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

Quality improvement initiative: implementing and redefining video review of real-time neonatal procedures using action research

Video review (VR) of procedures in the medical environment can be used to drive quality improvement. However, first it has to be implemented in a safe and effective way. Our primary objective was to (re)define a guideline for implementing interprofessional VR in a neonatal intensive care unit (NICU). Our secondary objective was to determine the rate of acceptance by providers attending VR. For 9 months, VR sessions were evaluated with a study group, consisting of different stakeholders. A questionnaire was embedded at the end of each session to obtain feedback from providers on the session and on the safe learning environment. In consensus meetings, success factors and preconditions were identified and divided into different factors that influenced the rate of adoption of VR. The number of providers who recorded procedures and attended VR sessions was determined. A total of 18 VR sessions could be organised, with an equal distribution of medical and nursing staff. After the 9-month period, 101/125 (81%) of all providers working on the NICU attended at least 1 session and 80/125 (64%) of all providers recorded their performance of a procedure at least 1 time. In total, 179/297 (61%) providers completed the questionnaire. Almost all providers (99%) reported to have a positive opinion about the review sessions. Preconditions and success factors related to implementation were identified and addressed, including improving the pathway for obtaining consent, preparation of VR, defining the role of the chair during the session and building a safe learning environment. Different strategies were developed to ensure findings from sessions were used for quality improvement. VR was successfully implemented on our NICU and we redefined our guideline with various preconditions and success factors. The adjusted guideline can be helpful for implementation of VR in emergency care settings.

Using Simulation-Based Training to Improve Neonatal Resuscitation Clinical Competency, Confidence, and Comfort Level of NICU Caregivers

BACKGROUND

Approximately 10% of newborns require resuscitation at delivery or during a neonatal intensive care unit (NICU) stay. Neonatal intensive care unit caregivers competent in providing neonatal resuscitation decrease perinatal mortality and improve neonatal outcomes. Infrequency of resuscitation events, lack of repetition, and inexperience leave caregivers feeling un-prepared for emergency situations. There is a need for educational strategies to maintain competency and increase confidence and comfort level.

METHOD

This quality improvement project used a pre-post survey design. Competency was assessed during simulated mock codes using the Creighton Competency Evaluation Instrument. Self-perceived confidence and comfort level were assessed using a pre-post survey.

RESULTS

Descriptive statistics indicated that the average score on the Creighton Competency Evaluation Instrument fell below the targeted minimally competent goal of 80%. Practical significance was noted between the pre-intervention and post-intervention means of both perceived confidence and comfort level.

CONCLUSION

Simulation-based education may increase the competency, confidence, and comfort level of NICU caregivers and should be conducted routinely. Similar projects could be replicated at other institutions to address continuing competency with neonatal resuscitation. [J Contin Educ Nurs. 2024;55(4):175-180.].

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.

Combining activity and grimace scores reflects perinatal stability in infants <32 weeks gestational age

BACKGROUND

Over 95% of infants less than 32 weeks gestational age-very preterm infants (VPTI)-require cardiorespiratory support at birth. Clinical condition at birth is assessed by the Apgar score, but the precision and accuracy of activity and grimace has not been evaluated. We hypothesised activity and grimace could predict the level of cardiorespiratory support required for stabilisation.

METHODS

Two hundred twenty-nine videos of VPTI resuscitations at Monash Children's Hospital and The Royal Women's Hospital, Melbourne were evaluated, with 78 videos eligible for assessment. Activity and grimace were scored (0, 1, or 2) by seven consultant neonatologists, with inter-rater reliability assessed. Activity and grimace were correlated with the maximum level of cardiorespiratory support required for stabilisation.

RESULTS

Kendall's Coefficient of Concordance (W) showed strong interobserver agreement for activity (W = 0.644, p < 0.001) and grimace (W = 0.722, p < 0.001). Neither activity nor grimace independently predicted the level of cardiorespiratory support required. Combining activity and grimace showed non-vigorous infants (combined score <2) received more cardiorespiratory support than vigorous (combined score ≥ 2).

CONCLUSION

Scoring of activity and grimace was consistent between clinicians. Independently, activity and grimace did not correlate with perinatal stabilisation. Combined scoring showed non-vigorous infants had greater resuscitation requirements.

IMPACT

Our study evaluates the precision and accuracy of activity and grimace to predict perinatal stability, which has not been validated in infants <32 weeks gestational age. We found strong score agreement between assessors, indicating video review is a practical and precise method for grading of activity and grimace. Combined scoring to allow a dichotomous evaluation of infants as non-vigorous or vigorous showed the former group required greater cardiorespiratory support at birth.

