanced residents' performance in simulation.

Video recording in the delivery room: current status, implications and implementation

Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.

What and when to debrief: a scoping review examining interprofessional clinical debriefing

INTRODUCTION

Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.

METHODS

Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.

RESULTS

Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.

CONCLUSIONS

The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

Mothers' acceptability of using novel technology with video and audio recording during newborn resuscitation: A cross-sectional survey

OBJECTIVE

This study aims to assess the acceptability of a novel technology, MAchine Learning Application (MALA), among the mothers of newborns who required resuscitation.

SETTING

This study took place at Bharatpur Hospital, which is the second-largest public referral hospital with 13 000 deliveries per year in Nepal.

DESIGN

This is a cross-sectional survey.

DATA COLLECTION AND ANALYSIS

Data collection took place from January 21 to February 13, 2022. Self-administered questionnaires on acceptability (ranged 1-5 scale) were collected from participating mothers. The acceptability of the MALA system, which included video and audio recordings of the newborn resuscitation, was examined among mothers according to their age, parity, education level and technology use status using a stratified analysis.

RESULTS

The median age of 21 mothers who completed the survey was 25 years (range 18-37). Among them, 11 mothers (52.4%) completed their bachelor's or master's level of education, 13 (61.9%) delivered first child, 14 (66.7%) owned a computer and 16 (76.2%) carried a smartphone. Overall acceptability was high that all participating mothers positively perceived the novel technology with video and audio recordings of the infant's care during resuscitation. There was no statistical difference in mothers' acceptability of MALA system, when stratified by mothers' age, parity, or technology usage (p>0.05). When the acceptability of the technology was stratified by mothers' education level (up to higher secondary level vs. bachelor's level or higher), mothers with Bachelor's degree or higher more strongly felt that they were comfortable with the infant's care being video recorded (p = 0.026) and someone using a tablet when observing the infant's care (p = 0.046). Compared with those without a computer (n = 7), mothers who had a computer at home (n = 14) more strongly agreed that they were comfortable with someone observing the resuscitation activity of their newborns (71.4% vs. 14.3%) (p = 0.024).

CONCLUSION

The novel technology using video and audio recordings for newborn resuscitation was accepted by mothers in this study. Its application has the potential to improve resuscitation quality in low-and-middle income settings, given proper informed consent and data protection measures are in place.

Newborn resuscitation timelines: Accurately capturing treatment in the delivery room

OBJECTIVES

To evaluate the use of newborn resuscitation timelines to assess the incidence, sequence, timing, duration of and response to resuscitative interventions.

METHODS

A population-based observational study conducted June 2019-November 2021 at Stavanger University Hospital, Norway. Parents consented to participation antenatally. Newborns ≥28 weeks' gestation receiving positive pressure ventilation (PPV) at birth were enrolled. Time of birth was registered. Dry-electrode electrocardiogram was applied as soon as possible after birth and used to measure heart rate continuously during resuscitation. Newborn resuscitation timelines were generated from analysis of video recordings.

RESULTS

Of 7466 newborns ≥28 weeks' gestation, 289 (3.9%) received PPV. Of these, 182 had the resuscitation captured on video, and were included. Two-thirds were apnoeic, and one-third were breathing ineffectively at the commencement of PPV. PPV was started at median (quartiles) 72 (44, 141) seconds after birth and continued for 135 (68, 236) seconds. The ventilation fraction, defined as the proportion of time from first to last inflation during which PPV was provided, was 85%. Interruption in ventilation was most frequently caused by mask repositioning and auscultation. Suctioning was performed in 35% of newborns, in 95% of cases after the initiation of PPV. PPV was commenced within 60 s of birth in 49% of apnoeic and 12% of ineffectively breathing newborns, respectively.

CONCLUSIONS

Newborn resuscitation timelines can graphically present accurate, time-sensitive and complex data from resuscitations synchronised in time. Timelines can be used to enhance understanding of resuscitation events in data-guided quality improvement initiatives.

