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Grace MA, O'Malley R. Using In Situ Simulation to Identify Latent Safety Threats in Emergency Medicine: A Systematic Review. Simul Healthc 2024; 19:243-253. [PMID: 37725494 DOI: 10.1097/sih.0000000000000748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
SUMMARY STATEMENT This review aimed to explore existing literature on the use of in situ simulation to identify latent safety threats in emergency medicine. Studies were required to take place in a clinically active emergency department and have either a primary or secondary aim of identifying latent safety threats. A total of 2921 articles were retrieved through database searches and a total of 15 were deemed to meet the inclusion criteria.Latent safety threats were detected by a variety of methods including documentation during debrief/discussion (66%), during the simulation itself (33%), participant surveys (20%), and video analysis (20%). Using a multimodality approach with input from observers and participants from different professional backgrounds yielded the highest number of threats per simulation case (43 per case). Equipment was the most commonly reported threat (83%), followed by teamwork/communication (67%). Some studies did not report on mitigation of identified risks; formal processes should be implemented for the management of latent safety threats identified by in situ simulation. Future research should focus on translational outcomes to further strengthen the position of in situ simulation in emergency medicine.
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Affiliation(s)
- Margaret A Grace
- From the Mater Misericordiae University Hospital, Dublin (M.G.); and National University of Ireland, Galway, Ireland (R.O.M.)
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2
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Tachejian S, Moussa A. 360-degree virtual reality video to teach neonatal resuscitation: an exploratory development study. Sci Rep 2024; 14:14383. [PMID: 38909130 PMCID: PMC11193781 DOI: 10.1038/s41598-024-65299-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 06/19/2024] [Indexed: 06/24/2024] Open
Abstract
Simulation is an effective training method for neonatal resuscitation (NR). However, the limitations brought about by the COVID-19 pandemic, and other resource constraints, have necessitated exploring alternatives. Virtual reality (VR), particularly 360-degree VR videos, have gained attraction in medical training due to their immersive qualities. The primary objectives of the study were to produce a high quality 360-degree virtual reality (VR) video capturing NR simulation and to determine if it could be an acceptable adjunct to teach NR. The secondary objective was to determine which aspects of NR could benefit from the incorporation of such a video in training. This was an exploratory development study. The first part consisted of producing the video using a GoPro action camera, Adobe Premiere Pro, and Unity Editor. In the second part participants were recruited, based on level of experience, to watch the video and answer questionnaires to determine acceptability (user experience and cognitive load) and aspects of NR which could benefit from the video. The video was successfully developed. Forty-six participants showed a strong general appreciation. User experience revealed high means (> 6) in the positive subscales and low means (< 4) for immersion side effect, with no difference between groups. Cognitive load was higher than anticipated. Participants indicated that this video could be effective for teaching crisis resource management principles, human and environment interactions, and procedural skills. The 360-degree VR video could be a potential new simulation adjunct for NR. Future studies are needed to evaluate learning outcomes of such videos.
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Affiliation(s)
- Sevag Tachejian
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ahmed Moussa
- Division of Neonatology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada.
- CHU Sainte-Justine Research Center, Montreal, QC, Canada.
- Centre for Applied Health Sciences Education (CPASS), Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.
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3
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Soghier L. Improving Neonatal Patient Outcomes Using Simulation-based Education. J Pediatr 2024; 266:113875. [PMID: 38096976 DOI: 10.1016/j.jpeds.2023.113875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 12/31/2023]
Affiliation(s)
- Lamia Soghier
- Children's National Hospital, Washington, District of Columbia.
