Auditing documentation on delivery room management using video and physiological recordings

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.

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.

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.

Time to improve documentation of neonatal resuscitation: a narrative review

A complete, objective and systematic documentation of delivery room resuscitation is important for research, for quality improvement, for teaching and as a reference for postresuscitation care. However, documentation during neonatal resuscitation is usually paper-based, retrospective, inaccurate and unreliable. In this narrative review, we discuss the strengths and pitfalls of current documentation methods in neonatal resuscitation, as well as the challenges of introducing new or emerging technologies in this field. In particular, we discuss innovations in electronic and automated medical records, video recording and Smartphones and Tablet Apps. Given the lack of a consensus standard, we finally propose a list of items that should be part of any neonatal resuscitation documentation method.

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.

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.

Video-based reflection on neonatal interventions during COVID-19 using eye-tracking glasses: an observational study

OBJECTIVE

The aim of this study was to determine the experience with, and the feasibility of, point-of-view video recordings using eye-tracking glasses for training and reviewing neonatal interventions during the COVID-19 pandemic.

DESIGN

Observational prospective single-centre study.

SETTING

Neonatal intensive care unit at the Leiden University Medical Center.

PARTICIPANTS

All local neonatal healthcare providers.

INTERVENTION

There were two groups of participants: proceduralists, who wore eye-tracking glasses during procedures, and observers who later watched the procedures as part of a video-based reflection.

MAIN OUTCOME MEASURES

The primary outcome was the feasibility of, and the proceduralists and observers' experience with, the point-of-view eye-tracking videos as an additional tool for bedside teaching and video-based reflection.

RESULTS

We conducted 12 point-of-view recordings on 10 different patients (median gestational age of 30.9±3.5 weeks and weight of 1764 g) undergoing neonatal intubation (n=5), minimally invasive surfactant therapy (n=5) and umbilical line insertion (n=2). We conducted nine video-based observations with a total of 88 observers. The use of point-of-view recordings was perceived as feasible. Observers further reported the point-of-view recordings to be an educational benefit for them and a potentially instructional tool during COVID-19.

CONCLUSION

We proved the practicability of eye-tracking glasses for point-of-view recordings of neonatal procedures and videos for observation, educational sessions and logistics considerations, especially with the COVID-19 pandemic distancing measures reducing bedside teaching opportunities.

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.

Oxygen saturation after birth in resuscitated neonates in Uganda: a video-based observational study

BACKGROUND

Monitoring of peripheral capillary oxygen saturation (SpO₂) during neonatal resuscitation is standard of care in high-resource settings, but seldom performed in low-resource settings. We aimed to measure SpO₂ and heart rate during the first 10 min of life in neonates receiving positive pressure ventilation (PPV) according to the Helping Babies Breathe (HBB) protocol and compare results with SpO₂ and heart rate targets set by the American Heart Association (AHA).

METHODS

A cross-sectional study was conducted at Mulago National Referral Hospital, Kampala, Uganda, as a substudy of the NeoSupra Trial. SpO₂ and heart rate were measured on apnoeic neonates (≥34 weeks) who received PPV according to HBB (room air). Those who remained distressed after PPV received supplemental oxygen (O₂). All resuscitations were video recorded and data were extracted by video review at 1 min intervals until 10 min post partum. Data were analysed for all observations and separately for only observations before and during PPV.

RESULTS

49 neonates were analysed. Median SpO₂ at 5 min (n=39) was 67% (49-88) with 59% of the observations below AHA target of 80%. At 10 min median SpO₂ (n=44) was 93% (80-97) and 32% were below AHA target of 85%. When only observations before and during PPV were analysed, median SpO₂ at 5 min (n=18) was 52% (34-66) and 83% were below AHA target. At 10 min (n=15), median SpO₂ was 72% (57-89) and 67% were below AHA target. Median heart rates were above AHA target of 100 beats/min at all time intervals.

CONCLUSIONS

A high proportion of neonates resuscitated with PPV after birth failed to reach the AHA SpO₂ target in this small sample, implying an increased risk of hypoxic-ischaemic encephalopathy. Further studies in low-resource settings are needed to evaluate baseline data and the need for supplemental O₂ and optimal SpO₂ during PPV.

