Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study

Use of real-time respiratory function monitor improves neonatal face mask ventilation: Cross-over simulation study

BACKGROUND

Neonatal resuscitation airway training can be difficult as there is no feedback on the face mask technique. "JUNO" is a training respiratory function monitor that provides feedback on mask leak, ventilatory rate, and tidal volume.

OBJECTIVE

To evaluate whether the use of the JUNO improves face mask ventilation techniques in manikin models.

METHODS

We conducted an observational cross-over study with our unit staff. Following instructions, each participant performed a single-person technique, followed by a two-person technique with no JUNO feedback. This was repeated with JUNO feedback visible. A similar sequence was performed both in term and preterm manikins, giving a total of 8 sequences. Each participant was instructed to perform 1 min of positive pressure ventilation providing 30 inflations/minute for all of the simulations. Each of the simulation data underwent a data cleaning process.

RESULTS

Thirty-eight subjects provided a total of 304 sequences of positive pressure ventilation. A total of 13 354 inflations were analyzed. The feedback group had significantly lower rates of inflations with leak >60%, lower rates of excessive tidal volumes, lower mean leak percentage, and a lower mean inspiratory tidal volumes. When analyzed based on the technique (single person and two-person), similar positive results were noted in the "feedback group", across all the strata of staff. All of the staff reported that JUNO improved their ventilation technique and would recommend it for staff training.

CONCLUSIONS

The use of JUNO significantly improved mask ventilation consistently across manikin types, staff roles, and techniques (either single- or two-person).

Optimization of manual ventilation quality using respiratory function monitoring in neonates: A two-phase intervention trial

OBJECTIVE

The aim of this study was the evaluation of the impact of a respiratory function monitor (RFM, Neo100, Monivent AB, Gothenburg, Sweden) on the quality of ventilation in neonates.

METHODS

This single-center two-phase intervention study was conducted at the Neonatal Intensive Care Unit and the delivery room of the Medical University of Vienna. Patients with clinical need for positive pressure ventilation were included in either of two consecutive study phases: (i) patients were ventilated with a hidden RFM (control) or (ii) visible RFM (intervention) during manual positive pressure ventilations. The duration of each phase was approximately six months. The primary outcome was the percentage of ventilations within a tidal volume range of 4-8 ml/kg (pVTe).

RESULTS

A total of 90 patients (GA 22-66 weeks) were included. The primary outcome was significantly higher in the intervention group with a visible RFM (53.7%, SD 22.6) than in the control group without the monitor (37.3%, SD 20.5); (p < 0.001, mean difference [i.e., change in percentage points]: 16.95% CI: 7.4-35). In terms of secondary outcomes, excessive tidal volumes (>8ml/kg), potentially associated with an increased risk of brain injury, could be significantly reduced when a RFM was visible during ventilation (10.9% [IQR 26.4] vs. 29.5% [IQR 38.1]; p = 0.004). Furthermore, mask leakage could be significantly decreased (37.3% [SD 22.7] vs. 52.7% [SD 23.0]; p = 0.002).

CONCLUSION

Our results suggest that the clinical application of a RFM for manual ventilation of preterm and term infants leads to a significant improvement in ventilation parameters.

Meeting the need for effective and standardized neonatology training: a pan-European Master's Curriculum

Neonatology is a pediatric sub-discipline focused on providing care for newborn infants, including healthy newborns, those born prematurely, and those who present with illnesses or malformations requiring medical care. The European Training Requirements (ETR) in Neonatology provide a framework for standardized quality and recognition of equality of training throughout Europe. The latest ETR version was approved by the Union of European Medical Specialists (UEMS) in April 2021. Here, we present the curriculum of the European School of Neonatology Master of Advanced Studies (ESN MAS), which is based on the ETR in Neonatology and aims to provide a model for effective and standardized training and education in neonatal medicine. We review the history and theory that form the foundation of contemporary medical education and training, provide a literature review on best practices for medical training, pediatric training, and neonatology training specifically, including educational frameworks and evidence-based systems of evaluation. The ESN MAS Curriculum is then evaluated in light of these best practices to define its role in meeting the need for a standardized empirically supported neonatology training curriculum for physicians, and in the future for nurses, to improve the quality of neonatal care for all infants. IMPACT STATEMENT: A review of the neonatology training literature was conducted, which concluded that there is a need for standardized neonatology training across international contexts to keep pace with growth in the field and rapidly advancing technology. This article presents the European School of Neonatology Master of Advanced Studies in Neonatology, which is intended to provide a standardized training curriculum for pediatricians and nurses seeking sub-specialization in neonatology. The curriculum is evaluated in light of best practices in medical education, neonatology training, and adult learning theory.