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Lim CY, Song MR. Sustained Effect of Simulation-Based Resuscitation Education on Knowledge, Self-Confidence, and Performance Ability of Neonatal Intensive Care Unit Nurses. J Contin Educ Nurs 2024; 55:79-86. [PMID: 37971225 DOI: 10.3928/00220124-20231109-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Simulation education is essential for the development of nurses' practical skills. This study evaluated the impact and duration of simulation-based neonatal resuscitation education on the knowledge, self-confidence, and performance ability of neonatal intensive care unit (NICU) nurses. METHOD This quasi-experimental study was conducted in South Korea and included 35 NICU nurses working in tertiary hospitals between August and October 2021. Simulation-based neonatal resuscitation education (NRE) was provided for 80 minutes, and its effectiveness was measured in terms of nurses' knowledge, self-confidence, and performance ability. Data collection was conducted before, 1 week after, 3 weeks after, and 5 weeks after the training, and the collected data were calculated and analyzed using a t test and repeated measures analysis of variance. RESULTS Simulation-based NRE improved knowledge, self-confidence, and performance in neonatal resuscitation. Performance ability showed greater improvement than knowledge or self-confidence, and all three areas showed significant differences in score changes over time. CONCLUSION The duration of the training effect should be considered an important factor. [J Contin Educ Nurs. 2024;55(2):79-86.].
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Sawyer T, Gray MM. Competency-based assessment in neonatal simulation-based training. Semin Perinatol 2023; 47:151823. [PMID: 37748942 DOI: 10.1016/j.semperi.2023.151823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Simulation is a cornerstone of training in neonatal clinical care, allowing learners to practice skills in a safe and controlled environment. Competency-based assessment provides a systematic approach to evaluating technical and behavioral skills observed in the simulation environment to ensure the learner is prepared to safely perform the skill in a clinical setting. Accurate assessment of competency requires the creation of tools with evidence of validity and reliability. There has been considerable work on the use of competency-based assessment in the field of neonatology. In this chapter, we review neonatal simulation-based training, examine competency-based assessment tools, explore methods to gather evidence of the validity and reliability, and review an evidence-based approach to competency-based assessment using simulation.
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Affiliation(s)
- Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, United States; Neonatal Education and Simulation-based Training (NEST) Program, Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, United States.
| | - Megan M Gray
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, United States; Neonatal Education and Simulation-based Training (NEST) Program, Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, United States
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Schram A, Jensen HI, Gamborg M, Lindhard M, Rölfing J, Kjaergaard-Andersen G, Bie M, Jensen RD. Exploring the relationship between simulation-based team training and sick leave among healthcare professionals: a cohort study across multiple hospital sites. BMJ Open 2023; 13:e076163. [PMID: 37899150 PMCID: PMC10618977 DOI: 10.1136/bmjopen-2023-076163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/11/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVE Burnout and mental illness are frequent among healthcare professionals, leading to increased sick leave. Simulation-based team training has been shown to improve job satisfaction and mental health among healthcare professionals. This study seeks to investigate the relationship between simulation-based team training and sick leave. DESIGN Cohort study. SETTING AND INTERVENTION Five Danish hospitals. PARTICIPANTS A total of 15 751 individuals were screened for eligibility. To meet the eligibility criteria, individuals had to be employed in the same group (intervention or control) for the whole study period. A total of 14 872 individuals were eligible for analysis in the study. INTERVENTION From 2017 to 2019, a simulation-based team training intervention was implemented at two hospital sites. Three hospital sites served as the control group. OUTCOME MEASURES Data on sick leave from 2015 to 2020 covered five hospital sites. Using a difference-in-difference analysis, the rate of sick leave was compared across hospital sites (intervention vs control) and time periods (before vs after intervention). RESULTS Significant alterations in sick leave were evident when comparing the intervention and control groups. When comparing groups over time, the increase in sick leave was -0.3% (95% CI -0.6% to -0.0%) lower in the intervention group than in the control group. The difference-in-difference for the complete case analysis showed that this trend remained consistent, with analysis indicating a comparable lower increase in sick leave by -0.7% (95% CI -1.3% to -0.1%) in the intervention group. CONCLUSION The increase in sick leave rate was statistically significantly lower in the intervention group, implying that simulation-based team training could serve as a protective factor against sick leave. However, when investigating this simulation intervention over 5 years, other potential factors may have influenced sick leave, so caution is required when interpreting the results.
