Predicting neonatal intubation competency in trainees

Predictors of successful neonatal intubation in inexperienced operators: a secondary, non-randomised analysis of the SHINE trial

OBJECTIVE

Neonatal endotracheal intubation is a lifesaving but technically difficult procedure, particularly for inexperienced operators. This secondary analysis in a subgroup of inexperienced operators of the Stabilization with nasal High flow during Intubation of NEonates randomised trial aimed to identify the factors associated with successful intubation on the first attempt without physiological stability of the infant.

METHODS

In this secondary analysis, demographic factors were compared between infants intubated by inexperienced operators and those intubated by experienced operators. Following this, for inexperienced operators only, predictors of successful intubation without physiological instability were analysed.

RESULTS

A total of 251 intubations in 202 infants were included in the primary intention-to-treat analysis of the main trial. Inexperienced operators were more likely to perform intubations in larger and more mature infants in the neonatal intensive care unit where premedications were used. When intubations were performed by inexperienced operators, the use of nasal high flow therapy (nHF) and a higher starting fraction of inspired oxygen were associated with a higher rate of safe, successful intubation on the first attempt. There was a weaker association between premedication use and first attempt success.

CONCLUSIONS

In inexperienced operators, this secondary, non-randomised analysis suggests that the use of nHF and premedications, and matching the operator to the infant and setting, may be important to optimise neonatal intubation success.

TRIAL REGISTRATION NUMBER

ACTRN12618001498280.

Video laryngoscopy-assisted less-invasive surfactant administration quality improvement initiative

OBJECTIVE

To describe the use of quality improvement methodology in transitioning from delivery of surfactant by INSURE (INtubation-SURfactant administration-Extubation) to video laryngoscope-assisted LISA (less-invasive surfactant administration) for infants with respiratory distress syndrome (RDS) receiving non-invasive ventilatory support.

SETTING

Two large neonatal intensive care units (NICUs) at Northwell Health (New Hyde Park, New York, USA).

STUDY POPULATION

Infants with RDS receiving continuous positive airway pressure in the NICU and eligible for surfactant administration.

RESULTS

LISA was initiated in our NICUs in January 2021, after extensive guideline development, education programmes, hands-on training and provider credentialing. Our Specific, Measurable, Achievable, Relevant and Timely aim was to deliver surfactant by LISA for 65% of total doses by 31 December 2021. This goal was achieved within 1 month of go-live. In total, 115 infants received at least one dose of surfactant during the year. Of those, 79 (69%) received it via LISA and 36 (31%) via INSURE. Two Plan-Do-Study-Act cycles contributed to improved adherence to guidelines on timely surfactant administration and both written and video documentation.

CONCLUSIONS

Safe and effective introduction of LISA with the use of video laryngoscopy is achievable with careful planning, clear clinical guidelines, adequate hands-on training and comprehensive safety and quality control.

Neonatal airway management training using simulation-based educational methods and technology

Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.

Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial

OBJECTIVE

To assess if simulation-based just-in-time training (JITT, short video and simulation) is superior to video training (5-minute video) in acquiring skill in neonatal endotracheal intubation (ETI).

STUDY DESIGN

A Canadian multicenter randomized trial recruited junior residents who performed neonatal ETI from July 2017 to June 2021. The primary outcomes were overall and first attempt ETI success rate. Secondary outcomes included number of attempts, duration of attempts, ETI-related complications, and residents' confidence level. Statistical analysis included generalized estimating equations, mixed model analysis, Mann-Whitney test, and χ² tests.

RESULTS

Sixty-five residents performed 139 ETI. The overall success rate was similar for both groups (67% vs 70%, P = .71). However, the first attempt success rate was higher for the simulation-based JITT group (54% vs 41%, P = .035). The mean duration of attempts was shorter (35 [SD, 9] vs 62 [SD, 9] seconds, P = .048) and the median number of attempts had a tendency to be lower for the simulation-based JITT group (1 [IQR, 1; 1] vs 1 [IQR, 1; 2], P = .02). There were more mucosal trauma events in the simulation-based JITT group (P = .02). Residents in both groups reported similar confidence level in performing ETI.

CONCLUSIONS

Compared with video training, simulation-based JITT for neonatal ETI did not improve overall success rate. However, simulation-based JITT improved first attempt success rate and decreased the number and the duration of ETI attempts. With its positive clinical impact, simulation-based JITT can become an educational adjunct to neonatal ETI training for residents.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02809924.