Assessment of Visual Attention in Teams with or without Dedicated Team Leaders: A Neonatal Simulation-Based Pilot Randomised Cross-Over Trial Utilising Low-Cost Eye-Tracking Technology

BACKGROUND

Eye-tracking technology could be used to study human factors during teamwork.

OBJECTIVES

This work aimed to compare the visual attention (VA) of a team member acting as both a team leader and managing the airway, compared to a team member performing the focused task of managing the airway in the presence of a dedicated team leader. This work also aimed to report differences in team performance, behavioural skills, and workload between the two groups using validated tools.

METHODS

We conducted a simulation-based, pilot randomised controlled study. The participants included were volunteer paediatric trainees, nurse practitioners, and neonatal nurses. Three teams consisting of four team members were formed. Each team participated in two identical neonatal resuscitation simulation scenarios in a random order, once with and once without a team leader. Using a commercially available eye-tracking device, we analysed VA regarding attention to (1) a manikin, (2) a colleague, and (3) a monitor. Only the trainee who was the airway operator would wear eye-tracking glasses in both simulations.

RESULTS

In total, 6 simulation scenarios and 24 individual role allocations were analysed. Participants in a no-team-leader capacity had a greater number of total fixations on manikin and monitors, though this was not significant. There were no significant differences in team performance, behavioural skills, and individual workload. Physical demand was reported as significantly higher by participants in the group without a team leader. During debriefing, all the teams expressed their preference for having a dedicated team leader.

CONCLUSION

In our pilot study using low-cost technology, we could not demonstrate the difference in VA with the presence of a team leader.

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.

Nursing practice of routine gastric aspiration in preterm infants and its link to necrotizing enterocolitis: is the practice still clinically relevant?

The practice of routine gastric residual aspiration in preterm infants remains controversial, with conflicting evidence regarding its impact on necrotizing enterocolitis (NEC). As front-line caregivers, nurses play a vital role in gastric aspiration procedures and must be informed by evidence. This quasi-experimental nursing study aimed to assess whether gastric aspiration is clinically relevant in reducing the risk of NEC in preterm infants.A total of 250 preterm infants from two NICUs in Egypt were allocated to the gastric aspiration (n = 125) and non-aspiration (n = 125) groups. Feeding practices, gastric residuals, and incidence/severity of NEC were compared between groups according to modified Bell's criteria. Risk factors were analyzed using multivariate regression. There were no significant baseline differences between the groups. The gastric residual attributes and feeding outcomes did not differ substantially from aspiration. The overall incidence of NEC was 14-15%, with no significant differences in the odds of onset or progression of NEC by stage between the groups. Lower gestational age and birth weight emerged as stronger predictors of NEC. Routine gastric aspiration does not appear to directly prevent or reduce the severity of NEC in this population. Although gastric residuals retain clinical importance, study findings question assumptions that aspiration protects against NEC and informs nursing practice. Evidence-based feeding protocols must continually evolve through ongoing research on modifiable risk factors for this devastating intestinal disease in preterm infants.