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Affiliation(s)
| | - Hanne Irene Jensen
- Department of Anaesthesiology and Intensive Care, Lillebaelt Hospital-University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Maria Gamborg
- MidtSim, Central Denmark Region, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | - Morten Lindhard
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
- Department of Paediatrics, Randers Regional Hospital, Randers, Denmark
| | - Jan Rölfing
- MidtSim, Central Denmark Region, Aarhus N, Denmark
- Department of Orthopaedics, Aarhus Universitet, Aarhus, Denmark
| | - Gunhild Kjaergaard-Andersen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anaesthesiology and Intensive Care, Lillebaelt Hospital-University Hospital of Southern Denmark, Vejle, Denmark
| | - Magnus Bie
- MidtSim, Central Denmark Region, Aarhus N, Denmark
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Farhadi R, Azandehi BK, Amuei F, Ahmadi M, Zazoly AZ, Ghorbani AA. Enhancing residents' neonatal resuscitation competency through team-based simulation training: an intervention educational study. BMC MEDICAL EDUCATION 2023; 23:743. [PMID: 37817195 PMCID: PMC10563222 DOI: 10.1186/s12909-023-04704-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 09/20/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Neonatal resuscitation training in a simulated delivery room environment is a new paradigm in pediatric medical education. The purpose of this research is to highlight team-based simulation as an effective method of teaching neonatal resuscitation to senior pediatric residents. METHODS In an intervention educational study, we evaluated the impact of team-based simulation training in the development of neonatal resuscitation. A team consisting of a three-person group of senior pediatric residents performed neonatal resuscitation on a low-fidelity newborn simulator based on the stated scenario. Video-based structured debriefing was performed and followed by the second cycle of scenario and debriefing to evaluate the feasibility of conducting team-based simulation training in a lesser-resourced environment. Evaluation criteria included megacode scores which is a simulation performance checklist, pre-and post-test scores to evaluate residents' knowledge and confidence, the survey checklist as a previously developed questionnaire assessing residents' satisfaction, and debriefing from live and videotaped performances. Four months after the end of the training course, we measured the behavioral changes of the residents by conducting an OSCE test to evaluate post-training knowledge retention. Mean ± SD was calculated for megacode, satisfaction (survey checklist), and OSCE scores. Pre- and post-program gains were statistically compared. The first three levels of Kirkpatrick's training effectiveness model were used to evaluate the progress of the program. RESULTS Twenty-one senior residents participated in the team-based simulation. The mean ± SD of the megacode score was 35.6 ± 2.2. The mean ± SD of the overall satisfaction score for the evaluation of the first level of the Kirkpatrick model was 96.3 ± 3.7. For the evaluation of the second level of the Kirkpatrick model, the pre-posttest gain in overall confidence score had a statistically significant difference (P = 0.001). All residents obtained a passing grade in OSCE as an evaluation of the third level. CONCLUSIONS Team-based simulation training in neonatal resuscitation improves the knowledge, skills, and performance of pediatric residents and has a positive effect on their self-confidence and leadership skills. There is still a need to investigate the transfer of learning and abilities to real-life practice, and further research on cost-effectiveness and impact on patient outcomes is warranted.
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Affiliation(s)
- Roya Farhadi
- Associate Professor, Pediatric Infectious Diseases Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Bita Khalili Azandehi
- Ph.D. of Medical Education, Social Security Organization, Education & Research Unit, Valiasr Regional Hospital, Sari Azad university, Ghaemshahr, Iran
| | - Fattane Amuei
- Assistant Proffessor, Center for Studies and Development of Medical Sciences Education, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mozhgan Ahmadi
- Head Nurse of Neonatology ward, Boo-Ali Sina educational and therapeutic center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Atefeh Zabihi Zazoly
- Assistant Professor, Operating Room Department, School of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Asghar Ghorbani
- Assistant professor, School of Aliied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran.
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Quinn J, Quinn M, Lieu B, Bohnert J, Halamek LP, Profit J, Fuerch JH, Chitkara R, Yamada NK, Gould J, Lee HC. Neonatal Healthcare Professionals' Experiences When Implementing a Simulation and Debriefing Program in Neonatal Intensive Care Settings: A Qualitative Analysis. Adv Neonatal Care 2023; 23:425-434. [PMID: 37399571 PMCID: PMC10524557 DOI: 10.1097/anc.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment. PURPOSE This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU). METHODS Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes. RESULTS There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support. IMPLICATIONS FOR PRACTICE AND RESEARCH NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.