Videolaryngoscopy in neonatal clinical care

Endotracheal intubation is a life-saving procedure for many newborns. Historically, it has been achieved by obtaining an airway view through the mouth via direct laryngoscopy. It is a skill that takes time and practice to achieve proficiency. Increasing evidence for the benefit of videolaryngoscopy in adults and the new development of technology has allowed videolaryngoscopy to become a reality in neonatal care. Studies have examined its use as both a technique to improve intubation safety and success, and as a training tool for those learning the skill in this vulnerable population. We present the current evidence for videolaryngoscopy in neonates in different settings where intubation may be required, in addition to exploring the challenges and practicalities of implementing this technique into clinical practice.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine

Background

Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees.

Methods

This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods.

Results

There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods.

Conclusions

The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Learning pediatric emergency medicine over time: A realist evaluation of a longitudinal pediatric emergency medicine clinical experience

Introduction

Emergency medicine (EM) practitioners must be proficient at caring for patients of all ages, including pediatric patients. Traditionally, EM trainees learn pediatric emergency medicine (PEM) through block rotations. This is problematic due to the seasonal nature of pediatric diseases and infrequent critical events. Spaced repetition learning theory suggests PEM would be better learned through longitudinal rotations. The transition to competency-based medical education (CBME) in Canada is accelerating the need to find novel ways to attain competencies in postgraduate training. At McMaster University, senior EM trainees can choose either traditional PEM blocks or longitudinal rotations. Our objective was to understand how learners experience these different rotations given the transition to CBME in Canada.

Methods

Using a realist framework of program evaluation, we conducted semistructured interviews with key stakeholders (trainees, program directors, attending physicians) in EM. The realist framework was used to understand how context interacts with theoretical mechanisms to produce outcomes of interest. Data were analyzed using inductive, conventional content analysis. All investigators coded a subset of transcripts independently and in duplicate to achieve intercoder agreement.

Results

A total of 13 interviews were completed with trainees (n = 11) and staff physicians (n = 2). The learning experience exists within an educational and clinical context, which are logistically distinct but inseparable. The longitudinal learning experience appears to improve learning through spaced repetition, which prevents atrophy of skills and knowledge while also benefitting from the offsetting of seasonal variability associated with many pediatric diseases. Improved feedback and entrustment are facilitated through the building of coaching relationships over time. Barriers to the learning experience are related mainly to logistical difficulties associated with resolving longitudinal and blocked learning experiences. Improved relationships with the interprofessional team may provide distinct learning opportunities and improved team functioning. Block rotations were identified as more valuable to junior trainees learning fundamental concepts.

Conclusions

Longitudinal learning provides numerous advantages to learning PEM, including increased case variety, spaced repetition of core concepts, and a perception of greater entrustment of the learner through formation of coaching relationships over time. Future projects looking to quantify the differences between longitudinal and block learning to objectively show a difference in skills and knowledge are needed.

Part 5: Essentials of Neonatal-Perinatal Medicine Fellowship: evaluation of competence and proficiency using Milestones

The Accreditation Council for Graduate Medical Education (ACGME) Pediatric Subspecialty Milestone Project competencies are used for Neonatal-Perinatal Medicine (NPM) fellows. Milestones are longitudinal markers that range from novice to expert (levels 1-5). There is no standard approach to the required biannual evaluation of fellows by fellowship programs, resulting in significant variability among programs regarding procedural experience and exposure to pathology during clinical training. In this paper, we discuss the opportunities that Milestones provide, potential strategies to address challenges, and future directions.

Safe emergency neonatal airway management: current challenges and potential approaches

This review examines the airway adjuncts currently used to acutely manage the neonatal airway. It describes the challenges encountered with facemask ventilation and intubation. Evidence is presented on how to optimise intubation safety and success rates with the use of videolaryngoscopy and attention to the intubation environment. The supraglottic airway (laryngeal mask airway) is emerging as a promising neonatal airway adjunct. It can be used effectively with little training to provide a viable alternative to facemask ventilation and intubation in neonatal resuscitation and be used as an alternative conduit for the administration of surfactant.

Nasal High-Flow Therapy during Neonatal Endotracheal Intubation

BACKGROUND

Neonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt.

METHODS

We performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant.

RESULTS

The primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3).

CONCLUSIONS

Among infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.).

Simulation for Neonatal Endotracheal Intubation Training: How Different Is It From Clinical Practice?

INTRODUCTION

Neonatal endotracheal intubation is a critical skill that is difficult for learners to acquire even with simulation-based training (SBT). Trainees prefer clinical experiences over SBT. The objective of the study was to explore the differences between SBT and clinical practice in acquiring neonatal intubation skills to inform mannequin design and to improve fidelity.