Impact of a virtual reality-based simulation training for shoulder dystocia on human and technical skills among caregivers: a randomized-controlled trial

This study analyzed the adherence to the modified Advanced Life Support in Obstetrics (ALSO) algorithm (HELP-RER) for handling shoulder dystocia (SD) using a virtual reality (VR) training modality. Secondary outcomes were improvements in the post-training diagnosis-to-delivery time, human skills factors (HuFSHI), and perceived task-load index (TLX). Prospective, case-control, single-blind, 1:1 randomized crossover study. Participants were shown a 360° VR video of SD management. The control group was briefed theoretically. Both groups underwent HuFSHI and HELP-RER score assessments at baseline and after the manikin-based training. The TLX questionnaire was then administered. After a washout phase of 12 weeks, we performed a crossover, and groups were switched. There were similar outcomes between groups during the first training session. However, after crossover, the control group yielded significantly higher HELP-RER scores [7 vs. 6.5; (p = 0.01)], with lower diagnosis-to-delivery-time [85.5 vs. 99 s; (p = 0.02)], and TLX scores [57 vs. 68; (p = 0.04)]. In the multivariable linear regression analysis, VR training was independently associated with improved HELP-RER scores (p = 0.003). The HuFSHI scores were comparable between groups. Our data demonstrated the feasibility of a VR simulation training of SD management for caregivers. Considering the drawbacks of common high-fidelity trainings, VR-based simulations offer new perspectives.

Demands of surgical teams in robotic-assisted surgery: An assessment of intraoperative workload within different surgical specialties

BACKGROUND

Current approaches to assessing workload in robotic-assisted surgery (RAS) focus on surgeons and lack real-world data. Understanding how workload varies by role and specialty aids in identifying effective ways to optimize workload.

METHODS

SURG-TLX surveys with six domains of workload were administered to surgical staff at three sites. Staff reported workload perceptions for each domain on a 20-point Likert scale, and aggregate scores were determined per participant.

RESULTS

188 questionnaires were obtained across 90 RAS procedures. Significantly higher aggregate scores were reported for gynecology (Mdn ​= ​30.00) (p ​= ​0.034) and urology (Mdn ​= ​36.50) (p ​= ​0.006) than for general (Mdn ​= ​25.00). Surgeons reported significantly higher scores for task complexity (Mdn ​= ​8.00) than both technicians (Mdn ​= ​5.00) (p ​= ​0.007), and nurses (Mdn ​= ​5.00).

CONCLUSIONS

Staff reported significantly higher workload during urology and gynecology procedures, and experienced significant differences in domain workload by role and specialty, elucidating the need for tailored workload interventions.

Eye-tracking during simulated endotracheal newborn intubation: a prospective, observational multi-center study

BACKGROUND

The aim was to assess health care providers' (HCPs) visual attention (VA) by using eye-tracking glasses during a simulated neonatal intubation.

METHODS

HCPs from three pediatric and neonatal departments (Feldkirch and Vienna, Austria, and Edmonton, Canada) completed a simulated neonatal intubation scenario while wearing eye-tracking glasses (Tobii Pro Glasses 2^®, Tobii, Stockholm, Sweden) to record their VA. Main outcomes included duration of intubation, success rate, and VA. We further compared orotracheal and nasotracheal intubations.

RESULTS

30 participants were included. 50% completed the intubation within 30 s (M = 35.40, SD = 16.01). Mostly nasotracheal intubations exceeded the limit. Experience was an important factor in reducing intubation time. VA differed between more and less experienced HCPs as well as between orotracheal and nasotracheal intubations. Participants also focused on different areas of interest (AOIs) depending on the intubator's experience. More experience was associated with a higher situational awareness (SA) and fewer distractions, which, however, did not transfer to significantly better intubation performance.

CONCLUSION

Half of the intubations exceeded the recommended time limit. Differences in intubation duration depending on type of intubation were revealed. VA differed between HCPs with different levels of experience and depended on duration and type of intubation.

IMPACT

Simulated neonatal intubation duration differs between orotracheal and nasotracheal intubation. Visual attention during simulated neonatal intubation shows differences depending on intubation duration, intubator experience, type of intubation, and level of distraction. Intubator experience is a vital parameter for reducing intubation duration and improving intubator focus on task-relevant stimuli.

