Simulation in neonatal transport medicine

Enhancing team success in the neonatal intensive care unit: challenges and opportunities for fluid teams

Fluid teams, characterized by frequent changes in team membership, are vital in the neonatal intensive care unit (NICU) due to high patient acuity and the need for a wide range of specialized providers. However, many challenges can hinder effective teamwork in this setting. This article reviews the challenges related to fluid teamwork in the NICU and discusses recommendations from team science to address each challenge. Drawing from the current literature, this paper outlines three challenges that can hinder fluid teamwork in the NICU: incorporating patient families, managing hierarchy among team members, and facilitating effective patient handoffs. The review concludes with recommendations for managing NICU teamwork differently using strategies from team science.

Comparison of four neonatal transport scoring methods in the prediction of mortality risk in full-term, out-born infants: a single-center retrospective cohort study

Neonatal transport scoring systems can assess severity before and after transport, improve transport efficiency, and predict the occurrence of critical illness. The aim of this study was to compare four neonatal transport scoring methods to predict mortality risk and clinical utility within the first week after transportation. This was a single-center retrospective cohort study. All patients were full-term, out-born neonates. Each patient was assessed by the Transport Risk Index of Physiologic Stability (TRIPS), Mortality Index for Neonatal Transportation (MINT), Transport-Related Mortality Score (TREMS), and Neonatal Critical Illness Score (NCIS) scoring methods. Receiver operating characteristic (ROC) curves and decision curve analysis (DCA) for each method were compared for their utility in predicting mortality risk within the 1st week after admission. In total, 368 full-term infants were included (368/770, 47.8% of all transported infants). Within the 1st week after admission, five infants (1.36%, 5/368) died while receiving advanced life support and full treatment, and 24 infants (6.52%, 24/368) died soon after they were discharged against medical advice. The areas under the curve (AUCs) for the MINT, TRIPS, TREMS, and NCIS for the prediction of mortality were 0.822, 0.827, 0.643, and 0.731, respectively (all p < 0.05). However, the clinical net benefits for the MINT and TRIPS were far superior than those for the NCIS and TREMS.

CONCLUSION

It was concluded that the TRIPS and MINT might be more suitable for the prediction of mortality in full-term, out-born neonates in the neonatal intensive care unit (NICU) within the 1st week after transportation.

WHAT IS KNOWN

• Neonatal transport scores can assess not only the mortality risk during transportation but also the mortality risk of critically ill newborns after admission to the NICU. • The effectiveness of neonatal transport scores in predicting mortality risk is different.

WHAT IS NEW

• Our data indicate that the diagnostic efficacy of the MINT, TRIPS, and NCIS in the prediction of full-term infant mortality was high. • The TRIPS and MINT scores had better clinical utility and could be used to predict mortality within the 1st week after transportation in full-term out-born neonates.

Neonatal Simulation Program: A 5 Years Educational Journey From Qatar

We describe the process of implementation, adaptation, expansion and some related clinical intuitional impacts of the neonatal simulation program since its launch in 2016 in a non-simulation neonatal unit. The team has developed 6 types of curricula: 1 full-day course and 5 half-day workshops. A total of 35 free of charge simulation courses/workshops were conducted, 32 in Qatar and 3 abroad with a total of 799 diverse participants. There was a steady increase in the overall success rate of PICC insertion from 81.7% (309/378) to 97.6% (439/450) across 3 years (P < 0.0001). The first attempt PICC insertion success rate has been also increased from 57.7% (218/378) to 66.9% (301/450) across 3 years. The mean duration of PICC insertion has been improved from 39.7 ± 25 to 34.9 ± 12.4 min after implementing the program (P = 0.33). The mean duration of the LISA catheter insertion at the beginning of the workshop was 23.5 ± 15.9 compared to 12.1 ± 8.5 s at the end of the workshop (P = 0.001). When it came to clinical practise in real patients by the same participants, the overall LISA catheter insertion success rate was 100% and the first attempt success rate was 80.4%. The mean duration of LISA catheter insertion in real patients was 26.9 ± 13.9 s compared to the end of the workshop (P = 0.001). The mean duration of the endotracheal intubation at the beginning of the workshop was 12.5 ± 9.2 compared to 4.2 ± 3.8 s at the end of the workshop (P = 0.001). In real patients, the first-attempt intubation success rate has been improved from 37/139 (26.6%) in the first year to 141/187 (75.5%) in the second year after the program implementation (P = 0.001). The mean duration of successful endotracheal intubation attempts has been improved from 39.1 ± 52.4 to 20.1 ± 9.9 s (P = 0.78). As per the participants, the skills learned in the program sessions help in protecting neonates from potential harm and improve the overall neonatal outcome. Implementing a neonatal simulation program is a promising and feasible idea. Our experience can be generalised and replicated in other neonatal care institutions.