METHODS

A basic qualitative study using semistructured interviews was conducted to determine the experience of newly competent trainees (second- and third-year neonatal-perinatal medicine fellows) and their instructors in developing intubation skills. Participants were asked to compare learning through SBT with clinical practice in terms of context, equipment, and environment. Their responses were analyzed using an inductive approach.

RESULTS

Thirty-two participants (20 fellows and 12 faculty) indicated that SBT does not equal the real experience. Specifically, the look, feel, and function of the simulators differ enough from the real patient and the clinical environmental that they do not elicit the desired learning responses. The clinical environment prompted heightened emotions and had a chaotic atmosphere that was not fully captured by SBT. Participants suggested that programs use SBT in the initial phases of training only to gain basic skills and they provided several solutions for mannequin and SBT session design.

CONCLUSIONS

Simulation-based training does not fully prepare neonatal-perinatal medicine fellows for neonatal intubation. Mannequins with unique active features, such as multiple airway configurations, slipperiness, secretions, and softer textures should be developed. Realistic environments that replicate the interprofessional nature and stressors of the clinical environment might better prepare learners for the complexity of clinical practice.

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.

Validation of an Instrument for Real-Time Assessment of Neonatal Intubation Skills: A Randomized Controlled Simulation Study

OBJECTIVE

This study aimed to evaluate the construct validity and reliability of real-time assessment of a previously developed neonatal intubation scoring instrument (NISI).

STUDY DESIGN

We performed a randomized controlled simulation study at a simulation-based research and training facility. Twenty-four clinicians experienced in neonatal intubation ("experts") and 11 medical students ("novices") performed two identical elective intubations on a neonatal patient simulator. Subjects were randomly assigned to either the intervention group, receiving predefined feedback between the two intubations, or the control group, receiving no feedback. Using the previously developed NISI, all intubations were assessed, both in real time and remotely on video. Construct validity was evaluated by (1) comparing the intubation performances, expressed as percentage scores, with and without feedback, and (2) correlating the intubation performances with the subjects' level of experience. The intrarater reliability, expressed as intraclass correlation coefficient (ICC), of real-time assessment compared with video-based assessment was determined.

RESULTS

The intervention group contained 18 subjects, the control group 17. Background characteristics and baseline intubation scores were comparable in both groups. The median (IQR) change in percentage scores between the first and second intubation was significantly different between the intervention and control group (11.6% [4.7-22.8%] vs. 1.4% [0.0-5.7%], respectively; p = 0.013). The 95% CI for this 10.2% difference was 2.2 to 21.4%. The subjects' experience level correlated significantly with their percentage scores (Spearman's R = 0.70; p <0.01). ICC's were 0.95 (95% CI: 0.89-0.97) and 0.94 (95% CI: 0.89-0.97) for the first and second intubation, respectively.

CONCLUSION

Our NISI has construct validity and is reliable for real-time assessment.

KEY POINTS

· Our neonatal intubation scoring instrument has construct validity.. · Our instrument can be reliably employed to assess neonatal intubation skills directly in real time.. · It is suitable for formative assessment, i.e., providing direct feedback during procedural training..

Conceptualizing intubation sharing: A descriptive qualitative study of videolaryngoscopy for pediatric emergency airway management

BACKGROUND

This study characterizes clinical and educational practices around the use of videolaryngoscopy in pediatric emergency airway management through qualitative exploration.

METHODS

This is a descriptive qualitative study using semi-structured interviews of emergency medicine physicians. Physicians were selected by theoretical sampling from urban, tertiary care pediatric hospitals across the United States until theoretical data saturation was achieved. The study applied a constructivist grounded theory approach to data collection and analysis. Manual line-by-line coding of interview transcripts was used initially, then grouped into categories with constant comparative analysis to generate the final coding scheme organized by themes and subthemes. Finally, memo-writing and iterative analysis meetings explored relationships between themes and identified an interpretive model.

RESULTS

Theoretical saturation was achieved after 10 of the initial 12 interviews. Emerging from the data were six themes that describe the concept of intubation sharing: (1) Videolaryngoscopy encompasses multiple modalities that all provide a shared view and ability to record; (2) Airway experts and systems help realize the full potential of videolaryngoscopy; (3) Videolaryngoscopy can be a clinical, educational, quality assurance and research tool; (4) Some skills required for videolaryngoscopy are unique, while others overlap with direct laryngoscopy; (5) Videolaryngoscopy allows a coaching laryngoscopist to provide real-time guidance to the primary laryngoscopist from a shared view; (6) Videolaryngoscopy provides an opportunity for post-intubation coaching and feedback and shared learning from a single experience for the provider community.