Experimental validation of a portable tidal volume indicator for bag valve mask ventilation

INTRODUCTION

Short-term emergency ventilation is most typically accomplished through bag valve mask (BVM) techniques. BVMs like the AMBU® bag are cost-effective and highly portable but are also highly prone to user error, especially in high-stress emergent situations. Inaccurate and inappropriate ventilation has the potential to inflict great injury to patients through hyper- and hypoventilation. Here, we present the BVM Emergency Narration-Guided Instrument (BENGI) - a tidal volume feedback monitoring device that provides instantaneous visual and audio feedback on delivered tidal volumes, respiratory rates, and inspiratory/expiratory times. Providing feedback on the depth and regularity of respirations enables providers to deliver more consistent and accurate tidal volumes and rates. We describe the design, assembly, and validation of the BENGI as a practical tool to reduce manual ventilation-induced lung injury.

METHODS

The prototype BENGI was assembled with custom 3D-printed housing and commercially available electronic components. A mass flow sensor in the central channel of the device measures air flow, which is used to calculate tidal volume. Tidal volumes are displayed via an LED ring affixed to the top of the BENGI. Additional feedback is provided through a speaker in the device. Central processing is accomplished through an Arduino microcontroller. Validation of the BENGI was accomplished using benchtop simulation with a clinical ventilator, BVM, and manikin test lung. Known respiratory quantities were delivered by the ventilator which were then compared to measurements from the BENGI to validate the accuracy of flow measurements, tidal volume calculations, and audio cue triggers.

RESULTS

BENGI tidal volume measurements were found to lie within 4% of true delivered tidal volume values (95% CI of 0.53 to 3.7%) when breaths were delivered with 1-s inspiratory times, with similar performance for breaths delivered with 0.5-s inspiratory times (95% CI of 1.1 to 6.7%) and 2-s inspiratory times (95% CI of -1.1 to 2.3%). Audio cues "Bag faster" (1.84 to 2.03 s), "Bag slower" (0.35 to 0.41 s), and "Leak detected" (43 to 50%) were triggered close to target trigger values (2.00 s, 0.50 s, and 50%, respectively) across varying tidal volumes.

CONCLUSIONS

The BENGI achieved its proposed goals of accurately measuring and reporting tidal volumes delivered through BVM systems, providing immediate feedback on the quality of respiratory performance through audio and visual cues. The BENGI has the potential to reduce manual ventilation-induced lung injury and improve patient outcomes by providing accurate feedback on ventilatory parameters.

Respiratory function monitoring to improve the outcomes following neonatal resuscitation: a systematic review and meta-analysis

IMPORTANCE

Animal and observational human studies report that delivery of excessive tidal volume (V_T) at birth is associated with lung and brain injury. Using a respiratory function monitor (RFM) to guide V_T delivery might reduce injury and improve outcomes.

OBJECTIVE

To determine whether use of an RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room reduces in-hospital mortality and morbidity of infants <37 weeks' gestation.

STUDY SELECTION

Randomised controlled trials (RCTs) comparing RFM in addition to clinical assessment versus clinical assessment alone during mask ventilation in the delivery room of infants born <37 weeks' gestation.

DATA ANALYSIS

Risk of bias was assessed using Covidence Collaboration tool and pooled into a meta-analysis using a random-effects model. The primary outcome was death prior to discharge.

MAIN OUTCOME

Death before hospital discharge.

RESULTS

Three RCTs enrolling 443 infants were combined in a meta-analysis. The pooled analysis showed no difference in rates of death before discharge with an RFM versus no RFM, relative risk (RR) 95% (CI) 0.98 (0.64 to 1.48). The pooled analysis suggested a significant reduction for brain injury (a combination of intraventricular haemorrhage and periventricular leucomalacia) (RR 0.65 (0.48 to 0.89), p=0.006) and for intraventricular haemorrhage (RR 0.69 (0.50 to 0.96), p=0.03) in infants receiving positive pressure ventilation with an RFM versus no RFM.

CONCLUSION

In infants <37 weeks, an RFM in addition to clinical assessment compared with clinical assessment during mask ventilation resulted in similar in-hospital mortality, significant reduction for any brain injury and intraventricular haemorrhage. Further trials are required to determine whether RFMs should be routinely available for neonatal resuscitation.

