Positive pressure ventilation coaching during neonatal bag-mask ventilation: A simulation-based pilot study

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.

Format Changes Improve Learner Satisfaction in Local Neonatal Resuscitation Program Skills Education

BACKGROUND

The Neonatal Resuscitation Program (NRP) is a national education program that prepares learners to resuscitate newborn babies. Our local Texas Children's Hospital (TCH) NRP educational class incorporates skills training and high-fidelity simulations of neonatal resuscitation scenarios. The skills training had four elements we believed were not ideal. 1. Learners went to skills stations in groups, but different teams were formed for performing the scenario simulations in the latter half of the class. 2. The skills stations were visited in random order and not necessarily the actual order in the skills would be performed in a clinical situation. 3. Educational content presented at the skills station was highly variable depending on the instructor. 4. Emphasis was on instructors teaching content over learners practicing and demonstrating skills. In March 2019 we restructured the skills education portion completely to address all four of these problems.

OBJECTIVES

To determine how changes to the design of our skills education affected learner satisfaction with the NRP course.

METHODS

Using the principles of situated cognition, the skills education was restructured by leadership planning and consensus. We made four changes. 1. Teams were assigned from the beginning of class, and these teams practiced all skills and performed the simulations together. 2. Every team went through the skills stations in the order they would perform them in an actual resuscitation. 3. Videos were made to teach the "gold standard" information needed for the skills stations. 4. Instructors were asked to think of themselves as coaches and not teachers, letting the videos do the education, and they focused on improving skill performance. A survey was designed and disseminated by e-mail to all learners of the first 13 classes taught using the new educational format (n=196). The survey asked learners to compare their experience of the new format compared to their memory of the previous format.

RESULTS

A total of 163 learners responded and completely finished the survey (83% response rate). Of the 163 respondents, 109 learners (67%) had taken the course in the past at TCH and filled out the survey questions comparing the new format to the past format. Out of the total, 93% of learners (n=101) judged the new format to be "better" or "much better." The percentage of learners that attributed the improvement to the changes we made were: 70% for team assignments from the beginning (n=76), 74% for skills performed in order (n=81), 68% for video-based education (n=74), and 76% for instructors as coaches (n=83). Learners rated the videos used for education very highly.

CONCLUSIONS

The reformat of our skills education has improved our learners' experience during NRP training. The highest-rated change was asking our instructors to operate as coaches rather than teachers.

Provider Visual Attention Correlates With the Quality of Pediatric Resuscitation: An Observational Eye-Tracking Study

Background

Eye-tracking devices are an innovative tool to understand providers' attention during stressful medical tasks. The knowledge about what gaze behaviors improve (or harm) the quality of clinical care can substantially improve medical training. The aim of this study is to identify gaze behaviors that are related to the quality of pediatric resuscitation.

Methods

Forty students and healthcare providers performed a simulated pediatric life support scenario, consisting of a chest compression task and a ventilation task, while wearing eye-tracking glasses. Skill Reporter software measured chest compression (CC) quality and Neo Training software measured ventilation quality. Main eye-tracking parameters were ratio [the number of participants who attended a certain area of interest (AOI)], dwell time (total amount of time a participant attended an AOI), the number of revisits (how often a participant returned his gaze to an AOI), and the number of transitions between AOIs.

Results

The most salient AOIs were infant chest and ventilation mask (ratio = 100%). During CC task, 41% of participants also focused on ventilation bag and 59% on study nurse. During ventilation task, the ratio was 61% for ventilation bag and 36% for study nurse. Percentage of correct CC rate was positively correlated with dwell time on infant chest (p = 0.044), while the overall CC quality was negatively correlated with dwelling outside of pre-defined task-relevant AOIs (p = 0.018). Furthermore, more dwell time on infant chest predicted lower leakage (p = 0.042). The number of transitions between AOIs was unrelated to CC parameters, but correlated negatively with mask leak during ventilations (p = 0.014). Participants with high leakage shifted their gaze more often between ventilation bag, ventilation mask, and task-irrelevant environment.

Conclusion

Infant chest and ventilation mask are the most salient AOIs in pediatric basic life support. Especially the infant chest AOI gives beneficial information for the resuscitation provider. In contrast, attention to task-irrelevant environment and frequent gaze shifts seem to harm the quality of care.

Simulation in Neonatal Resuscitation

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