CONCLUSIONS

Through this multicenter qualitative interview study, we derived the concept of intubation sharing through videolaryngoscopy for real-time and remote coaching, for both the primary laryngoscopist and the community of emergency medicine providers who intubate.

Declining Procedures in Pediatric Critical Care Medicine Using a National Database

Supplemental Digital Content is available in the text.

Objectives:

To investigate the change in rate of invasive procedures (endotracheal intubation, central venous catheters, arterial catheters, and peripheral inserted central venous catheters) performed in PICUs per admission over time. Secondarily, to investigate the change in type of respiratory support over time.

Design:

Retrospective study of prospectively collected data using the Virtual Pediatric Systems (VPS; LLC, Los Angeles, CA) database.

Setting:

North American PICUs.

Patients:

Patients admitted from January 2009 to December 2017.

Interventions:

None.

Measurements and Main Results:

There were 902,624 admissions from 161 PICUs included in the analysis. Since 2009, there has been a decrease in rate of endotracheal intubations, central venous catheters placed, and arterial catheters placed and an increase in the rate of peripheral inserted central venous catheter insertion per admission over time after controlling for severity of illness and unit level effects. As compared to 2009, the incident rate ratio for 2017 for endotracheal intubation was 0.90 (95% CI, 0.83–0.98; p = 0.017), for central venous line placement 0.69 (0.63–0.74; p < 0.001), for arterial catheter insertion 0.85 (0.79–0.92; p < 0.001), and for peripheral inserted central venous catheter placement 1.14 (1.03–1.26; p = 0.013). Over this time period, in a subgroup with available data, there was a decrease in the rate of invasive mechanical ventilation and an increase in the rate of noninvasive respiratory support (bilevel positive airway pressure/continuous positive airway pressure and high-flow nasal oxygen) per admission.

Conclusions:

Over 9 years across multiple North American PICUs, the rate of endotracheal intubations, central catheter, and arterial catheter insertions per admission has decreased. The use of invasive mechanical ventilation has decreased with an increase in noninvasive respiratory support. These data support efforts to improve exposure to invasive procedures in training and structured systems to evaluate continued competency.

Augmented Reality-Assisted Video Laryngoscopy and Simulated Neonatal Intubations: A Pilot Study

BACKGROUND

For novice providers, achieving competency in neonatal intubation is becoming increasingly difficult, possibly because of fewer intubation opportunities. In the present study, we compared intubation outcomes on manikins using direct laryngoscopy (DL), indirect video laryngoscopy (IVL) using a modified disposable blade, and augmented reality-assisted video laryngoscopy (ARVL), a novel technique using smart glasses to project a magnified video of the airway into the intubator's visual field.

METHODS

Neonatal intensive care nurses (n = 45) with minimal simulated intubation experience were randomly assigned (n = 15) to the following 3 groups: DL, IVL, and ARVL. All participants completed 5 intubation attempts on a manikin using their assigned modalities and received verbal coaching by a supervisor, who viewed the video while assisting the IVL and ARVL groups. The outcome and time of each attempt were recorded.

RESULTS

The DL group successfully intubated on 32% of attempts compared to 72% in the IVL group and 71% in the ARVL group (P < .001). The DL group intubated the esophagus on 27% of attempts, whereas there were no esophageal intubations in either the IVL or ARVL groups (P < .001). The median (interquartile range) time to intubate in the DL group was 35.6 (22.9-58.0) seconds, compared to 21.6 (13.9-31.9) seconds in the IVL group and 20.7 (13.2-36.5) seconds in the ARVL group (P < .001).

CONCLUSIONS

Simulated intubation success of neonatal intensive care nurses was significantly improved by using either IVL or ARVL compared to DL. Future prospective studies are needed to explore the potential benefits of this technology when used in real patients.

Neonatal videolaryngoscopy as a teaching aid: the trainees' perspective

INTRODUCTION

Neonatal intubation is a challenging skill to acquire. A randomised controlled trial (RCT) found junior trainees had higher intubation success rates if their supervisor shared their airway view on a videolaryngoscope screen compared with intubations where the supervisor could not see the videolaryngoscope screen. The intubations in the trial were supervised by a group of experienced neonatologists who developed an intubation teaching package that aimed to be informative, consistent and supportive. We surveyed the trainees to assess their experiences of the intubation attempts.

METHODS

Trainees participating in the RCT completed questionnaires anonymously after each intubation attempt. Questionnaires used 5-point Likert scales and free comment sections. Quantitative analysis was performed using descriptive statistics. In a qualitative analysis, free comments were coded to identify central recurring themes.