TRIAL REGISTRATION NUMBER

This is a substudy to the trial 'Neonatal Resuscitation with Supraglottic Airway Trial (NeoSupra)'; ClinicalTrials.gov Registry (NCT03133572).

Documentation during neonatal resuscitation: a systematic review

OBJECTIVE

Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room resuscitations.

METHODS

A systematic literature search in MEDLINE was conducted to identify original studies that reported the quality of documentation records during newborn resuscitation in the delivery room. Data extracted from the studies included population characteristics, methodology, documentation protocols, use of gold standard and main results (initial assessment of heart rate and peripheral oxygen saturation, respiratory support and supplementary oxygen).

RESULTS

In total, 197 records were screened after initial database search, of which seven studies met the inclusion criteria and were finally included in this review. Four studies were chart reviews and three studies compared conventional documentation methods with video recording. Only one study tested an intervention to improve documentation. Documentation was often inaccurate and important resuscitation events and interventions were poorly recorded. Lack of uniformity among studies preclude pooled analysis, but it seems that complex or advanced procedures were more accurately reported than basic interventions.

CONCLUSIONS

There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of documentation seems to be unsatisfactory. There is a need for consensus guidelines and innovative solutions in newborn resuscitation documentation.

Measures of Stress Exposure for Hospitalized Preterm Infants

BACKGROUND

Extended hospitalization in neonatal intensive care units subjects preterm infants to multiple stress exposures that affect long-term cognitive functioning, motor development, and stress reactivity. Measurement of stress exposure is challenging with multiple measures of stress exposure in use, including counts of skin-breaking or invasive procedures or counts of noxious sensory exposures.

OBJECTIVES

The purpose of this analysis was to compare measures of stress exposure commonly used by researchers and to determine the predictive validity of these measures for early neurobehavior. We accomplished this objective through the following specific aims: (a) describe the stress exposures of preterm infants in the first 2 weeks of life, (b) determine the correlations among measures of stress exposure, and (c) compare the predictive validity of measures of stress exposure for early neurobehavior.

METHODS

Very preterm infants born between 28 and 31 weeks postmenstrual age were enrolled from four neonatal intensive care units in a large Midwest city. We measured stress exposure over the first 14 days of life for each infant as a count of skin-breaking procedures, a count of invasive procedures, and cumulative scores derived from the Neonatal Infant Stressor Scale. Neurobehavior was assessed at 35 weeks postmenstrual age using the motor development and vigor and alertness/orientation subscales from the Neurobehavioral Assessment of the Preterm Infant. We used Spearman's rho to determine correlations among the measures of stress exposure and multiple linear regression to determine the predictive validity of each stress exposure measure for neurobehavioral outcomes.

RESULTS

Seventy-one preterm infants were included in the analysis. We found marked variance across individuals in all measures of stress exposure. There were moderate-high correlations among the measures of stress exposure. No measure of stress exposure was associated with early neurobehavior.

DISCUSSION

The stress experiences of hospitalized preterm infants vary. This variance is reflected in all measures of stress exposure. Because measures of stress exposure are highly correlated, the most objective measure requiring the least interpretation should be used. However, the currently available measures of stress exposure used in this analysis may not reflect the infant's physiological stress responses and fail to associate with early neurobehavior.

Improving the Quality of Provided Care: Lessons Learned From Auditing Neonatal Stabilization

Video and physiological parameter recording of neonatal stabilization was implemented at the Neonatal Intensive Care Unit (NICU) of the Leiden University Medical Center. In order to improve documentation and the quality of care provided during neonatal transition, we implemented weekly plenary audits reviewing recordings of neonatal stabilization in 2014. In audits, provided care is reviewed, discussing, among others, mask technique, compliance to the prevailing local guideline, and clinical decision making and alternative treatment options. In this perspective, we argue that auditing neonatal stabilization is a valuable tool to improve patient safety and the quality of care provided during neonatal stabilization. We, therefore, report lessons learned and areas for improvement that could be identified and addressed during audits conducted at our NICU. Important areas for improvement were guideline compliance, documentation, the usage of medical devices, the conduct of delivery room studies, and clinical decision making. By reporting our experiences, we hope to encourage other NICUs to also implement regular audit meetings, fitting to their improvement needs.