Recommendations on the skills profile and standards of the neonatal transport system in Spain

The first hours of life of a sick or premature newborn are crucial for its prognosis and therefore delivery should take place in a center prepared for that degree of complexity. When this condition is not met, the newborn must be transferred in an optimal and safe way to the center that can offer the necessary care. The training, staffing, organization and coordination of the neonatal transport team are essential to guarantee a safe transfer. Being aware of the interest and the advances that are currently taking place in this area of ​​pediatrics, the Standards Commission and the Neonatal Transport Commission of the Spanish Society of Neonatology have prepared this document. In it, both the provision of human and material resources necessary as well as the bases of clinical stabilization in transport to carry out the neonatal transfer in a safe way and proportionate to the needs of the critical newborn have been exhaustively reviewed and detailed.

[Recommendations on the skills profile and standards of the neonatal transport system in Spain]

The first hours of life of a sick or premature newborn are crucial for its prognosis and therefore delivery should take place in a center prepared for that degree of complexity. When this condition is not met, the newborn must be transferred in an optimal and safe way to the center that can offer the necessary care. The training, staffing, organization and coordination of the neonatal transport team are essential to guarantee a safe transfer. Being aware of the interest and the advances that are currently taking place in this area of pediatrics, the Standards Commission and the Neonatal Transport Commission of the Spanish Society of Neonatology have prepared this document. In it, both the provision of human and material resources necessary as well as the bases of clinical stabilization in transport to carry out the neonatal transfer in a safe way and proportionate to the needs of the critical newborn have been exhaustively reviewed and detailed.

Utilizing Simulation to Identify Latent Safety Threats During Neonatal Magnetic Resonance Imaging Procedure

INTRODUCTION

Transfer of infants for magnetic resonance imaging (MRI) from the neonatal intensive care unit (NICU) requires exposure to unfamiliar environments and involve multiple complex human and system interactions, which can compromise patient safety. In situ simulation (ISS) offers an opportunity to identify latent safety threats (LSTs) that may occur during this high-risk procedure. Our primary aim was to use ISS to identify modifiable LSTs during the MRI procedure: involving neonatal transport to/from NICU to the MRI and the MRI scan. Secondarily, we compared the overall performance and needs of specialized versus nonspecialized transport personnel.

METHODS

In situ simulations of the MRI procedure (transport and scan) were performed for 9 months involving specialized and nonspecialized transport personnel. Two simulation scenarios were used, one involving an intubated infant and one nonintubated infant. After each simulation, participants underwent a standardized debriefing and answered questionnaires on safety threats and team function. The results were then used to identify and implement mitigation strategies.

RESULTS

Among 10 simulations completed, 7 were by specialized and 3 by nonspecialized teams. In total, 116 LSTs were identified (22 involving medication, 12 equipment, and 82 resources/system issues). Preprocedure deliberation with anticipation/preparedness for patient deterioration, and the need for clinical checklists and protocols were identified as important requirements. After completion of the project, protocols (ie, sedation), checklists (ie, pretransport), and policies (ie, environmental orientation) were adapted to address the gaps.

CONCLUSIONS

In situ simulations were able to identify important safety risks during transport of neonatal patients from the NICU to the MRI suite, informing changes in MRI transport policy.

Mixed-Reality Simulation for a Pediatric Transport Team: A Pilot Study

OBJECTIVE

Transport medicine requires a complex set of skills including fast-paced medical decision making, in-depth medical knowledge, procedural competence, interpersonal and communication skills, leadership, and professionalism. There has been a call for more training in these areas. Simulation-based training can be a way to acquire these necessary skills and bridge the gap to higher-quality transport care. The purpose of this study was to develop a novel mixed-reality simulation program to enhance medical and communication skills for a pediatric transport team.

