Search

Introduction: Primary peritoneal drainage (PPD) is described as a temporizing procedure to treat perforated necrotizing enterocolifts (NEC) in unstable premature infants prior to laparotomy. Some infants treated with PPD survive without further intervention. Laparotomy is recommended for patients who do not significantly improve following PPD. Methods: To determine the efficacy of "salvage" laparotomy we reviewed our experience with perforated NEC in ELBW infants treated from 1993 to 98. We analyzed data using Mann-Whitney U and [chi square] tests where appropriate; significance defined as p [is less than] .05. Results: We treated 26 infants with perforated NEC and birthweight [is less than] 1000 grams. PPD was used in 17 patients, and primary laparotomy (LAP) in 9. Patients undergoing PPD had a lower birthweight, 677 [+ or -] 143g versus 807 [+ or -] 113g for LAP (p=.02) and more co-morbid conditions 2.7 versus 1.7 (p=.002). Survival was similar between these groups 7/17 versus 5/9 (p=.68). Of the 17 patients treated with PPD, 7 survived without further intervention with intact gastrointestinal (GI) function. Five of these had persistent signs of sepsis for 5-15 days following drainage but responded to continued antibiotic therapy. The remaining 10 patients deteriorated. Six died without further intervention; four within 48 hours of fulminant sepsis and two died of other causes (intracranial bleeding and pulmonary failure) with an intact GI tract. The remaining four patients were believed to be salvageable and underwent "salvage laparotomy" 5-19 days following PPD. Indications included abdominal distention, requirement for vasoactive drugs, and failure of GI function. All four of these patients died. None of them were ever weaned from mechanical ventilation or tolerated any enteral feedings. These four non-surviving patients had a mean post-operative hospital stay of 84 [+ or -] 20 days and a hospital cost of $660,000 compared to 34 [+ or -] 11 days and $306,000 for the non-surviving PPD patients who did not have salvage laparotomy. Conclusions: PPD is often successful as definitive therapy for perforated NEC in ELBW infants. Patients undergoing PPD may manifest persistent signs of sepsis for 6-10 days following PPD. This is not an indication for laparotomy as most recover fully without operation. "Salvage laparotomy" for failure of PPD was ineffective, costly, and only prolonged death. Appropriate selection criteria for PPD versus LAP are not clear and await results of a prospective study., RA Dimmitt, AH Meier, ED Skarsgard, LP Halamek, BM Smith, RL Moss (all MD, FAAP); Stanford Univ SOM Depts. Surgery and Pediatrics, Stanford, CA [...]

Objective: Reproducibly define CPAP Belly Syndrome (CBS) in preterm infants and describe associated demographics, mechanical factors, and outcomes., Study Design: A retrospective case-control study was conducted in infants <32 weeks gestation in the Stanford Children's NICU from January 1, 2020 to December 31, 2021. CBS was radiographically defined by a pediatric radiologist. Data analysis included descriptive statistics and comparator tests., Results: Analysis included 41 infants with CBS and 69 infants without. CBS was associated with younger gestational age (median 27.7 vs 30 weeks, p < 0.001) and lower birthweight (median 1.00 vs 1.31 kg, p < 0.001). Infants with CBS were more likely to receive bilevel respiratory support and higher positive end expiratory pressure. Infants with CBS took longer to advance enteral feeds (median 10 vs 7 days, p = 0.003) and were exposed to more abdominal radiographs., Conclusions: Future CBS therapies should target small infants, prevent air entry from above, and aim to reduce time to full enteral feeds and radiographic exposure., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Objective: This study aimed to determine if prefilled epinephrine syringes will reduce time to epinephrine administration compared with conventional epinephrine during standardized simulated neonatal resuscitation., Study Design: Timely and accurate epinephrine administration during neonatal resuscitation is lifesaving in bradycardic infants. Current epinephrine preparation is inefficient and error-prone. For other emergency use drugs, prefilled medication syringes have decreased error and administration time. Twenty-one neonatal intensive care unit nurses were enrolled. Each subject engaged in four simulated neonatal resuscitation scenarios involving term or preterm manikins using conventional epinephrine or novel prefilled epinephrine syringes specified for patient weight and administration route. All scenarios were video-recorded. Two investigators analyzed video recordings for time to epinephrine preparation and administration. Differences between conventional and novel techniques were evaluated using the Wilcoxon Signed Rank Tests., Results: Twenty-one subjects completed 42 scenarios with conventional epinephrine and 42 scenarios with novel prefilled syringes. Epinephrine preparation was faster using novel prefilled epinephrine syringes (median = 17.0 s, interquartile range [IQR] = 13.3-22.8) compared with conventional epinephrine (median = 48.0 s, IQR = 40.5-54.9, n  = 42, z  = 5.64, p  < 0.001). Epinephrine administration was also faster using novel prefilled epinephrine syringes (median = 26.9 s, IQR = 22.1-33.2) compared with conventional epinephrine (median = 57.6 s, IQR = 48.8-66.8, n  = 42, z  = 5.63, p  < 0.001). In a poststudy survey, all subjects supported the clinical adoption of prefilled epinephrine syringes., Conclusion: During simulated neonatal resuscitation, epinephrine preparation and administration are faster using novel prefilled epinephrine syringes, which may hasten return of spontaneous circulation and be lifesaving for bradycardic neonates in clinical practice., Key Points: · Currently, epinephrine administration in neonatal resuscitation is inefficient and error prone.. · Prefilled epinephrine syringes hasten medication administration in simulated neonatal resuscitation.. · Clinical use of prefilled epinephrine syringes may be lifesaving for bradycardic neonates.., Competing Interests: None declared., (Thieme. All rights reserved.)