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Affiliation(s)
- Jenny Quinn
- California Perinatal Quality Care Collaborative (CPQCC), Stanford (Drs Jenny Quinn, Profit, Gould, and Lee, Mr Lieu, and Ms Bohnert); NorthBay Medical Center, Fairfield, California (Dr Jenny Quinn); Oregon Health & Science University, School of Nursing, Portland (Dr Megan Quinn); Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California (Drs Halamek, Profit, Fuerch, Chitkara, Yamada, and Gould); Center for Advanced Pediatric & Perinatal Education (CAPE), Palo Alto, California (Drs Halamek, Fuerch, Chitkara, and Yamada); and Division of Neonatology, Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California (Dr Lee)
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9
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Neonatal Resuscitation: A Critical Incident Technique Study Exploring Pediatric Registered Nurses' Experiences and Actions. Adv Neonatal Care 2023; 23:220-228. [PMID: 36905225 DOI: 10.1097/anc.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Teamwork during neonatal resuscitation is essential. Situations arise quickly and unexpectedly and are highly stressful, requiring pediatric registered nurses (pRN) to respond effectively and in a structured manner. In Sweden, pRNs work in all pediatric settings including the neonatal intensive care unit. The experience and actions of pRNs are seldom explored, and studies within this area could develop and improve strategies for neonatal resuscitation situations. PURPOSE To describe pRNs' experiences and actions during neonatal resuscitation. METHODS A qualitative interview study based on the critical incident technique was performed. Sixteen pRNs from 4 neonatal intensive care units in Sweden were interviewed. RESULTS Critical situations were divided into 306 experiences and 271 actions. pRNs' experiences were divided into 2 categories: individual- and team-focused experiences. Critical situations were managed by individual- or team-focused actions.
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Vadla MS, Moshiro R, Mdoe P, Eilevstjønn J, Kvaløy JT, Hhoki BH, Ersdal H. Newborn resuscitation simulation training and changes in clinical performance and perinatal outcomes: a clinical observational study of 10,481 births. ADVANCES IN SIMULATION (LONDON, ENGLAND) 2022; 7:38. [PMID: 36335400 PMCID: PMC9636744 DOI: 10.1186/s41077-022-00234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/23/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Annually, 1.5 million intrapartum-related deaths occur; fresh stillbirths and early newborn deaths. Most of these deaths are preventable with skilled ventilation starting within the first minute of life. Helping Babies Breathe is an educational program shown to improve simulated skills in newborn resuscitation. However, translation into clinical practice remains a challenge. The aim was to describe changes in clinical resuscitation and perinatal outcomes (i.e., fresh stillbirths and 24-h newborn deaths) after introducing a novel simulator (phase 1) and then local champions (phase 2) to facilitate ongoing Helping Babies Breathe skill and scenario simulation training. METHODS This is a 3-year prospective before/after (2 phases) clinical observational study in Tanzania. Research assistants observed all deliveries from September 2015 through August 2018 and recorded labor/newborn information and perinatal outcomes. A novel simulator with automatic feedback to stimulate self-guided skill training was introduced in September 2016. Local champions were introduced in October 2017 to motivate midwives for weekly training, also team simulations. RESULTS The study included 10,481 births. Midwives had practiced self-guided skill training during the last week prior to a real newborn resuscitation in 34% of cases during baseline, 30% in phase 1, and 71% in phase 2. Most real resuscitations were provided by midwives, increasing from 66% in the baseline, to 77% in phase 1, and further to 83% in phase 2. The median time from birth to first ventilation decreased between baseline and phase 2 from 118 (85-165) to 101 (72-150) s, and time pauses during ventilation decreased from 28 to 16%. Ventilations initiated within the first minute did not change significantly (13-16%). The proportion of high-risk deliveries increased during the study period, while perinatal mortality remained unchanged. CONCLUSIONS This study reports a gradual improvement in real newborn resuscitation skills after introducing a novel simulator and then local champions. The frequency of trainings increased first after the introduction of motivating champions. Time from birth to first ventilation decreased; still, merely 16% of newborns received ventilation within the first minute as recommended. This is a remaining challenge that may require more targeted team-scenario training and quality improvement efforts to improve.