Provider Visual Attention Correlates With the Quality of Pediatric Resuscitation: An Observational Eye-Tracking Study

Background

Eye-tracking devices are an innovative tool to understand providers' attention during stressful medical tasks. The knowledge about what gaze behaviors improve (or harm) the quality of clinical care can substantially improve medical training. The aim of this study is to identify gaze behaviors that are related to the quality of pediatric resuscitation.

Methods

Forty students and healthcare providers performed a simulated pediatric life support scenario, consisting of a chest compression task and a ventilation task, while wearing eye-tracking glasses. Skill Reporter software measured chest compression (CC) quality and Neo Training software measured ventilation quality. Main eye-tracking parameters were ratio [the number of participants who attended a certain area of interest (AOI)], dwell time (total amount of time a participant attended an AOI), the number of revisits (how often a participant returned his gaze to an AOI), and the number of transitions between AOIs.

Results

The most salient AOIs were infant chest and ventilation mask (ratio = 100%). During CC task, 41% of participants also focused on ventilation bag and 59% on study nurse. During ventilation task, the ratio was 61% for ventilation bag and 36% for study nurse. Percentage of correct CC rate was positively correlated with dwell time on infant chest (p = 0.044), while the overall CC quality was negatively correlated with dwelling outside of pre-defined task-relevant AOIs (p = 0.018). Furthermore, more dwell time on infant chest predicted lower leakage (p = 0.042). The number of transitions between AOIs was unrelated to CC parameters, but correlated negatively with mask leak during ventilations (p = 0.014). Participants with high leakage shifted their gaze more often between ventilation bag, ventilation mask, and task-irrelevant environment.

Conclusion

Infant chest and ventilation mask are the most salient AOIs in pediatric basic life support. Especially the infant chest AOI gives beneficial information for the resuscitation provider. In contrast, attention to task-irrelevant environment and frequent gaze shifts seem to harm the quality of care.

Advanced Clinical Neonatal Nursing Students' Transfer of Performance: From Skills Training With Real-Time Feedback on Ventilation to a Simulated Neonatal Resuscitation Scenario

BACKGROUND

Advanced clinical neonatal nurses are expected to have technical skills including bag-mask ventilation. Previous studies on neonatal bag-mask ventilation skills training focus largely on medical students and/or physicians. The aim of this study was to investigate whether advanced clinical neonatal nursing students' bag-mask ventilation training with real-time feedback resulted in transfer of bag-mask ventilation performance to a simulated setting without feedback on ventilation.

MATERIALS AND METHODS

Students in advanced clinical neonatal nursing practiced bag-mask ventilation on a premature manikin (Premature Anne, Laerdal Medical, Stavanger, Norway) during skills training. A flow sensor (Neo Training, Monivent AB, Gothenburg, Sweden) was placed between the facemask and the self-inflating bag (Laerdal Medical), and visual feedback on mask leak (%), expiratory tidal volume (VT _e in ml/kg), ventilation rate and inflation pressure was provided. Two months later, the students participated in a simulated neonatal resuscitation scenario. The same variables were recorded, but not fed back to the students. We compared ventilation data from skills- and simulation training. A structured questionnaire was used to investigate the students' self-perceived neonatal ventilation competence before and after the skills- and simulation training.

RESULTS

Mask leakage and ventilation rate was higher, and VT _e lower and highly variable in the simulated scenario compared with skills training (all p < 0.001). There was no statistically significant difference in inflation pressure (p = 0.92). The fraction of ventilations with VT _e within the target range was lower during simulation (21%) compared to skills training (30%) (p < 0.001). There was no difference in the students' self-perceived competence in bag-mask ventilation before vs. after skills- and simulation training.

CONCLUSION

Skills training with real-time feedback on mask leak, ventilation rate, tidal volume, and inflation pressure did not result in objective or subjective improvements in bag-mask ventilation in a simulated neonatal resuscitation situation. Incorrect VT _e delivery was common even when feedback was provided. It would be of interest to study whether more frequent training, and training both with and without feedback, could improve transfer of performance to a simulated resuscitation setting.