Enhanced monitoring during neonatal resuscitation

Immediately after birth through spontaneous breaths, infants' clear lung liquid replacing it with air, and gradually establishing a functional residual capacity to achieve gas exchange. Most infants start breathing independently after birth and ~3% of infants who require positive pressure ventilation. When newborns fail to start breathing the current neonatal resuscitation guidelines recommend initiatingpositive pressure ventilationusing a face mask and a ventilation device. Adequate ventilation is the cornerstone of successful neonatal resuscitation; therefore, it is mandatory that anybody involved in neonatal resuscitation is trained in mask ventilation techniques. One of the main problems with mask ventilation is that it is very subjective with direct feedback lacking and not uncommonly, the resuscitator does not realise that their technique is unsatisfactory. Many studies have shown that monitoring tidal volume and leak around the mask or endotracheal tube enables the resuscitator to identify the problem and adjust their technique to reduce the leak and deliver and appropriate tidal volume. This chapter discusses the currently available monitoring devices used during stabilization/resuscitation in the delivery room.

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.

Quality Improvement Project to Decrease Delivery Room Intubations in Preterm Infants

BACKGROUND AND OBJECTIVES

Avoidance of delivery room intubation (DRI) reduces death or bronchopulmonary dysplasia (BPD) in preterm neonates. Our objective with this quality improvement project was to decrease DRI rates by improving face mask positive pressure ventilation (Fm-PPV) among infants born ≤29 weeks' gestation.

METHODS

Key drivers of change were identified from a retrospective review of resuscitation records. A resuscitation bundle to optimize Fm-PPV including the use of a small round mask and end-tidal CO₂ detectors, increasing peak inspiratory pressure when indicated, and debriefing after each intubation were implemented in consecutive plan-do-study-act cycles. The DRI rate was tracked by using a control chart. Resuscitation practice and outcomes of pre-quality improvement cohort (QIC) (January 2014-September 2015) were compared with post-QIC (October 2015-December 2016).

RESULTS

Of the 314 infants who were resuscitated, 180 belonged to the pre-QIC and 134 to the post-QIC. The antenatal steroid administration rate was higher in the post-QIC (54% vs 88%). More infants in the post-QIC had resolution of bradycardia after Fm-PPV (56% vs 77%, P = .02). Infants in the post-QIC had lower DRI rates (58% vs 37%, P < .01), lower need for mechanical ventilation (85% vs 70%, P < .01), lower rates of BPD (26% vs 13%, P < .01), and severe retinopathy of prematurity (14% vs 5%, P = .01). Rates of DRI, BPD, and severe retinopathy of prematurity remained lower even after controlling for the potential confounders.

CONCLUSIONS

Implementation of a resuscitation bundle decreased the DRI rate and improved outcomes of preterm infants.

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.

Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study

OBJECTIVES

To determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation.

DESIGN SETTING AND PATIENTS

A prospective observational study in an unselected population at Stavanger University Hospital, Norway, from October 2016 until September 2017.

INTERVENTIONS

Using a data collection form and video recordings, we registered and analysed resuscitative interventions.

MAIN OUTCOME MEASURES

Incidence of continuous positive airway pressure (CPAP), positive pressure ventilation (PPV), intubation, chest compressions and intravenous fluid or epinephrine boluses. Short-term outcomes of resuscitated newborns.

RESULTS

All 4693 newborns in the study period were included in the study. Two hundred and ninety-one (6.2%) newborns received interventions in the first minutes of life beyond drying and stimulation. PPV was provided in 170 (3.6%) while CPAP (without PPV) was provided in 121 (2.6%) newborns. Duration of PPV was median (IQR) 106 s (54-221). Intubations were performed in 19 (0.4%) newborns, with a mean (SD) intubation time of 47 (21) s. Ten (0.2%) newborns received chest compressions and epinephrine was administrated in three (0.1%) newborns. Sixty-three per cent of the treated newborns from 34 weeks' gestational age were returned to parental care without further follow-up.

CONCLUSIONS

The need for resuscitative interventions after birth was frequent in this unselected population in a high-resource setting, but full cardiopulmonary resuscitation was rare. Short-term outcomes were good, suggesting that most newborns treated with resuscitative interventions were not severely affected.