Record, reflect and refine: using video review as an initiative to improve neonatal care

BACKGROUND

The goal of every medical team is to provide optimal care for their patients. We aimed to use video review (VR) sessions to identify and address areas for improvement in neonatal care.

METHODS

For nine months, neonatal procedures (stabilization at birth, intubations and sterile line insertions) were video recorded and reviewed with the neonatal care providers. Action research was used to identify and address areas for improvement which were categorized as (1) protocol/equipment adjustments, (2) input for research, (3) aspects of variety, or (4) development of educational material or training programs.

RESULTS

Eighteen VR sessions were organized with a mean(SD) of 17(5) staff members participating. In total, 120 areas for improvement were identified and addressed, of which 84/120 (70%) were categorized as aspects of variety, 20/120 (17%) as development of educational material or training programs, 10/120 (8%) as protocol/equipment adjustments, and 6/120 (5%) as input for research. The areas for improvement were grouped in themes per category, including sterility, technique, equipment, communication, teamwork, parents' perspective and ventilation.

CONCLUSION

Our study showed that regularly organized VR empowered healthcare providers to identify and address a large variety of areas for improvement, contributing to continuous learning and improvement processes.

IMPACT

Video review empowered healthcare providers to identify areas for improvement in neonatal care Video review gave providers the opportunity to address identified areas for improvement, either by enhancing the application of external evidence (i.e. guidelines), learning from individual clinical expertise or strengthening resilience and teamwork Embedding regularly organized video review sessions allowed for continuous monitoring of care by providers, which can be beneficial for creating ongoing learning and improvement processes The structured pathways, supporting implementation of changes that were proposed based on the video review sessions, could help other centers make use of the potential video review has to offer.

The Evolution of Neonatal Patient Safety

Human factors science teaches us that patient safety is achieved not by disciplining individual health care professionals for mistakes, but rather by designing systems that acknowledge human limitations and optimize the work environment for them. Incorporating human factors principles into simulation, debriefing, and quality improvement initiatives will strengthen the quality and resilience of the process improvements and systems changes that are developed. The future of patient safety in neonatology will require continued efforts to engineer and re-engineer systems that support the humans who are at the interface of delivering safe patient care.

Neonatal Resuscitation: A Critical Incident Technique Study Exploring Pediatric Registered Nurses' Experiences and Actions

BACKGROUND

Teamwork during neonatal resuscitation is essential. Situations arise quickly and unexpectedly and are highly stressful, requiring pediatric registered nurses (pRN) to respond effectively and in a structured manner. In Sweden, pRNs work in all pediatric settings including the neonatal intensive care unit. The experience and actions of pRNs are seldom explored, and studies within this area could develop and improve strategies for neonatal resuscitation situations.

PURPOSE

To describe pRNs' experiences and actions during neonatal resuscitation.

METHODS

A qualitative interview study based on the critical incident technique was performed. Sixteen pRNs from 4 neonatal intensive care units in Sweden were interviewed.

RESULTS

Critical situations were divided into 306 experiences and 271 actions. pRNs' experiences were divided into 2 categories: individual- and team-focused experiences. Critical situations were managed by individual- or team-focused actions.

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.

State-of-the art training in neonatal resuscitation

Healthcare training has traditionally emphasized acquisition and recall of vast amounts of content knowledge; however, delivering care during resuscitation of neonates requires much more than content knowledge. As the science of resuscitation has progressed, so have the methodologies and technologies used to train healthcare professionals in the cognitive, technical and behavioral skills necessary for effective resuscitation. Simulation of clinical scenarios, debriefing, virtual reality, augmented reality and audiovisual recordings of resuscitations of human neonates are increasingly being used in an effort to improve human and system performance during this life-saving intervention. In the same manner, as evidence has accumulated to support the guidelines for neonatal resuscitation so, too, has affirmation of training methodologies and technologies. This guarantees that training in neonatal resuscitation will continue to evolve to meet the needs of healthcare professionals charged with caring for newborns at one of the most vulnerable times in their lives.

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.

Video simulation to learn pediatric resuscitation skills tailored to a low resource setting: A pilot program in Iquitos, Peru

Introduction:

The Hospital Regional de Loreto in Peru partners with the University of California Los Angeles Global Health Program to enhance educational experiences for US and Peruvian trainees. University of California Los Angeles Pediatric faculty led intermittent in-person code simulation sessions for Peruvian residents, and there is a need for regular education on this topic.

Methods:

University of California Los Angeles residents created a video simulation of a patient in respiratory distress. The video was presented to Hospital Regional de Loreto trainees in pediatrics. Stakeholder interviews and reuse of the video after initial presentation assessed acceptability of this mode of education by the site. Pre- and post-surveys using numerical rating scales evaluated the educational utility of this specific simulation video. Paired t-tests compared the pre- and post-surveys in the effectiveness of increasing the trainees’ comfort of specific resuscitation skills.