Retrospectively Assessed Muscle Tone and Skin Colour following Airway Suctioning in Video-Recorded Infants Receiving Delivery Room Positive Pressure Ventilation

Background: Recently, the International Liaison Committee on Resuscitation published a systematic review that concluded that routine suctioning of clear amniotic fluid in the delivery room might be associated with lower oxygen saturation (SpO2) and 10 min Apgar score. The aim of this study was to examine the effect of delivery room airway suctioning on the clinical appearance, including muscle tone and skin colour, of video-recorded term and preterm infants born through mainly clear amniotic fluid. Methods: This was a single-centre observational study using transcribed video recordings of neonatal stabilizations. All infants who received delivery room positive pressure ventilation (PPV) from August 2014 to November 2016 were included. The primary outcome was the effect of airway suctioning on muscle tone and skin colour (rated 0−2 according to the Apgar score), while the secondary outcome was the fraction of infants for whom airway suction preceded the initiation of PPV as a surrogate for “routine” airway suctioning. Results: Airway suctioning was performed in 159 out of 302 video recordings and stimulated a vigorous cry in 47 (29.6%) infants, resulting in improvements in muscle tone (p = 0.09) and skin colour (p < 0.001). In 43 (27.0%) infants, airway suctioning preceded the initiation of PPV. Conclusions: In this single-centre observational study, airway suctioning stimulated a vigorous cry with resulting improvements in muscle tone and skin colour. Airway suctioning was often performed prior to the initiation of PPV, indicating a practice of routine suctioning and guideline non-compliance.

Effects of simulation-based education for neonatal resuscitation on medical students' technical and non-technical skills

Simulation is a learner-centered practice that helps develop and maintain knowledge, skills, and competencies. This study evaluated the effect of neonatal resuscitation simulation-based education for medical students in the fifth year (part of the regular clinical clerkship program) on the perceived performance of their technical and non-technical skills. In addition, we analyzed the difference between instructor's and learners' evaluations of technical skills after the simulation. A one-group pretest-posttest design was adopted. The simulation-based education of the neonatal resuscitation program (NRP) was conducted for 40 medical students from July to November 2020 at a medical school in South Korea. The simulation-based education comprised 5 minutes of pre-briefing, 10 minutes of running the simulation, and 30 minutes of debriefing (using a recorded video). The perceived performance of students' technical and non-technical skills before and after the simulation was compared by collecting and analyzing the pre- and post-questionnaires. The perceived performance of technical (p = .001) and non-technical skills (p < .001) was found to have significantly increased after the simulation. Particularly, the performance of technical skills, such as diagnostic (p = .007) and therapeutic actions (p < .001) and non-technical skills, such as leadership (p < .001), teamwork (p = .001), and task management (p = .020) improved significantly. There was no significant difference in the evaluations of the technical performance of the instructor and learners after the simulation (p = .953). Simulation-based education can improve technical skills, such as diagnostic and therapeutic actions for neonatal resuscitation. It is also effective in enhancing non-technical skills, such as leadership, teamwork, and task management. Further, after the simulation-based education, students can fully self-evaluate through objective reflection and improve their clinical competency.

Usability, acceptability and feasibility of a novel technology with visual guidance with video and audio recording during newborn resuscitation: a pilot study

OBJECTIVE

Inadequate adherence to resuscitation for non-crying infants will have poor outcome and thus rationalise a need for real-time guidance and quality improvement technology. This study assessed the usability, feasibility and acceptability of a novel technology of real-time visual guidance, with sound and video recording during resuscitation.

SETTING

A public hospital in Nepal.

DESIGN

A cross-sectional design.

INTERVENTION

The technology has an infant warmer with light, equipped with a tablet monitor, NeoBeat and upright bag and mask. The tablet records resuscitation activities, ventilation sound, heart rate and display time since birth. Healthcare providers (HCPs) were trained on the technology before piloting.

DATA COLLECTION AND ANALYSIS

HCPs who had at least 8 weeks of experience using the technology completed a questionnaire on usability, feasibility and acceptability (ranged 1-5 scale). Overall usability score was calculated (ranged 1-100 scale).

RESULTS

Among the 30 HCPs, 25 consented to the study. The usability score was good with the mean score (SD) of 68.4% (10.4). In terms of feasibility, the participants perceived that they did not receive adequate support from the hospital administration for use of the technology, mean score (SD) of 2.44 (1.56). In terms of acceptability, the information provided in the monitor, that is, time elapsed from birth was easy to understand with mean score (SD) of 4.60 (0.76).

CONCLUSION

The study demonstrates reasonable usability, feasibility and acceptability of a technological solution that records audio visual events during resuscitation and provides visual guidance to improve care.