RESULTS

Two hundred and six questionnaires were completed by 36 trainees. The majority reported that the guidance received during intubation was helpful, the postprocedure feedback was educational and their confidence levels were increased. Trainees appreciated a controlled environment and calm, consistent guidance. They found intubations in the delivery room, those involving unstable infants, large audiences and parental presence more stressful. Responses were positive whether the videolaryngoscope screen was visible or covered, emphasising the importance of consistent guidance. Overall, 16% of intubations were reported as intimidating.

CONCLUSION

The shared airway view offered by videolaryngoscopy was well received. In addition, taking measures to control the setting, with standardised guidance and feedback, improved confidence and created a more positive learning experience.

A Physics-based Virtual Reality Simulation Framework for Neonatal Endotracheal Intubation

Neonatal endotracheal intubation (ETI) is a complex procedure. Low intubation success rates for pediatric residents indicate the current training regimen is inadequate for achieving positive patient out-comes. Computer-based training systems in this field have been limited due to the complex nature of simulating in real-time, the anatomical structures, soft tissue deformations and frequent tool interactions with large forces which occur during actual patient intubation. This paper addresses the issues of neonatal ETI training in an attempt to bridge the gap left by traditional training methods. We propose a fully interactive physics-based virtual reality (VR) simulation framework for neonatal ETI that converts the training of this medical procedure to a completely immersive virtual environment where both visual and physical realism were achieved. Our system embeds independent dynamics models and interaction devices in separate modules while allowing them to interact with each other within the same environment, which offers a flexible solution for multi-modal medical simulation scenarios. The virtual model was extracted from CT scans of a neonatal patient, which provides realistic anatomical structures and was parameterized to allow variations in a range of features that affect the level of difficulty. Moreover, with this manikin-free VR system, we can capture and visualize an even larger set of performance parameters in relation to the internal geometric change of the virtual model for real-time guidance and post-trial assessment. Lastly, validation study results from a group of neonatologists are presented demonstrating that VR is a promising platform to train medical professionals effectively for this procedure.

Neonatal postgraduate training program for physician assistants: meeting a need in neonatal care

There is a growing need for advanced practice providers in the NICU. Physician assistants (PAs) with postgraduate training in neonatology can help meet these demands. The premise of training PAs to work in the NICU is being adopted by multiple centers nationwide. Unfortunately, there are no standardized curricula for neonatal PA training that can be utilized to initiate residencies. Since our program is the longest running neonatal PA residency in the nation, we are in a unique position to share the accumulated experiences of our curriculum development. In this article, we describe our neonatal PA residency as it exists today with selected lessons learned. In addition, we present mixed qualitative and quantitative assessments of graduates. We believe that neonatal PA residency graduates become ideal candidates to fill the growing national need. We propose that our model program can be a stepping stone to enhance the role of PAs in neonatal care.

Neonatal Intubation Practice and Outcomes: An International Registry Study

BACKGROUND AND OBJECTIVES

Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety.

METHODS

We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression.

RESULTS

We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57).

CONCLUSIONS

We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.

What Do NICU Fellows Identify as Important for Achieving Competency in Neonatal Intubation?

BACKGROUND

Tracheal intubation (TI) is one of the most important interventions for the stabilization of critically ill neonates. Competency in airway management is essential for neonatal fellows. No studies have assessed which educational models, techniques, or instructions are perceived by neonatal fellows as the most beneficial for achieving competency in TI.

OBJECTIVES

This study identifies which factors are considered most helpful in achieving intubation competency.

METHOD

This was a mixed-method study. Semi-structured phone interviews addressed training experience for neonatal intubation. Through qualitative analysis, common themes were identified. RedCap electronic surveys and procedure logs were used to assess procedural experience.

RESULTS

Forty-two fellows from 5 programs completed phone interviews. Fellows recalled 6-10 intubation attempts before fellowship. Independent statements related to achieving intubation competency were analyzed and coded into 5 main themes (Procedure, Practice, Perceptual Environment, Personnel, and Preparation). A large proportion of the statements focused on the use of video laryngoscopy.

CONCLUSIONS

The themes identified by neonatal-perinatal medicine (NPM) fellows as being the most beneficial in achieving proficiency in neonatal TI are categorized as "The 5 Ps." Careful review of these themes may be utilized to develop validated curriculums that enhance the teaching of TI and optimize the achievement of TI competency among NPM fellows.

A Randomized Controlled Trial of a Video-Enhanced Advanced Airway Curriculum for Pediatric Residents

PURPOSE

Pediatric advanced airway management is a low-frequency but critical procedure, making it challenging for trainees to learn. This study examined the impact of a curriculum integrating prerecorded videos of patient endotracheal intubations on performance related to simulated pediatric intubation.