Results:

Stakeholder interviews revealed the video simulation was integrated into formal intern orientation trainings as well as used for resident and physician trainings multiple times in the year after the introduction. Twenty trainees completed the pre-intervention survey and 19 completed the post-intervention survey. Trainee comfort with code team leadership (2.6 ± 0.9, 3.5 ± 0.09, p = 0.03) and arrhythmia recognition/automated external defibrillator (AED) management (2.4 ± 0.9, 3.1 ± 0.9, p = 0.03) increased significantly with the video intervention. There was no significant difference in comfort with other skills. Overall, trainees rated the helpfulness of the video as an average of 4.2 (±1.1) out of 5. The most common positive feedback included the utility of reviewing medication dosing and the skill of performing chest compressions. The most common suggestions for improvement were to review more pathophysiology and simulate available resources at Hospital Regional de Loreto more realistically.

Conclusion:

E-learning is an acceptable mode of education in a resource-limited setting when tailored to the local context. This pilot project demonstrated short-term improvement in reported confidence and skills with some aspects of pediatric resuscitation.

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.

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.

Implementation and Outcomes of a Telehealth Neonatology Program in a Single Healthcare System

Background: Intermountain Healthcare, an early adopter and champion for newborn video-assisted resuscitation (VAR), identified a reduction in facility-level transfers and an estimated savings of $1. 2 million in potentially avoided transfers in a 2018 study. This study was conducted to increase understanding of VAR at the individual, newborn level. Study Aim: To compare transfers to a newborn intensive care unit (NICU), length of stay (LOS), and days of life on oxygen between newborns managed by neonatal VAR and those receiving standard care (SC). Methods: This retrospective, nonequivalent group study includes infants born in an Intermountain hospital between 2013 and 2017, 34 weeks gestation or greater, and requiring oxygen support in the first 15 minutes of life. Data came from billing and clinical records from Intermountain's enterprise data warehouse and chart reviews. We used logistic regression to estimate neonatal VAR's impact on transfers. Negative binomial regression estimated the impact on LOS and days of life on supplemental oxygen. Results: The VAR intervention was used in 46.2 percent of post-implementation cases and is associated with (1) a 12 percentage points reduction in the transfer rate, p = 0.02, (2) a reduction in spoke hospital (SH) LOS of 8.33 h (p < 0.01) for all transfers; (3) a reduction in SH LOS of 2.21 h (p < 0.01) for newborns transferred within 24 h; (4) a reduction in SH LOS of 17.85 h (p = 0.06) among non-transferred newborns; (5) a reduction in days of life on supplemental oxygen of 1.4 days (p = 0.08) among all transferred newborns, and (6) a reduction in days of life on supplemental oxygen of 0.41 days (p = 0.04) among non-transferred newborns. Conclusion: This study provides evidence that neonatal VAR improves care quality and increases local hospitals' capabilities to keep patients close to home. There is an ongoing demand for support to rural and community hospitals for urgent newborn resuscitations, and complex, mandatory NICU transfers. Efforts may be necessary to encourage neonatal VAR since the intervention was only used in 46.2 percent of this study's potential cases. Additional work is needed to understand the short- and long-term impacts of Neonatal VAR on health outcomes.

Simulation in Neonatal Resuscitation

Approximately 1 in 10 newborns will require basic resuscitation interventions at birth. Some infants progress to require more advanced measures including the provision of positive pressure ventilation, chest compressions, intubation and administration of volume/cardiac medications. Although advanced resuscitation is infrequent, it is crucial that personnel adequately trained in these techniques are available to provide such resuscitative measures. In 2000, Louis Halmalek et al. called for a "New Paradigm in Pediatric Medical Education: Teaching Neonatal Resuscitation in a Simulated Delivery Room Environment." This was one of the first articles to highlight simulation as a method of teaching newborn resuscitation. The last decades have seen an exponential growth in the area of simulation in newborn care, in particular in newborn resuscitation and stabilization. Simulation is best defined as an instructional strategy "used to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner." Simulation training has now become an important point of how we structure training and deliver improved healthcare to patients. Some of the key aspects of simulation training include feedback, deliberate practice, outcome measurement, retention of skills and curriculum integration. The term "Train to win" is often used in sporting parlance to define how great teams succeed. The major difference between sports teams is that generally their game day comes once a week, whereas in newborn resuscitation every day is potentially "game day." In this review we aim to summarize the current evidence on the use of simulation based education and training in neonatal resuscitation, with particular emphasis on the evidence supporting its effectiveness. We will also highlight recent advances in the development of simulation based medical education in the context of newborn resuscitation to ensure we "train to win."