RETAIN: A Board Game That Improves Neonatal Resuscitation Knowledge Retention

Background: The current resuscitation guidelines recommend frequent simulation based medical education (SBME). However, the current SBME approach is expensive, time-intensive, and requires a specialized lab and trained instructors. Hence, it is not offered routinely at all hospitals. We designed the board game "RETAIN" to train healthcare providers (HCPs) in neonatal resuscitation in a cost-friendly and accessible way. Objectives: To examine if a board game-based training simulator improves knowledge retention in HCPs. Methods: "RETAIN" consists of a board using an image of a baby, visual objects, adjustable timer, monitors, and action cards. Neonatal HCPs at the Royal Alexandra Hospital were invited to participate. Participants completed a written pre-test (resuscitation of a 24-week infant), then played the board game (starting with a tutorial followed by free playing of three evidence-based neonatal resuscitation scenarios). Afterwards, a post-test with the same resuscitation scenario and an opinion survey was completed. The answers from the pre- and post-test were compared to assess HCPs' knowledge retention. Results: Thirty HCPs (four doctors, 12 nurses, and 14 respiratory therapist) participated in the study. Overall, we observed a 10% increase in knowledge retention between the pre- and post-test (49-59%, respectively). Temperature management showed the most knowledge gain between the pre- and post-test (14-46%, respectively). Placement of a hat (10-43%), plastic wrap (27-67%), and temperature probe (7-30%) improved between the pre- and post-test. Conclusion: Knowledge retention increased by 12% between pre- and post-test (49-61%, respectively). The improvement in performance and knowledge supports the use of board game simulations for clinical training.

Accuracy of real-time delivery room resuscitation documentation

OBJECTIVE

To assess the accuracy of real-time delivery room resuscitation documentation.

DESIGN

Retrospective observational study.

SETTING

Level 3 academic neonatal intensive care unit.

PARTICIPANTS

Fifty infants with video recording of neonatal resuscitation.

MAIN OUTCOME MEASURES

Vital sign assessments and interventions performed during resuscitation. The accuracy of written documentation was compared with video gold standard.

RESULTS

Timing of initial heart rate assessment agreed with video in 44/50 (88%) records; the documented heart rate was correct in 34/44 (77%) of these. Heart rate and oxygen saturation were documented at 5 min of life in 90% of resuscitations. Of these, 100% of heart rate and 93% of oxygen saturation values were correctly recorded. Written records accurately reflected the mode(s) of respiratory support for 89%-100%, procedures for 91%-100% and medications for 100% of events.

CONCLUSION

Real-time documentation correctly reflects interventions performed during delivery room resuscitation but is less accurate for early vital sign assessments.

Adherence to the neonatal resuscitation algorithm for preterm infants in a tertiary hospital in Spain

BACKGROUND

There is evidence that delivery room resuscitation of very preterm infants often deviates from internationally recommended guidelines. There were no published data in Spain regarding the quality of neonatal resuscitation. Therefore, we decided to evaluate resuscitation team adherence to neonatal resuscitation guidelines after birth in very preterm infants.

METHODS

We conducted an observational study. We video recorded resuscitations of preterm infants < 32 weeks' gestational age and evaluated every step during resuscitation according to a score-sheet specifically designed for this purpose, following Carbine's method, where higher scores indicated that more intense resuscitation maneuvers were required. We divided the score achieved by the total possible points per patient to obtain the percentage of adherence to the algorithm. We also compared resuscitations performed by staff neonatologists to those performed by pediatricians on-call. We compared percentages of adherence to the algorithm with the Chi-square test for large groups and Fisher's exact test for smaller groups. We compared assigned Apgar scores with those given after analyzing the recordings and described them by their median and interquartile range. We measured the interrater agreement between Apgar scores with Cohen's kappa coefficient. Linear and logarithmic regressions were drawn to characterize the pattern of algorithm adherence. Statistical analysis was performed using SPSS V.20. A p-value < 0.05 was considered significant. Our Hospital Ethics Committee approved this project, and we obtained parental written consent beforehand.

RESULTS

Sixteen percent of our resuscitations followed the algorithm. The number of mistakes per resuscitation was low. Global adherence to the algorithm was 80.9%. Ventilation and surfactant administration were performed best, whereas preparation and initial steps were done with worse adherence to the algorithm. Intubation required, on average, 2.2 attempts; success on the first attempt happened in 33.3% of cases. Only 12.5% of intubations were achieved within the allotted 30 s. Many errors were attributable to timing. Resuscitations led by pediatricians on-call were performed as correctly as those by staff neonatologists.