METHOD

The authors conducted a randomized controlled educational trial for pediatric residents between January 2015 and June 2016 at Boston Children's Hospital. Investigators collecting data were blinded to the intervention. The control group received a standard didactic curriculum including still images, followed by simulation on airway trainers. The intervention group received a video-enhanced didactic curriculum including deidentified intubation clips recorded using a videolaryngoscope, followed by simulation. The study assessed intubation skills on simulated infant and pediatric airway scenarios of varying difficulty immediately after instruction and at three months.

RESULTS

Forty-nine trainees completed the curriculum: 23 received the video-enhanced curriculum and 26 received the standard curriculum. Median time to successful intubation was 18.5 and 22 seconds in the video-enhanced and standard groups, respectively. Controlling for mannequin age and difficulty, residents receiving the video-enhanced curriculum successfully intubated faster (hazard ratio [95% confidence interval]: 1.65 [1.25, 2.19]). Video-enhanced curriculum participants also demonstrated decreased odds of requiring multiple attempts and of esophageal intubation. At three-month follow-up, residents who received the video-enhanced curriculum remained faster at intubation (hazard ratio [95% confidence interval]: 1.93 [1.23, 3.02]).

CONCLUSIONS

Integrating videos of patient intubations into an airway management curriculum improved participating pediatric residents' intubation performance on airway trainers with sustained improvement at three months.

The amount of supervision trainees receive during neonatal resuscitation is variable and often dependent on subjective criteria

OBJECTIVE

Measure variation in delivery room supervision provided by neonatologists using hypothetical scenarios and determine the factors used to guide entrustment decisions.

STUDY DESIGN

A survey was distributed to members of the American Academy of Pediatrics Section on Perinatal Pediatrics. Neonatologists were presented with various newborn resuscitation scenarios and asked to choose the level of supervision they thought appropriate and grade factors on their importance in making entrustment decisions.

RESULTS

There was significant variation in supervision neonatologists deemed necessary for most scenarios (deviation from the mode 0.36-0.69). Post-graduate year of training and environmental circumstances influence the amount of autonomy neonatologists grant trainees. Few neonatologists have objective assessment of a trainees' competence in neonatal resuscitation available to them and most never document how the trainee performed.

CONCLUSION

Delivery room supervision is often determined by subjective evaluation of trainees' competence and may not provide a level of supervision congruent with their capability.

A randomized controlled trial: does coaching using video during direct laryngoscopy improve residents' success in neonatal intubations?

OBJECTIVE

To evaluate the intubation success rates of residents who receive coaching from supervisors concurrently viewing infants' airways via video during direct laryngoscopy (VDL), as compared with coaching during traditional direct laryngoscopy without video (TDL).

STUDY DESIGN

In a randomized controlled trial, 48 first and second-year residents performed neonatal intubations using VDL or TDL. The primary outcome was intubation success rates. Data were analyzed using the Pearson X² and Student's t-test.

RESULTS

The overall intubation success rate was greater in the VDL vs. TDL group (57% vs. 33%, P < 0.05). First-year residents and residents intubating their first patient had higher intubation success rates in the VDL vs. TDL group (58% vs. 23% and 50% vs. 17%, respectively, P < 0.05).

CONCLUSIONS

Resident coaching using VDL improved neonatal intubation success rates. Incorporating VDL as a coaching tool can optimize the quality of training during limited opportunities to achieve procedural competency and improve intubation-related patient outcomes.

Improving neonatal intubation safety: A journey of a thousand miles

Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.

Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees

Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions. Objective: Our hypothesis was that over the past decade the rate of procedures performed by Pediatric Critical Care Medicine Fellowship trainees decreased. Methods: Retrospective review at a single institution, tertiary, academic, children's hospital of patients admitted from July 1, 2007-June 30, 2017 to the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit. A Poisson regression model with a scale adjustment for over-dispersion estimated by the square root of Pearson's Chi-Square/DOF was applied. Results: There has been a statistically significant decrease in the average rate of central venous lines (p = 0.004; -5.72; 95% CI: -9.45, -1.82) and arterial lines (p = 0.02; -7.8; 95% CI: -13.90, -1.25) per Fellow per years in Fellowship over the last 10 years. There was no difference in the rate of intubations per Fellow per years in Fellowship (p = 0.27; 1.86; 95% CI:-1.38, 5.24). Conclusions: There has been a statistically significant decrease in the rate of central venous lines and arterial lines performed by Pediatric Critical Care Medicine Fellowship trainees per number of years in Fellowship over the last 10 years. Educators need to be constantly reassessing the clinical landscape in an effort to make sure that trainees are receiving adequate educational experiences as this has the potential for an impact on the education of trainees and the safety of the patients that they care for.