The design of health care environments and the technologies used within them have tremendous influence on the performance of the professionals who care for patients in those spaces. In turn, the performance of those professionals greatly impacts the safety of the care that is delivered to patients. Active and latent safety errors can be greatly reduced by rigorous testing of the patient care environment. · Prior to the approval of final design specifications and actual construction.. · After construction is complete before the first patients move in.. · On an ongoing basis once patient care is in progress.. While there are numerous types of testing that can be conducted, this manuscript will focus on the use of simulated clinical scenarios in realistic/real physical environments to detect and remediate weaknesses in the design of those environments with a focus on their use in perinatal centers. KEY POINTS: · Environmental design influences human performance.. · Realistic clinical simulation can improve the design.. · Simulation should be done on a continuous basis.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To evaluate impact of a multihospital collaborative quality improvement project implementing in situ simulation training for neonatal resuscitation on clinical outcomes for infants born preterm., Study Design: Twelve neonatal intensive care units were divided into 4 cohorts; each completed a 15-month long program in a stepped wedge manner. Data from California Perinatal Quality Care Collaborative were used to evaluate clinical outcomes. Infants with very low birth weight between 22 through 31 weeks gestation were included. Primary outcome was survival without chronic lung disease (CLD); secondary outcomes included intubation in the delivery room, delivery room continuous positive airway pressure, hypothermia (<36°C) upon neonatal intensive care unit admission, severe intraventricular hemorrhage, and mortality before hospital discharge. A mixed effects multivariable regression model was used to assess the intervention effect., Results: Between March 2017 and December 2020, a total of 2626 eligible very low birth weight births occurred at 12 collaborative participating sites. Rate of survival without CLD at participating sites was 74.1% in March to August 2017 and 76.0% in July to December 2020 (risk ratio 1.03; [0.94-1.12]); no significant improvement occurred during the study period for both participating and nonparticipating sites. The effect of in situ simulation on all secondary outcomes was stable., Conclusions: Implementation of a multihospital collaborative providing in situ training for neonatal resuscitation did not result in significant improvement in survival without CLD. Ongoing in situ simulations may have an impact on unit practice and unmeasured outcomes., Competing Interests: Declaration of Competing Interest The research reported in this article was supported by the National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; grant R01 HD087425). The content is solely the responsibility of the authors and does not necessarily Eunice Kennedy Shriver NICHD or National Institutes of Health. The authors declare no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: The authors declare no conflict of interest.

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., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 by The National Association of Neonatal Nurses.)

Human factors science teaches us that patient safety is achieved not by disciplining individual health care professionals for mistakes, but rather by designing systems that acknowledge human limitations and optimize the work environment for them. Incorporating human factors principles into simulation, debriefing, and quality improvement initiatives will strengthen the quality and resilience of the process improvements and systems changes that are developed. The future of patient safety in neonatology will require continued efforts to engineer and re-engineer systems that support the humans who are at the interface of delivering safe patient care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Debriefing is crucial for enhancing learning following healthcare simulation. Various validated tools have been shown to have contextual value for assessing debriefers. The Debriefing Assessment in Real Time (DART) tool may offer an alternative or additional assessment of conversational dynamics during debriefings., Methods: This is a multi-method international study investigating reliability and validity. Enrolled raters (n = 12) were active simulation educators. Following tool training, the raters were asked to score a mixed sample of debriefings. Descriptive statistics are recorded, with coefficient of variation (CV%) and Cronbach's α used to estimate reliability. Raters returned a detailed reflective survey following their contribution. Kane's framework was used to construct validity arguments., Results: The 8 debriefings (μ = 15.4 min (SD 2.7)) included 45 interdisciplinary learners at various levels of training. Reliability (mean CV%) for key components was as follows: instructor questions μ = 14.7%, instructor statements μ = 34.1%, and trainee responses μ = 29.0%. Cronbach α ranged from 0.852 to 0.978 across the debriefings. Post-experience responses suggested that DARTs can highlight suboptimal practices including unqualified lecturing by debriefers., Conclusion: The DART demonstrated acceptable reliability and may have a limited role in assessment of healthcare simulation debriefing. Inherent complexity and emergent properties of debriefing practice should be accounted for when using this tool., (© 2023. The Author(s).)