Learning with digital recording and video review of delivery room resuscitation

Digital recording and video review of delivery room resuscitations is a proven useful tool to evaluate neonatal resuscitation program (NRP) technical and non-technical skills. It is also valuable for research, quality improvement, and individual and group learning. Digital recording and video review programs are growing in number, and planning and implementation of digital recording requires careful thought. Consideration of technology requirements, policy implementation, and stakeholder involvement is essential to implement a successful digital recording and video review program. Video review can then be applied for individual and team-based learning. An approach to sustainability and on-going quality review of the program are key components critical to success.

Versorgung und Reanimation des reifen Neugeborenen nach der Geburt

Die volle Reanimation eines Neugeborenen mit Beatmungen, Thoraxkompressionen und der Gabe von Medikamenten ist ein äußerst seltenes Ereignis, das selbst neonatologische Teams immer wieder vor Herausforderungen stellt. Gerade in diesen seltenen und häufig dramatischen Situationen ist schnelles und umsichtiges Handeln im Team gefragt. Dabei ist die effektivste und meist einzig notwendige Maßnahme für die erfolgreiche Versorgung eines nicht spontan atmenden Neugeborenen eine suffiziente Maskenbeatmung. Wird diese effektiv durchgeführt, sind beim Neugeborenen in den seltensten Fällen tatsächlich Thoraxkompressionen notwendig. Im März 2021 wurde vom European Resuscitation Council (ERC) die neue Leitlinie zur Reanimation von Neugeborenen publiziert. Auf Basis dieser Leitlinie beschreibt der vorliegende Beitrag detailliert den im Algorithmus der Versorgung und Reanimation von reifen Neugeborenen dargestellten Handlungsablauf. Er richtet sich damit einerseits insbesondere an NichtneonatologInnen, die für die Versorgung v. a. von reifen Neugeborenen nach der Geburt verantwortlich sind. Andererseits soll er auch jenen zur Unterstützung dienen, die medizinisches Personal in der Versorgung von lebensbedrohten Neugeborenen trainieren und den Algorithmus der Neugeborenenreanimation als didaktisches Konzept vermitteln.

Video recording as an objective assessment tool of health worker performance in neonatal resuscitation at a district hospital in Pemba, Tanzania: a feasibility study

OBJECTIVES

To assess the feasibility of using video recordings of neonatal resuscitation (NR) to evaluate the quality of care in a low-resource district hospital.

DESIGN

Prospective observational feasibility study.

SETTING

Chake-Chake Hospital, a district hospital in Pemba, Tanzania, in April and May 2019.

PARTICIPANTS

All delivering women and their newborns were eligible for participation.

MAIN OUTCOME MEASURES

Motion-triggered cameras were mounted on resuscitation tables and provided recordings that were analysed for quality of care indicators based on the national NR algorithm. Assessment of feasibility was conducted using Bowen's 8-point framework for feasibility studies.

RESULTS

91% (126 of 139) of women and 96% (24 of 26) of health workers were comfortable or very comfortable with the video recordings. Of 139 newborns, 8 underwent resuscitation with bag and mask ventilation. In resuscitations, heat loss prevention measures were not performed in half of the cases (four of eight), clearing the airway was not performed correctly in five of eight cases, and all newborns were suctioned vigorously and repeatedly, even when not indicated. In a quarter (two of eight) of cases, the newborn's head was not positioned correctly. Additionally, two of the eight newborns needing ventilation were not ventilated within the first minute of life. In none of the eight cases did ventilation appear to be performed effectively.

CONCLUSIONS

It proved feasible to use video recordings to assess quality of care during NR in a low-resource setting, and the method was considered acceptable for the delivering women and health workers. Recordings of eight resuscitations all demonstrated deviations from NR guidelines.