Failure of Invasive Airway Placement on the First Attempt Is Associated With Progression to Cardiac Arrest in Pediatric Acute Respiratory Compromise

OBJECTIVES

The aim of this study was to describe the proportion of acute respiratory compromise events in hospitalized pediatric patients progressing to cardiopulmonary arrest, and the clinical factors associated with progression of acute respiratory compromise to cardiopulmonary arrest. We hypothesized that failure of invasive airway placement on the first attempt (defined as multiple attempts at tracheal intubation, and/or laryngeal mask airway placement, and/or the creation of a new tracheostomy or cricothyrotomy) is independently associated with progression of acute respiratory compromise to cardiopulmonary arrest.

DESIGN

Multicenter, international registry of pediatric in-hospital acute respiratory compromise.

SETTING

American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2014).

PATIENTS

Children younger than 18 years with an index (first) acute respiratory compromise event.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 2,210 index acute respiratory compromise events, 64% required controlled ventilation, 26% had return of spontaneous ventilation, and 10% progressed to cardiopulmonary arrest. There were 762 acute respiratory compromise events (34%) that did not require an invasive airway, 1,185 acute respiratory compromise events (54%) with successful invasive airway placement on the first attempt, and 263 acute respiratory compromise events (12%) with failure of invasive airway placement on the first attempt. After adjusting for confounding variables, failure of invasive airway placement on the first attempt was independently associated with progression of acute respiratory compromise to cardiopulmonary arrest (adjusted odds ratio 1.8 [95% CIs, 1.2-2.6]).

CONCLUSIONS

More than 1 in 10 hospitalized pediatric patients who experienced an acute respiratory compromise event progressed to cardiopulmonary arrest. Failure of invasive airway placement on the first attempt is independently associated with progression of acute respiratory compromise to cardiopulmonary arrest.

Video Laryngoscopy vs. Direct Laryngoscopy in Teaching Neonatal Endotracheal Intubation: A Simulation-Based Study

BACKGROUND

Neonatal endotracheal intubation is a life-saving procedural skill where best practices have been developed from expert opinion. Few empirical studies have examined how this skill should be taught.

OBJECTIVE

To determine whether a video laryngoscope (VL) assisted intubation training curriculum compared to a traditional direct laryngoscope (DL) assisted curriculum improves neonatal intubation performance of novice intubators in a simulated setting.

METHODS

A randomized trial of novice intubators was conducted at the University of Texas-Houston from 6/2013-8/2013. Eligible candidates were randomly assigned to control group (DL curriculum) or intervention group (VL curriculum). Those in the intervention group received instruction with VL videos and practice with Storz C-MAC® VL (Karl Storz, Tuttlingen, Germany) in addition to a traditional curriculum. Intubation performance was evaluated in a simulated setting using a SimNewB® (Laerdal, NY, USA) manikin and traditional intubation equipment. The number of intubation attempts, outcome of each attempt, and time to successful intubation were recorded. The data was analyzed using Fisher's exact test and logistic regression where appropriate.

RESULTS

One hundred twenty-three trainees were enrolled, 62 (50%) in DL group and 61 (50%) in the VL group. Intubation success on first attempt was achieved by 69% (43/62) of the DL group vs. 61% (37/61) of the VL group, P=0.35. Time to successful intubation was 25 sec (interquartile range (IQR) 18, 32) in the DL group and 26.5 sec (IQR 20, 43) in the VL group, P=0.27. Those in the VL group were more likely to need more than two attempts to achieve intubation success, OR=3.09 (95% CI 1.03-9.28).

CONCLUSIONS

In a simulated setting, teaching with a VL curriculum did not improve intubation performance compared to teaching with DL. Further studies are needed to determine if VL-based teaching has an impact on clinical intubation performance.

Preparedness of pediatric residents for fellowship: a survey of US neonatal-perinatal fellowship program directors

OBJECTIVE

To evaluate the preparedness of pediatric residents entering accredited neonatal-perinatal medicine (NPM) fellowships in the United States.

STUDY DESIGN

A multi-domain, validated survey was distributed to Program Directors (PDs) of US NPM fellowship programs. The 47-item survey explored 5 domains: professionalism, independent practice, psychomotor ability, clinical evaluation, and academia. A systematic, qualitative analysis on free-text comments was also performed.