Aim: Positive pressure ventilation via a facemask is critical in neonatal resuscitation, but frequently results in mask leak, obstruction, and inadequate respiratory support. This systematic review aimed to determine whether the display of respiratory function monitoring improved resuscitation or clinical outcomes., Methods: Randomized controlled trials comparing outcomes when respiratory function monitoring was displayed versus not displayed for newborns requiring positive pressure ventilation at birth were selected and from databases (last search August 2022), and assessed for risk of bias using Cochrane Risk of Bias Tools for randomized control trials. The study was registered in the Prospective Register of Systematic Reviews. Grading of Recommendations, Assessment, Development and Evaluations was used to assess the certainty of evidence. Treatment recommendations were approved by the Neonatal Life Support Task Force of the International Liaison Committee on Resuscitation. Results reported primary and secondary outcomes and included resuscitation and clinical outcomes., Results: Of 2294 unique articles assessed for eligibility, three randomized controlled trials were included (observational studies excluded) (n = 443 patients). For predefined resuscitation and clinical outcomes, these studies either did not report the primary outcome (time to heart rate ≥ 100 bpm from birth), had differing reporting methods (achieving desired tidal volumes, significant mask leak) or did not find significant differences (intubation rate, air leaks, death before hospital discharge, severe intraventricular hemorrhage, chronic lung disease). Limitations included limited sample size for critical outcomes, inconsistent definitions amongst studies and unreported long-term outcomes., Conclusion: Although respiratory function monitoring has been utilized in clinical care, there is currently insufficient evidence to suggest its benefit for newborn infants receiving respiratory support for resuscitation at birth., Registration: PROSPERO CRD42021278169 (registered November 27, 2021)., Funding: The International Liaison Committee on Resuscitation provided support that included access to software platforms and teleconferencing., Competing Interests: One author (MT) participated in the van Zanten RCT’s design and protocol development, but was not involved in the execution, data analysis, data interpretation or manuscript preparation. She was excluded from bias assessment of this study. One author (YR) holds patents for pulse oximeter technology to guide oxygen titration in the delivery room. Georg Schmölzer and Peter Davis are the authors of one study.30 Neither was involved in selection of articles for inclusion, data extraction or analysis but both acknowledged their potential intellectual conflicts of interest and participated in the Task Force discussions., (© 2022 The Authors.)

Healthcare training has traditionally emphasized acquisition and recall of vast amounts of content knowledge; however, delivering care during resuscitation of neonates requires much more than content knowledge. As the science of resuscitation has progressed, so have the methodologies and technologies used to train healthcare professionals in the cognitive, technical and behavioral skills necessary for effective resuscitation. Simulation of clinical scenarios, debriefing, virtual reality, augmented reality and audiovisual recordings of resuscitations of human neonates are increasingly being used in an effort to improve human and system performance during this life-saving intervention. In the same manner, as evidence has accumulated to support the guidelines for neonatal resuscitation so, too, has affirmation of training methodologies and technologies. This guarantees that training in neonatal resuscitation will continue to evolve to meet the needs of healthcare professionals charged with caring for newborns at one of the most vulnerable times in their lives., Competing Interests: Disclosures The authors report no relevant conflicts of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Despite a recent rise in publications describing extracorporeal membrane oxygenation (ECMO) education, the scope and quality of ECMO educational research and curricular assessments have not previously been evaluated., Objective: The purposes of this study are 1 ) to categorize published ECMO educational scholarship according to Bloom's educational domains, learner groups, and content delivery methods; 2 ) to assess ECMO educational scholarship quality; and 3 ) to identify areas of focus for future curricular development and educational research., Methods: A multidisciplinary research team conducted a scoping review of ECMO literature published between January 2009 and October 2021 using established frameworks. The Medical Education Research Study Quality Instrument (MERSQI) was applied to assess quality., Results: A total of 1,028 references were retrieved; 36 were selected for review. ECMO education studies frequently targeted the cognitive domain (78%), with 17% of studies targeting the psychomotor domain alone and 33% of studies targeting combinations of the cognitive, psychomotor, and affective domains. Thirty-three studies qualified for MERSQI scoring, with a median score of 11 (interquartile range, 4; possible range, 5-18). Simulation-based training was used in 97%, with 50% of studies targeting physicians and one other discipline., Conclusion: ECMO education frequently incorporates simulation and spans all domains of Bloom's taxonomy. Overall, MERSQI scores for ECMO education studies are similar to those for other simulation-based medical education studies. However, developing assessment tools with multisource validity evidence and conducting multienvironment studies would strengthen future work. The creation of a collaborative ECMO educational network would increase standardization and reproducibility in ECMO training, ultimately improving patient outcomes., (Copyright © 2022 by the American Thoracic Society.)