Video recording emergency care and video-reflection to improve patient care; a narrative review and case-study of a neonatal intensive care unit

As the complexity of emergency care increases, current research methods to improve care are often unable to capture all aspects of everyday clinical practice. Video recordings can visualize clinical care in an objective way. They can be used as a tool to assess care and to reflect on care with the caregivers themselves. Although the use of video recordings to reflect on medical interventions (video-reflection) has increased over the years, it is still not used on a regular basis. However, video-reflection proved to be of educational value and can improve teams' management and performance. It has a positive effect on guideline adherence, documentation, clinical care and teamwork. Recordings can also be used for video-reflexivity. Here, caregivers review recordings together to reflect on their everyday practice from new perspectives with regard to context and conduct in general. Although video-reflection in emergency care has proven to be valuable, certain preconditions have to be met and obstacles need to be overcome. These include gaining trust of the caregivers, having a proper consent-procedure, maintaining confidentiality and adequate use of technical equipment. To implement the lessons learned from video-reflection in a sustainable way and to continuously improve care, it should be integrated in regular simulation training or education. This narrative review will describe the development of video recording in emergency care and how video-reflection can improve patient care and safety in new ways. On our own department, the NICU at the LUMC, video-reflection has already been implemented and we want to further expand this. We will describe the use of video-reflection in our own unit. Based on the results of this narrative review we will propose options for future research to increase the value of video-reflection.

Rapid Cycle Deliberate Practice Simulation Curriculum Improves Pediatric Trauma Performance: A Prospective Cohort Study

INTRODUCTION

Simulation-based medical education allows learners to refine and maintain clinical skills especially for high-stake situations such as trauma resuscitation. Despite the primary and secondary survey being its foundation, literature shows poor adherence with overall rates as low as 13%. This study evaluates the impact of rapid cycle deliberate practice (RCDP) on primary and secondary survey skill retention. We hypothesized that RCDP-trained surgery residents will have real-world clinical improvement in their survey completion in pediatric trauma resuscitations.

METHODS

We developed an RCDP trauma resuscitation curriculum. Videos of trauma resuscitations before and after curriculum implementation were scored by 2 blinded reviewers using a modified Pediatric Trauma Assessment Scoring Tool. Actual trauma care by residents who had received the curriculum (study group) was compared with care provided by residents who had not received the curriculum (precurriculum historical control group and a concurrent control group who provided care without receiving the curriculum).

RESULTS

One hundred eighty-eight videos were scored with 98 in study group, 33 in concurrent control group, and 57 in historical control group. There was a significant improvement in primary survey performance between study group and historical control group (P < 0.001), but no difference between study group and concurrent control group. There was a significant improvement between study group and 2 control groups in secondary survey performance (both P < 0.001).

CONCLUSIONS

The RCDP curriculum led to significant improvement in surgical residents' trauma survey performance and had clinical impact on actual patients, which is rare in pediatric trauma simulation literature.

Assessment of temporal variations in adherence to NRP using video recording in the delivery room

Introduction

Video recording and video evaluation tools have been successfully used to evaluate neonatal resuscitation performance. The objective of our study was to evaluate differences in Neonatal Resuscitation Program (NRP) adherence at time of birth between three temporal resuscitative periods using scored video recordings.

Methods

This is a retrospective review of in-situ resuscitation video recordings from a level 3 perinatal center between 2017 and 2018. The modified Neonatal Resuscitation Assessment (mNRA) scoring tool was used as a surrogate marker to assess NRP adherence during daytime, evening, and nighttime hours.

Results

A total of 260 resuscitations, of which 258 were births via Cesarean section, were assessed. mNRA composite scores were 86.2% during daytime hours, 87% during evening hours, and 86.6% during nighttime hours. There were no significant differences in mNRA composite scores between any of the three time periods. Differences remained statistically similar after controlling for complexity of resuscitations with administration of positive pressure ventilation (PPV), intubation, or chest compressions.

Conclusion

Overall adherence to NRP, as measured by composite mNRA scores as a surrogate marker, was high across all three daily resuscitative periods without significant differences between daytime, evening, and nighttime hours.

Tablet-Based Decision Support Tool Improves Performance of Neonatal Resuscitation: A Randomized Trial in Simulation

INTRODUCTION

Decision support tools (DST) may aid compliance of teams with the Neonatal Resuscitation Program (NRP) algorithm but have not been adequately tested in this population. Furthermore, the optimal team size for neonatal resuscitation is not known. Our aim was to determine whether use of a tablet-based DST or team size altered adherence to the NRP algorithm in teams of healthcare providers (HCPs) performing simulated neonatal resuscitation.

METHOD

One hundred nine HCPs were randomized into a team of 2 or 3 and into using a DST or memory alone while performing 2 simulation scenarios. The primary outcome was NRP compliance, assessed by the modified Neonatal Resuscitation Performance Evaluation (NRPE). Secondary outcomes were the subcomponents of the NRPE score, cumulative time error (the cumulative time in seconds to perform resuscitation tasks in error, early or late, from NRP guidelines), and the interaction between DST and team size.