CONCLUSIONS

Resuscitation often deviates from the internationally recognized algorithm. Perfectly performed resuscitations are infrequent, although global adherence to the algorithm is high. Neonatologists and pediatricians need intubation training.

Video analysis for the evaluation of vaginal births: a prospective observational study

AIMS OF THE STUDY Video documentation is nowadays well established in many fields of medicine, but mostly in unreal situations such as simulation training. We here present the application of video for teaching and learning purposes during the birth process. The aim of video documentation during labour is to provide an observational tool for obstetric care by midwives and obstetricians, with the opportunity for evaluation and education afterwards, especially in absence of the woman in labour and her family. METHODS Between February 2015 and June 2017, we conducted a prospective observational study on women aged over 18 years with singleton pregnancies with vertex presentation at term, who gave birth vaginally in the labour ward at the Division of Obstetrics of the University Hospital of Zurich. The end of birth (crowning of the head and fetal extraction) with the manual actions and manoeuvers performed was recorded on video in 100 births. Procedures were analysed afterwards by a senior consultant and evaluated with the staff involved. RESULTS We found frequent notable omissions during vaginal deliveries, concerning technical and nontechnical skills. Those aspects included inappropriate aseptic technique (e.g., no sterile underlay or sterile gloves), improper fetal head slowdown during expulsion, lack of visualisation of the perineum during fetal extraction/expulsion, lack of hip, shoulder and arm guiding while extracting the fetus, inappropriate episiotomy technique (wrong handling of the scissors, cutting angle too steep) and improper communication between the woman giving birth and the staff. During vacuum extractions, incorrect positioning of the cup, and inappropriate direction of pulling and handling of the cup were recorded. CONCLUSIONS Video analysis of obstetric procedures in the labour ward is an easily applicable and very useful tool for teaching and learning purposes. It contributes to showing and improving the quality of procedures and the interactions of the staff and can be used for staff evaluation. ​ Registered at ClinicalTrials.gov (registration number NCT02295904)

Growth Mindset Moderates the Effect of the Neonatal Resuscitation Program on Performance in a Computer-Based Game Training Simulation

This study examines for the first time the moderating role of growth mindset on the association between the time elapsed since participants' last refresher neonatal resuscitation program (NRP) course and their performance on neonatal resuscitation tasks in the RETAIN computer game training simulation. Participants were n = 50 health-care providers affiliated with a large university hospital. Results revealed that growth mindset moderated the relation between participants' task performance in the game and the time since their latest refresher NRP course. Specifically, participants who completed the course more recently (i.e., between 8 and 9 months before the current study) made significantly more mistakes in the game than the rest of the participants but only when they endorsed lower levels of growth mindset. Implications of this research include growth mindset interventions and increased screen time in simulation sessions that have the potential to help health-care providers achieve better performance on neonatal resuscitation clinical tasks.

Ethical dilemmas of recording and reviewing neonatal resuscitation

Neonatal resuscitation is provided to approximately 3% of neonates. Adequate ventilation is often the key to successful resuscitation, but this can be difficult to provide. There is increasing evidence that inappropriate respiratory support can have severe consequences. Several neonatal intensive care units have recorded and reviewed neonatal resuscitation procedures for quality assessment, education and research; however, ethical dilemmas sometimes make it difficult to implement this review process. We reviewed the literature on the development of recording and reviewing neonatal resuscitation and have summarised the ethical concerns involved. Recording and reviewing vital physiological parameters and video imaging of neonatal resuscitation in the delivery room is a valuable tool for quality assurance, education and research. Furthermore, it can improve the quality of neonatal resuscitation provided. We observed that ethical dilemmas arise as the review process is operating in several domains of healthcare that all have their specific moral framework with requirements and conditions on issues such as consent, privacy and data storage. These moral requirements and conditions vary due to local circumstances. Further research on the ethical aspects of recording and reviewing is desirable before wider implementation of this technique can be recommended.

The Breathing Effort of Very Preterm Infants at Birth

OBJECTIVE

To compare the respiratory effort of very preterm infants receiving positive pressure ventilation (PPV) with infants breathing on continuous positive airway pressure (CPAP), directly after birth.