METHODS

A mixed-reality simulation program using standardized patients portraying family members and high-fidelity manikins to simulate a medical emergency was developed and implemented for a pediatric transport team. Ten nurses, 9 respiratory therapists, and 8 emergency medical technicians participated. Pre-post self-perceptions of skill and program quality were assessed prospectively.

RESULTS

Team members rated the overall program quality highly, with a median 5 on a 5-point Likert scale. There was a statistically significant change in pre- versus postprogram self-perceptions of skill in the areas of communication (premedian = 3 vs. postmedian = 4, 5-point Likert scale, P < .001).

CONCLUSION

Mixed-reality simulation programs can enhance standard technical skills training by providing an additional relational element. Such programs are translatable to other institutions.

Using briefing, simulation and debriefing to improve human and system performance

Safety, effectiveness and efficiency are keys to performance in all high-risk industries; healthcare is no exception, and neonatal-perinatal medicine is one of the highest risk subspecialties within healthcare. Briefing, simulation and debriefing are methods used by professionals in high-risk industries to reduce the overall risk to life and enhance the safety of the human beings involved in receiving and delivering the services provided by those industries. Although relatively new to neonatal-perinatal medicine, briefing, simulation and debriefing are being practiced with increasing frequency and have become embedded in training exercises such as the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP). This chapter will define these terms and offer examples as to how they are used in high-risk activities including neonatal-perinatal medicine.

Lung ultrasound in the diagnosis of neonatal respiratory failure prior to patient transport

PURPOSE

Lung ultrasound (LUS) at the point-of-care is a new method that is increasingly used in neonatology. The aim of this study was to determine the utility of the addition of LUS prior to the interhospital transport of neonates with respiratory failure.

METHODS

LUS was performed on 50 newborns with respiratory failure prior to transport to a tertiary neonatal intensive care unit. We analyzed the performance of LUS for diagnosing the cause of respiratory failure, the concordance between LUS, chest X-ray (CXR) and final clinical diagnosis, and the impact of LUS on clinical decision making before transport.

RESULTS

LUS sensitivity for the diagnosis of respiratory distress syndrome was 91.3% (95%CI: 70.5-98.5%), and specificity was 92.6% (95%CI: 74.2-98.7%), whereas sensitivity and specificity of CXR were 69.6% (95%CI: 47.0-85.9%) and 81.5% (95%CI: 61.2-92.9%), respectively. For the recognition of pneumothorax (PTX) LUS had a sensitivity of 83.3% (95%CI: 36.5-99.1%) and a specificity of 100% (95%CI: 89.9-100%). For CXR, sensitivity was 16.7% (95%CI: 0.01-63.5%) and specificity was 97.7% (95%CI: 86.4-99.9%). The agreement between LUS and CXR in diagnosing the cause of respiratory failure was substantial (κ of 0.57 [95%CI: 0.40-0.74]) and the agreement between LUS and the final clinical diagnosis was very good (κ of 0.86 [95%CI: 0.74-0.98]). In 42% of the patients, a LUS examination prior to transport indicated the need for endotracheal tube repositioning or PTX decompression.

CONCLUSION

LUS may be a reliable imaging technique for differentiating the causes of respiratory failure before neonatal transport. Use of LUS may optimize the care of infants during transport.

[Neonatal transport for disasters]

Neonates are vulnerable to greater damage in disasters and thus have special needs for equipment and medical staff. It is necessary to establish a regional neonatal transport network, in order to provide a platform for effective information communication and resource sharing. Neonatal care centers for critically ill neonates at all levels need to develop a disaster response plan for neonatal transport, and master this plan. In case of disasters, neonatal transport should be directed at the government level, in order to arrange emergency transport resources in a unified, reasonable and efficient way. Meanwhile, the psychological needs of family members and rescue staff should be taken into account.

Neonatal Transport: Current Trends and Practices

Since the inception of organized neonatal transport in the 1940s, advances in clinical care and technology have made the neonatal intensive care unit even more mobile in terms of care delivery. There currently exists an emphasis on quality metrics and simulation-based training for transport team members to achieve high levels of individual and team competence. Emerging therapies such as active cooling for neuroprotective hypothermia and high-frequency ventilation provide evidence-based care in the transport environment to enhance clinical outcomes. Accreditation of neonatal transport programs is now embraced as an indicator of competency and compliance with transport standards.