RESULTS

Sixty-one PDs completed the survey, for a response rate of 62% (61/98). For entering fellows, PDs assessed performance in professionalism positively, including 76% as communicating effectively with parents and 90% treating residents/house-staff with respect. In contrast, most PDs rated performance in psychomotor abilities negatively, including 59% and 79% as deficient in bag-and-mask ventilation and neonatal endotracheal intubation, respectively. Although 62% of PDs assessed entering fellows positively for genuine interest in academic projects, fewer than 10% responded positively that entering fellows understood research protocol design, basic statistics, or were capable of writing a cohesive manuscript well. Thematic clustering of qualitative data revealed deficits in psychomotor ability and academia/scholarship.

CONCLUSIONS

On the basis of the perspective of front line educators, graduating pediatric residents are underprepared for subspecialty fellowship training in NPM. To provide the best preparation for pediatric graduates who pursue advanced training, changes to residency education to address deficiencies in these important competencies are warranted.

The Development of Tracheal Intubation Proficiency Outside the Operating Suite During Pediatric Critical Care Medicine Fellowship Training: A Retrospective Cohort Study Using Cumulative Sum Analysis

OBJECTIVE

Tracheal intubation is a core technical skill for pediatric critical care medicine fellows. Limited data exist to describe current pediatric critical care medicine fellow tracheal intubation skill acquisition through the training. We hypothesized that both overall and first-attempt tracheal intubation success rates by pediatric critical care medicine fellows improve over the course of training.

DESIGN

Retrospective cohort study at a single large academic children's hospital.

MATERIALS AND METHODS

The National Emergency Airway Registry for Children database and local QI database were merged for all tracheal intubations outside the Operating Suite by pediatric critical care medicine fellows from July 2011 to January 2015. Primary outcomes were tracheal intubation overall success (regardless of number of attempts) and first attempt success. Patient-level covariates were adjusted in multivariate analysis. Learning curves for each fellow were constructed by cumulative sum analysis.

RESULTS

A total of 730 tracheal intubation courses performed by 33 fellows were included in the analysis. The unadjusted overall and first attempt success rates were 87% and 80% during the first 3 months of fellowship, respectively, and 95% and 73%, respectively, during the past 3 months of fellowship. Overall success, but not first attempt success, improved during fellowship training (odds ratio for each 3 months, 1.08; 95% CI, 1.01-1.17; p = 0.037) after adjusting for patient-level covariates. Large variance in fellow's tracheal intubation proficiency outside the operating suite was demonstrated with a median number of tracheal intubation equal to 26 (range, 19-54) to achieve a 90% overall success rate. All fellows who completed 3 years of training during the study period achieved an acceptable 90% overall tracheal intubation success rate.

CONCLUSIONS

Tracheal intubation overall success improved significantly during the course of fellowship; however, the tracheal intubation first attempt success rates did not. Large variance existed in individual tracheal intubation performance over time. Further investigations on a larger scale across different training programs are necessary to clarify intensity and duration of the training to achieve tracheal intubation procedural competency.

Neonatal Resuscitation Training: Implications of Course Construct and Discipline Compartmentalization on Role Confusion and Role Ambiguity

BACKGROUND

The Neonatal Resuscitation Program's (NRP's) Sixth Edition introduced simulation-based training (SBT) into neonatal life support training. SBT offers neonatal emergency response teams a safe, secure environment to rehearse coordinated neonatal resuscitations. Teamwork and communication training can reduce tension and anxiety during neonatal medical emergencies.

PURPOSE

To discuss the implications of variability in number and type of simulation scenario, number and type of learners who comprise a course, and their influence upon scope of practice, role confusion, and role ambiguity.

METHODS

Relevant articles from MEDLINE, CINAHL, EMBASE, Google Scholar, the World Health Organization, the American Heart Association, and NRP were included in this integrative review of the literature.

FINDINGS/RESULTS

Purposeful synergy of optimal SBT course construct with teamwork and communication can resist discipline compartmentalization, role confusion, and role ambiguity. Five key themes were identified and coined the "5 Rights" of NRP SBT. These "5 Rights" can guide healthcare institutions with planning, implementation, and evaluation of NRP SBT courses.

IMPLICATIONS FOR PRACTICE

NRP SBT can facilitate optimal team function and reduce errors when teams of learners and varied scenarios are woven into the course construct. The simulated environment must be realistic and fully equipped to encourage knowledge transfer and attainment of the NRP's key behavioral outcomes.

IMPLICATIONS FOR RESEARCH

Investigation of teamwork and communication training with NRP SBT, course construct, discipline compartmentalization, and behavioral and clinical outcomes is indicated. Investigation of outcomes of SBT using a team-teaching model, combining basic and advanced practice NRP instructors, is indicated.