RESULTS

Decision support tool use improved total NRPE score when compared with memory alone (p = 0.015). There was no difference in NRPE score within teams of 2 compared with 3 HCPs. Cumulative time error was decreased with DST use compared with memory alone but was not significant (p = 0.057). Team size did not affect time error.

CONCLUSIONS

Teams with the DST had improved NRP adherence compared with teams relying on memory alone in 1 of 2 scenarios. Two and 3 HCP teams performed similarly. Given the positive results observed in the simulated environment, further testing the DST in the clinical environment is warranted.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Midwives' Evaluation of a Neonatal Resuscitation in High- and Low-Resource Settings

Aim: To assess midwives' evaluation of a real-life neonatal resuscitation and their opinion on importance of resuscitation interventions. Methods: Multicenter, multi-country study. Setting: Beira Central Hospital (Mozambique) and Azienda Ospedale-Università di Padova (Italy). Subjects: Sixteen Mozambican midwives and 18 Italian midwives. Interventions: Midwives' assessment was evaluated by using a predefined score, which graded each resuscitation intervention (0-2 points) and summed to a total score for each step (initial steps, bag-mask ventilation, and chest compressions). All scores were compared with referral scores given by two expert neonatologists. Results: Both Mozambican and Italian midwives overestimated their performance regarding of initial steps taken during resuscitation, chest compressions, high-oxygen concentrations (p < 0.01), and underestimated the importance of stimulation (p < 0.05). Mozambicans overestimated suctioning (p < 0.001). Participants agreed with experts about the importance of equipment preparation, using a warmer, drying the newborn, removing wet linen and heart rate assessment. Conclusion: Mozambican and Italian midwives overestimated the performance of a real-life neonatal resuscitation, with heterogeneous evaluation of the importance of several aspects of neonatal resuscitation. These findings may be useful for identifying educational goals.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Suboptimal heart rate assessment and airway management in infants receiving delivery room chest compressions: a quality assurance project

OBJECTIVE

In a previous audit, we demonstrated poor compliance with the neonatal resuscitation algorithm. Training can improve guideline compliance and performance. We aimed to prospectively collect detailed data on delivery room resuscitations to identify needs for educational interventions.

DESIGN

Observational study using video recordings of neonatal resuscitations. We analysed episodes where chest compressions (CCs) were provided.

SETTING

A Norwegian university hospital.

PATIENTS

All delivery room resuscitations August 2014 to November 2016.

INTERVENTIONS

The recordings were transcribed using Interact V.9 software (Mangold Int GmbH, Arnstorf, Germany). Supplementary information was collected from the patient electronic records.

MAIN OUTCOME MEASURES

Heart rate (HR) assessment, provision of positive pressure ventilation (PPV) and CC, endotracheal intubation and team communication.

RESULTS

Twenty-nine CC episodes were analysed. We identified team discordance in the decisions to perform CC and only 6 (21%) were retrospectively judged to be in need for CC: 8 (28%) infants had adequate spontaneous respiration, 18 (62%) infants received ineffective PPV and 5 (17%) had a HR >60 bpm. Only one infant was intubated before CC, and we could not identify a consistent pattern of ventilation corrective actions. One infant received CC without prior HR assessment. In some infants, CC duration was exceedingly short, and 11 (38%) of the infants that received CC were not admitted to the NICU. Six (21%) infants had no documentation of CPR in the delivery record.

CONCLUSIONS

Education and training should focus on team function and communication, correct and timely HR assessment, effective PPV, and indications for endotracheal intubation.

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network

BACKGROUND

Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown.

METHODS

The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program.

RESULTS

Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine.

CONCLUSIONS

The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.

Activity Recognition From Newborn Resuscitation Videos

OBJECTIVE

Birth asphyxia is one of the leading causes of neonatal deaths. A key for survival is performing immediate and continuous quality newborn resuscitation. A dataset of recorded signals during newborn resuscitation, including videos, has been collected in Haydom, Tanzania, and the aim is to analyze the treatment and its effect on the newborn outcome. An important step is to generate timelines of relevant resuscitation activities, including ventilation, stimulation, suction, etc., during the resuscitation episodes.