STUDY DESIGN

Recorded resuscitations of very preterm infants receiving PPV or CPAP after birth were analyzed retrospectively. The respiratory effort (minute volume and recruitment breaths [>8 mL/kg], heart rate, oxygen saturation, and oxygen requirement were analyzed for the first 2 minutes and in the fifth minute after birth.

RESULTS

Respiratory effort was analyzed in 118 infants, 87 infants receiving PPV and 31 infants receiving CPAP (median gestational age, 28 weeks [IQR, 26-29] vs 29 weeks [IQR, 29-30; P < .001); birth weight, 1059 g [IQR, 795-1300] vs 1205 g [IQR, 956-1418; P = .06]). The minute volume of spontaneous breaths of infants receiving PPV was lower at 2 minutes (37 mL/kg/minute [IQR, 15-69] vs 188 mL/kg/minute [IQR, 128-297; P < .001]) and at 5 minutes (112 mL/kg/minute [IQR, 46-229] vs 205 mL/kg/minute [IQR, 174-327; P < .001]). Recruitment breaths occurred less in the PPV group at 2 minutes (0 breaths/minute [IQR, 0-1] vs 4 breaths/minute [IQR, 1-8; P < .001]) and 5 minutes (0 breaths/minute [IQR, 0-3] vs 2 breaths/minute [IQR, 0-11; P = .01). The heart rate was lower in the PPV group (94 beats/minute [IQR, 68-128] vs 124 beats/minute [IQR, 100-144; P = .02]) as was oxygen saturation (50% [IQR, 35%-66%] vs 67% [IQR, 34%-80%; P = .04]), but not different at 5 minutes (heart rate, 149 beats/minute [IQR, 131-162] vs 150 beats/minute [IQR, 132-160; P = NS]; oxygen saturation , 91% [IQR, 80%-95%] vs 92% [IQR, 89%-97%; P = NS]). The oxygen requirement was higher (at 2 minutes, 30% [IQR, 21%-53%] vs 21% [IQR, 21%-29%; P = .05]; at 5 minutes, 39% [IQR, 22%-91%] vs 22% [IQR, 21%-31%; P = .003]).

CONCLUSION

Very preterm infants breathe at birth when receiving PPV, but the respiratory effort was significantly lower when compared with infants receiving CPAP only. The reduced breathing effort observed likely justified applying PPV in most infants.

Reducing Brain Injury of Preterm Infants in the Delivery Room

Cerebrovascular injury is one of the major detrimental consequences of preterm birth. Recent studies have focused their attention on factors that contribute to the development of brain lesions immediately after birth. Among those factors, hypothermia and lower cerebral oxygen saturation during delivery room resuscitation and high tidal volumes delivered during respiratory support are associated with increased risk of severe neurologic injury. In preterm infants, knowledge about causes and prevention of brain injury must be applied before and at birth. Preventive and therapeutic approaches, including correct timing of cord clamping, monitoring of physiological changes during delivery room resuscitation using pulse oximetry, respiratory function monitoring, near infrared spectroscopy, and alpha EEG, may minimize brain injury, Furthermore, postnatal administration of caffeine or other potential novel treatments (e.g., proangiogenic therapies, antioxidants, hormones, or stem cells) might improve long-term neurodevelopmental outcomes in preterm infants.

Time Perception during Neonatal Resuscitation

OBJECTIVE

To assess the accuracy of time perception during a simulated complex neonatal resuscitation.

STUDY DESIGN

Participants in 5 neonatal resuscitation program courses were directly involved in a complex simulation scenario. They were asked to assume the role of team leader, assistant 1, or assistant 2. At the end of the scenario, each participant completed a questionnaire on perceived time intervals for key resuscitation interventions. During the scenario, actual times were documented by an external observer and video recorded for later review. In addition, participants were asked to evaluate their self-perceived level of stress and preparation.

RESULTS

Health care providers (68 physicians and 40 nurses) were involved in 36 scenarios. Perceived time intervals for the initiation of key resuscitation interventions were shorter than the actual time intervals, regardless of the participant's role in the scenario. Self-assessed levels of stress and preparation did not influence time perception.