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Affiliation(s)
- May Sissel Vadla
- Faculty of Health Sciences, University of Stavanger, 4021, Stavanger, Norway.
| | - Robert Moshiro
- Muhimbili National Hospital, P.O Box 65000, Dar es Salaam, Tanzania
| | - Paschal Mdoe
- Haydom Lutheran Hospital, Box 9000, Haydom, Mbulu, Tanzania
| | | | - Jan Terje Kvaløy
- Department of Mathematics and Physics, University of Stavanger, 4036, Stavanger, Norway.,Department of Research, Stavanger University Hospital, 4011, Stavanger, Norway
| | | | - Hege Ersdal
- Faculty of Health Sciences, University of Stavanger, 4021, Stavanger, Norway.,Department of Anaesthesia, Stavanger University Hospital, 4011, Stavanger, Norway
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Doak A, Waskosky A. Golden Hour Education, Standardization, and Team Dynamics: A Literature Review. Neonatal Netw 2022; 41:281-288. [PMID: 36002277 DOI: 10.1891/nn-2021-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/25/2022]
Abstract
The "golden hour" is the critically important first 60 minutes in an extremely low birth weight neonate's life that can impact both short- and long-term outcomes. The golden hour concept involves several competing stabilization priorities that should be conducted systematically by highly specialized health care providers in both the hospital and transport settings for improvement in patient outcomes. Current literature supports utilizing an experienced team in the golden hour process to improve patient outcomes through standardization, improved efficiency, and positive team dynamics. Although a variety of teaching methods exist to train individuals in the care of extremely low birth weight infants, the literature supports the incorporation of low- or high-fidelity simulation-based training. In addition, initial and ongoing educational requirements of individuals caring for a golden hour-eligible infant in the immediate post-delivery phase, as well as ongoing care in the days and weeks to follow, are justified. Instituting standard golden hour educational requirements on an ongoing basis provides improved efficiency in team function and patient outcomes. The goal of this literature review was to determine whether implementation of golden hour response teams in both the inpatient and transport setting has shown improved outcomes and should be considered for neonatal intensive care units admitting or transporting golden hour eligible infants.
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Fawke J, Cusack J. Does death and disability matter? Resuscitation 2022; 178:38-39. [PMID: 35863665 DOI: 10.1016/j.resuscitation.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Joe Fawke
- University Hospitals Leicester NHS Trust, UK.
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Chang TP, Elkin R, Boyle TP, Nishisaki A, Walsh B, Benary D, Auerbach M, Camacho C, Calhoun A, Stapleton SN, Whitfill T, Wood T, Fayyaz J, Gross IT, Thomas AA. Characterizing preferred terms for geographically distant simulations: distance, remote and telesimulation. Simul Healthc 2022. [DOI: 10.54531/drkq7209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Simulationists lack standard terms to describe new practices accommodating pandemic restrictions. A standard language around these new simulation practices allows ease of communication among simulationists in various settings.
We explored consensus terminology for simulation accommodating geographic separation of participants, facilitators or equipment. We used an iterative process with participants of two simulation conferences, with small groups and survey ranking.