METHODS

We propose a two-step deep neural network system, ORAA-net, utilizing low-quality video recordings of resuscitation episodes to do activity recognition during newborn resuscitation. The first step is to detect and track relevant objects using Convolutional Neural Networks (CNN) and post-processing, and the second step is to analyze the proposed activity regions from step 1 to do activity recognition using 3D CNNs.

RESULTS

The system recognized the activities newborn uncovered, stimulation, ventilation and suction with a mean precision of 77.67%, a mean recall of 77,64%, and a mean accuracy of 92.40%. Moreover, the accuracy of the estimated number of Health Care Providers (HCPs) present during the resuscitation episodes was 68.32%.

CONCLUSION

The results indicate that the proposed CNN-based two-step ORAA-net could be used for object detection and activity recognition in noisy low-quality newborn resuscitation videos.

SIGNIFICANCE

A thorough analysis of the effect the different resuscitation activities have on the newborn outcome could potentially allow us to optimize treatment guidelines, training, debriefing, and local quality improvement in newborn resuscitation.

Using video to assess and improve patient safety during simulated and actual neonatal resuscitation

Neonatal resuscitation is an event that can cause high stress among healthcare professionals (HCPs) and is frequently associated with medical errors. Improving patient safety and reducing errors requires a concerted effort with a plan for improvement. Video can be used as a component of the improvement process at several points including standardizing educational information, assessing learner knowledge and skills during simulation, and assessing individual and team performance during actual neonatal resuscitations.

Object Detection During Newborn Resuscitation Activities

OBJECTIVE

Birth asphyxia is a major newborn mortality problem in low-resource countries. International guideline provides treatment recommendations; however, the importance and effect of the different treatments are not fully explored. The available data are collected in Tanzania, during newborn resuscitation, for analysis of the resuscitation activities and the response of the newborn. An important step in the analysis is to create activity timelines of the episodes, where activities include ventilation, suction, stimulation, etc. Methods: The available recordings are noisy real-world videos with large variations. We propose a two-step process in order to detect activities possibly overlapping in time. The first step is to detect and track the relevant objects, such as bag-mask resuscitator, heart rate sensors, etc., and the second step is to use this information to recognize the resuscitation activities. The topic of this paper is the first step, and the object detection and tracking are based on convolutional neural networks followed by post processing.

RESULTS

The performance of the object detection during activities were 96.97% (ventilations), 100% (attaching/removing heart rate sensor), and 75% (suction) on a test set of 20 videos. The system also estimate the number of health care providers present with a performance of 71.16%.

CONCLUSION

The proposed object detection and tracking system provides promising results in noisy newborn resuscitation videos.

SIGNIFICANCE

This is the first step in a thorough analysis of newborn resuscitation episodes, which could provide important insight about the importance and effect of different newborn resuscitation activities.

Improving Guideline Compliance and Documentation Through Auditing Neonatal Resuscitation

Objective: Evaluate whether weekly audits of neonatal resuscitation using video and physiological parameter recordings improved guideline compliance and documentation in medical records. Study design: Neonatal care providers of the Neonatal Intensive Care Unit (NICU) of Leiden University Medical Center reviewed recordings of neonatal resuscitation during weekly plenary audits since 2014. In an observational pre-post cohort study, we studied a cohort of infants born before and after implementation of weekly audits. Video and physiological parameter recordings of infants needing resuscitation were analyzed. These recordings were compared with the prevailing resuscitation guideline and corresponding documentation in the medical record using a pre-set checklist. Results: A total of 212 infants were included, 42 before and 170 after implementation of weekly audits, with a median (IQR) gestational age of 30 (27-35) weeks vs. 30 (29-33) weeks (p = 0.64) and birth weight of 1368 (998-1780) grams vs. 1420 (1097-1871) grams (p = 0.67). After weekly audits were implemented, providers complied more often to the guideline (63 vs. 77%; p < 0.001). Applying the correct respiratory support based on heart rate and respiration, air conditions (dry vs. humidified air), fraction of inspired oxygen (FiO₂), timely start of interventions and evaluation of delivered care improved. Total number of correctly documented items in medical records increased from 39 to 65% (p < 0.001). Greatest improvements were achieved in documentation of present providers, mode of respiratory support and details about transport to the NICU. Conclusion: Regular auditing using video and physiological parameter recordings of infants needing resuscitation at birth improved providers' compliance with resuscitation guideline and documentation in medical records.