CONCLUSIONS

Health care providers underestimate the passage of time, irrespective of their role in a simulated complex neonatal resuscitation. Participant's self-assessed levels of stress and preparation were not related to the accuracy of their time perception. These findings highlight the importance of assigning a dedicated individual to document interventions and the passage of time during a neonatal resuscitation.

Analyzing video recorded support of postnatal transition in preterm infants following a c-section

Background

Over the past years, research on neonatal resuscitation has focused on single interventions. The present study was performed to analyze the process quality of delivery room management of preterm infants born by c-section in our institution.

Methods

We performed a cross-sectional study of videos of preterm infants born by c-section. Videos were analyzed according to time point, duration and number of performed medical interventions. The study period occurred between January 2012 and December 2013. Infants were caterogized in 3 groups according to their gestational age.

Results

One hundred eleven videos were analyzed. 100 (90 %) of the infants were transferred to NICU and 91 (83 %) received respiratory support after a median of 0.5 min. All infants were auscultated after 8 (5–16) seconds median (IQR) and an oxygen saturation sensor was placed after 37 (28–52) seconds. 23 infants were intubated after 9 (6–17) minutes and 17 received exogenous surfactant; 29 % according to INSURE (intubation-surfactant-extubation) technique. The duration of intubation attempts was 47 (25–60) seconds. 51 % of the newborns received a sustained inflation for 8 (6–9) seconds. A successful IV-line placement occurred after 15 (12–20) minutes. 4 % of the infants were transported to the NICU without an IV-line after 3 (difference range: 2–5) unsuccessful attempts.

Conclusions

Using video analysis as a tool to study process quality, we conclude that interventions differ not only between but also within similar age groups. This data can be used for benchmarking with current guidelines and practice in other centers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1045-2) contains supplementary material, which is available to authorized users.

Cardiorespiratory Monitoring during Neonatal Resuscitation for Direct Feedback and Audit

Neonatal resuscitation is one of the most frequently performed procedures, and it is often successful if the ventilation applied is adequate. Over the last decade, interest in seeking objectivity in evaluating the infant's condition at birth or the adequacy and effect of the interventions applied has markedly increased. Clinical parameters such as heart rate, color, and chest excursions are difficult to interpret and can be very subjective and subtle. The use of ECG, pulse oximetry, capnography, and respiratory function monitoring can add objectivity to the clinical assessment. These physiological parameters, with or without the combination of video recordings, can not only be used directly to guide care but also be used later for audit and teaching purposes. Further studies are needed to investigate whether this will improve the quality of delivery room management. In this narrative review, we will give an update of the current developments in monitoring neonatal resuscitation.

Resuscitator's perceptions and time for corrective ventilation steps during neonatal resuscitation

BACKGROUND

The 2010 neonatal resuscitation program (NRP) guidelines incorporate ventilation corrective steps (using the mnemonic--MRSOPA) into the resuscitation algorithm. The perception of neonatal providers, time taken to perform these maneuvers or the effectiveness of these additional steps has not been evaluated.

METHODS

Using two simulated clinical scenarios of varying degrees of cardiovascular compromise--perinatal asphyxia with (i) bradycardia (heart rate--40 min(-1)) and (ii) cardiac arrest, 35 NRP certified providers were evaluated for preference to performing these corrective measures, the time taken for performing these steps and time to onset of chest compressions.

RESULTS

The average time taken to perform ventilation corrective steps (MRSOPA) was 48.9 ± 21.4s. Providers were less likely to perform corrective steps and proceed directly to endotracheal intubation in the scenario of cardiac arrest as compared to a state of bradycardia. Cardiac compressions were initiated significantly sooner in the scenario of cardiac arrest 89 ± 24 s as compared to severe bradycardia 122 ± 23 s, p < 0.0001. There were no differences in the time taken to initiation of chest compressions between physicians or mid-level care providers or with the level of experience of the provider.

CONCLUSIONS

Effective ventilation of the lungs with corrective steps using a mask is important in most cases of neonatal resuscitation. Neonatal resuscitators prefer early endotracheal intubation and initiation of chest compressions in the presence of asystolic cardiac arrest. Corrective ventilation steps can potentially postpone initiation of chest compressions and may delay return of spontaneous circulation in the presence of severe cardiovascular compromise.