Small groups (n = 121) and survey ranking (n = 54) were used with
This research has deepened our understanding of how simulationists interpret this terminology, including the derived themes: (1) physical distance/separation, (2) overarching nature of the term and (3) implications from existing terms. We further deepen the conceptual discussion on healthcare simulation aligned with the search of the terminologies. We propose there are nuances that prevent an early consensus recommendation. A taxonomy of descriptors specifying the conduct of
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Affiliation(s)
- Todd P Chang
- 1Division of Emergency Medicine & Transport, Children’s Hospital Los Angeles/Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rachel Elkin
- 2Division of Pediatric Emergency Medicine, New York-Presbyterian Morgan Stanley Children’s Hospital-Columbia University Irving Medical Center/Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Tehnaz P Boyle
- 3Division of Pediatric Emergency Medicine, Boston Medical Center/Boston University School of Medicine, Boston University, Boston, MA, USA
| | - Akira Nishisaki
- 4Division of Pediatric Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara Walsh
- 5Division of Emergency Medicine, Boston Children’s Hospital, Harvard University, Boston, MA, USA
| | - Doreen Benary
- 6Division of Pediatric Emergency Medicine, NYU Langone Medical Center, New York University, New York, NY, USA
| | - Marc Auerbach
- 7Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Cheryl Camacho
- 8Simulation and Outreach Education, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Aaron Calhoun
- 9Division of Critical Care, Norton Children’s Hospital, University of Louisville, Louisville, KY, USA
| | - Stephanie N Stapleton
- 10Department of Emergency Medicine, Boston Medical Center/Boston University School of Medicine, Boston, MA, USA
| | - Travis Whitfill
- 7Departments of Pediatrics and Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Trish Wood
- 11Starship Child Health, Auckland, New Zealand
| | - Jabeen Fayyaz
- 12Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Isabel T Gross
- 13Division of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Anita A Thomas
- 14Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA, USA
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14
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Schwindt EM, Stockenhuber R, Kainz T, Stumptner N, Henkel M, Hefler L, Schwindt JC. Neonatal simulation training decreases the incidence of chest compressions in term newborns. Resuscitation 2022; 178:109-115. [PMID: 35700883 DOI: 10.1016/j.resuscitation.2022.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/25/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022]
Abstract
AIM OF THE STUDY To determine the effectiveness of a multidimensional neonatal simulation-based medical education training programme on direct and indirect patient outcome parameters. METHODS This was a retrospective analytical study with a historical control group in a level II neonatal care unit (1,700 births per year). A multidimensional interdisciplinary training programme on neonatal resuscitation was implemented in 2015; pre-training (2012-2014) and post-training (2015-2019) eras were compared in terms of mortality (direct outcome) and the received intervention level immediately after birth (indirect outcome). Intervention levels were defined as follows: A) short-term non-invasive ventilation, B) prolonged non-invasive ventilation (>5 inflation breaths), C) chest compressions. RESULTS Of 13,950 neonates born during the study period, 826 full-term newborns received one of the three intervention levels for adaptation after birth. A total of 284 (34.4%) patients received short-term non-invasive ventilation (A), 477 (57.8%) had prolonged ventilation (B), and 65 (7.9%) chest compressions (C), respectively. Comparing the pre- and post-training eras, there was no significant reduction in mortality, and no significant changes were found in groups A or B. However, the risk for chest compressions (group C) decreased significantly from 0.91% in the pre-training era to 0.20% in the post-training era (p < 0.001). CONCLUSION Although there was no significant effect on neonatal mortality, regular interdisciplinary simulation training decreased the number of administered chest compressions immediately after birth. Further studies are needed to test indirect outcome-related parameters, such as frequency of chest compressions as a measure of effectiveness and impact of medical training.
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Affiliation(s)
- Eva M Schwindt
- Medical University Vienna, Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Waehringerguertel 18-20, 1090 Vienna, Austria; STAR - SIMCharacters Training and Research, Lehargasse 1, 1090 Vienna, Austria; Neonatal Working Group, Austrian Resuscitation Council, Villefortgasse 22, 8010 Graz, Austria
| | | | - Theresa Kainz
- Medical University Vienna, Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Waehringerguertel 18-20, 1090 Vienna, Austria
| | - Nicola Stumptner
- Department of Paediatrics and Adolescent Medicine, Hospital Barmherzige Schwestern Linz, Seilerstaette 4, 4010 Linz, Austria
| | - Martin Henkel
- Department of Paediatrics and Adolescent Medicine, Hospital Barmherzige Schwestern Linz, Seilerstaette 4, 4010 Linz, Austria
| | - Lukas Hefler
- Department of Obstetrics and Gynecology, Konventhospital Barmherzige Brueder and Ordensklinikum Linz, Seilerstaette 2-4, 4010 Linz, Austria
| | - Jens C Schwindt
- STAR - SIMCharacters Training and Research, Lehargasse 1, 1090 Vienna, Austria; Neonatal Working Group, Austrian Resuscitation Council, Villefortgasse 22, 8010 Graz, Austria
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15
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Thim S, Henriksen TB, Laursen H, Schram AL, Paltved C, Lindhard MS. Simulation-Based Emergency Team Training in Pediatrics: A Systematic Review. Pediatrics 2022; 149:185292. [PMID: 35237809 DOI: 10.1542/peds.2021-054305] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The rare event of handling critically ill children often challenge the emergency care team. Several studies have investigated effects of simulation-based team training to prepare for such events, but the body of evidence remains to be compiled. We performed a systematic review of the effects of simulation-based team training on clinical performance and patient outcome. METHODS From a search of MEDLINE, Embase, CINAHL, and Cochrane Library, we included studies of team training in emergency pediatric settings with reported clinical performance and patient outcomes. We extracted data using a predefined template and assessed risk of bias using the Cochrane risk-of-bias tool for randomized trials 2.0 and the Newcastle Ottawa Quality Assessment Scale. RESULTS We screened 1926 abstracts and included 79 studies. We identified 15 studies reporting clinical health care professional performance or patient outcomes. Four studies reported survival data, 5 reported time-critical clinical events, 5 reported adherence to guidelines, checklists or tasks, and 2 reported on airway management. Randomized studies revealed improved team performance in simulated reevaluations 2 to 6 months after intervention. A meta-analysis was impossible because of heterogeneous interventions and outcomes. Most included studies had significant methodological limitations. CONCLUSIONS Pediatric simulation-based team training improves clinical performance in time-critical tasks and adherence to guidelines. Improved survival was indicated but not concluded because of high risk of bias. Team performance and technical skills improved for at least 2 to 6 months. Future research should include longer-term measures of skill retention and patient outcomes or clinical measures of treatment quality whenever possible.
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Affiliation(s)
- Signe Thim
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tine Brink Henriksen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Laursen
- Medical Library, Regional Hospital Central Jutland, Viborg, Denmark
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16
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Bayoumi MAA, Elmalik EE, Ali H, D'Souza S, Furigay J, Romo A, Shyam S, Singh R, Koobar O, Al Shouli J, van Rens M, Abounahia FF, Gad A, Elbaba M, Lutfi S. Neonatal Simulation Program: A 5 Years Educational Journey From Qatar. Front Pediatr 2022; 10:843147. [PMID: 35386259 PMCID: PMC8977624 DOI: 10.3389/fped.2022.843147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammad A A Bayoumi
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Einas E Elmalik
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hossamaldein Ali
- Pediatric Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Sunitha D'Souza
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Jojo Furigay
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ava Romo
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Sunitha Shyam
- Medical Research Center, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Rajvir Singh
- Medical Research Center, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Olfa Koobar
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Jihad Al Shouli
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Matheus van Rens
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Fouad F Abounahia
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ashraf Gad
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Mostafa Elbaba
- Pediatric Department, Hamad General Hospital (HGH), Hamad Medical Corporation (HMC), Doha, Qatar
| | - Samawal Lutfi
- Neonatal Intensive Care Unit (NICU), Women's Wellness and Research Center (WWRC), Hamad Medical Corporation (HMC), Doha, Qatar
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17
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Brogaard L, Hvidman L, Esberg G, Finer N, Hjorth-Hansen KR, Manser T, Kierkegaard O, Uldbjerg N, Henriksen TB. Teamwork and Adherence to Guideline on Newborn Resuscitation-Video Review of Neonatal Interdisciplinary Teams. Front Pediatr 2022; 10:828297. [PMID: 35265565 PMCID: PMC8900704 DOI: 10.3389/fped.2022.828297] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/12/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Little is known about the importance of non-technical skills for the adherence to guidelines, when teams of midwives, obstetricians, anesthesiologists, and pediatricians resuscitate and support the transition of newborns. Non-technical skills are competences underpinning successful teamwork in healthcare. These are usually referred to as leadership, situational awareness, communication, teamwork, decision making, and coping with stress and fatigue. OBJECTIVE By review of videos of teams managing newborns with difficult transition, we aimed to investigate whether the level of the teams' non-technical skills was associated with the degree of adherence to guidelines for newborn resuscitation and transitional support at birth. METHODS Four expert raters independently assessed 43 real-life videos of teams managing newborns with transitional difficulties, two assessed the non-technical score and two assessed the clinical performance. Exposure was the non-technical score, obtained by the Global Assessment Of Team Performance checklist (GAOTP). GAOTP was rated on a Likert Scale 1-5 (1 = poor, 3 = average and 5 = excellent). The outcome was the clinical performance score of the team assessed according to adherence of the European Resuscitation Counsel (ERC) guideline for neonatal resuscitation and transitional support. The ERC guideline was adapted into the checklist TeamOBS-Newborn to facilitate a structured and simple performance assessment (low score 0-60, average 60-84, high 85-100). Interrater agreement was analyzed by intraclass correlation (ICC), Bland-Altman analysis, and Cohen's kappa weighted. The risk of high and low clinical performance was analyzed on the logit scale to meet the assumptions of normality and constant standard deviation. RESULTS Teams with an excellent non-technical score had a relative risk 5.5 [95% confidence interval (CI) 2.4-22.5] of high clinical performance score compared to teams with average non-technical score. In addition, we found a dose response like association. The specific non-technical skills associated with the highest degree of adherence to guidelines were leadership and teamwork, coping with stress and fatigue, and communication with parents. Inter-rater agreement was high; raters assessing non-technical skills had an interclass coefficient (ICC) 0.88 (95% CI 0.79-0.94); the neonatologists assessing clinical performance had an ICC of 0.81 (95% CI 0.66-0.89). CONCLUSION Teams with an excellent non-technical score had five times the chance of high clinical performance compared to teams with average non-technical skills. High performance teams were characterized by good leadership and teamwork, coping with stress, and fatigue and communication with parents.
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Affiliation(s)
- Lise Brogaard
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Hvidman
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Gitte Esberg
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Neil Finer
- Department of Neonatology, University of California, San Diego, San Diego, CA, United States
| | | | - Tanja Manser
- School of Applied Psychology, University of Applied Sciences and Arts Northwestern Switzerland, Olten, Switzerland
| | - Ole Kierkegaard
- Department of Obstetrics and Gynecology, Horsens Regional Hospital, Horsens, Denmark
| | - Niels Uldbjerg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tine B Henriksen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
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18
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Yousef N, Moreau R, Soghier L. Simulation in neonatal care: towards a change in traditional training? Eur J Pediatr 2022; 181:1429-1436. [PMID: 35020049 PMCID: PMC8753020 DOI: 10.1007/s00431-022-04373-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 12/28/2022]
Abstract
UNLABELLED Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement. CONCLUSION Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority. WHAT IS KNOWN • Simulation-based education has traditionally focused on procedural and technical skills. • Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation. WHAT IS NEW • There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. • Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.
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Affiliation(s)
- Nadya Yousef
- Division of Pediatrics and Neonatal Critical Care, Dept of Perinatal Medicine, "A.Béclère" Medical Center, Paris Saclay University Hospitals, APHP, Paris, France.
| | - Romain Moreau
- Division of Pediatrics and Neonatal Critical Care, Dept of Perinatal Medicine, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
| | - Lamia Soghier
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC USA ,Department of Neonatology, Children’s National, Washington, DC USA
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19
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Bettinger K, Mafuta E, Mackay A, Bose C, Myklebust H, Haug I, Ishoso D, Patterson J. Improving Newborn Resuscitation by Making Every Birth a Learning Event. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121194. [PMID: 34943390 PMCID: PMC8700033 DOI: 10.3390/children8121194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 06/14/2023]
Abstract
One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.
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Affiliation(s)
- Kourtney Bettinger
- Department of Pediatrics, University of Kansas School of Medicine, 3901 Rainbow Blvd, MS 4004, Kansas City, KS 66103, USA
| | - Eric Mafuta
- School of Public Health, University of Kinshasa, Kinshasa 11850, Democratic Republic of the Congo; (E.M.); (D.I.)
| | - Amy Mackay
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
| | - Carl Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
| | - Helge Myklebust
- Laerdal Medical Strategic Research Department, Tanke Svilandsgate 30, N-4002 Stavanger, Norway; (H.M.); (I.H.)
| | - Ingunn Haug
- Laerdal Medical Strategic Research Department, Tanke Svilandsgate 30, N-4002 Stavanger, Norway; (H.M.); (I.H.)
| | - Daniel Ishoso
- School of Public Health, University of Kinshasa, Kinshasa 11850, Democratic Republic of the Congo; (E.M.); (D.I.)
| | - Jackie Patterson
- Department of Pediatrics, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7596, Chapel Hill, NC 27599-7596, USA; (A.M.); (C.B.); (J.P.)
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