Background: Various rating tools aim to assess simulation debriefing quality, but their use may be limited by complexity and subjectivity. The Debriefing Assessment in Real Time (DART) tool represents an alternative debriefing aid that uses quantitative measures to estimate quality and requires minimal training to use. The DART is uses a cumulative tally of instructor questions (IQ), instructor statements (IS) and trainee responses (TR). Ratios for IQ:IS and TR:[IQ + IS] may estimate the level of debriefer inclusivity and participant engagement., Methods: Experienced faculty from four geographically disparate university-affiliated simulation centers rated video-based debriefings and a transcript using the DART. The primary endpoint was an assessment of the estimated reliability of the tool. The small sample size confined analysis to descriptive statistics and coefficient of variations (CV%) as an estimate of reliability., Results: Ratings for Video A (n = 7), Video B (n = 6), and Transcript A (n = 6) demonstrated mean CV% for IQ (27.8%), IS (39.5%), TR (34.8%), IQ:IS (40.8%), and TR:[IQ + IS] (28.0%). Higher CV% observed in IS and TR may be attributable to rater characterizations of longer contributions as either lumped or split. Lower variances in IQ and TR:[IQ + IS] suggest overall consistency regardless of scores being lumped or split., Conclusion: The DART tool appears to be reliable for the recording of data which may be useful for informing feedback to debriefers. Future studies should assess reliability in a wider pool of debriefings and examine potential uses in faculty development., (© 2022. The Author(s).)

Background: Debriefing is an essential skill for simulation educators and feedback for debriefers is recognised as important in progression to mastery. Existing assessment tools, such as the Debriefing Assessment for Simulation in Healthcare (DASH), may assist in rating performance but their utility is limited by subjectivity and complexity. Use of quantitative data measurements for feedback has been shown to improve performance of clinicians but has not been studied as a focus for debriefer feedback., Methods: A multi-centre sample of interdisciplinary debriefings was observed. Total debriefing time, length of individual contributions and demographics were recorded. DASH scores from simulation participants, debriefers and supervising faculty were collected after each event. Conversational diagrams were drawn in real-time by supervising faculty using an approach described by Dieckmann. For each debriefing, the data points listed above were compiled on a single page and then used as a focus for feedback to the debriefer., Results: Twelve debriefings were included (µ = 6.5 simulation participants per event). Debriefers receiving feedback from supervising faculty were physicians or nurses with a range of experience (n = 7). In 9/12 cases the ratio of debriefer to simulation participant contribution length was ≧ 1:1. The diagrams for these debriefings typically resembled a fan-shape. Debriefings (n = 3) with a ratio < 1:1 received higher DASH ratings compared with the ≧ 1:1 group (p = 0.038). These debriefings generated star-shaped diagrams. Debriefer self-rated DASH scores (µ = 5.08/7.0) were lower than simulation participant scores (µ = 6.50/7.0). The differences reached statistical significance for all 6 DASH elements. Debriefers evaluated the 'usefulness' of feedback and rated it 'highly' (µ= 4.6/5)., Conclusion: Basic quantitative data measures collected during debriefings may represent a useful focus for immediate debriefer feedback in a healthcare simulation setting., (© 2022. The Author(s).)

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.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: The biomechanics of the healthcare professionals (HCPs) performing the life-saving intervention of chest compressions in the neonatal population is poorly understood. The aim of this pilot study was to describe the variations in body position at a self-selected and a predetermined bed height during neonatal chest compressions. Measures of joint angles, time to postural sway and number of postural adjustments were chosen as indices for the stability of the HCP's position., Setting: Data were collected at a simulation-based research centre in which the patient care environment was replicated., Participants: HCPs with varying roles working in the neonatal intensive care unit and holding a current Neonatal Resuscitation Program Provider certification were recruited for this study., Interventions: Fifteen HCPs performed two trials of chest compressions, each lasting 2 min, at a predetermined bed height and a self-selected bed height. Trials were video recorded, capturing upper and lower body movements. Videos were analysed for time to postural sway and number of postural adjustments. Joint angles were measured at the start and end of each trial., Results: A statistically significant difference was found between the two bed height conditions for number of postural adjustments (p=0.02). While not statistically significant, time postural sway was increased in the choice bed height condition (85 s) compared with the predetermined bed height (45 s). After 30 s of chest compressions, mean shoulder and knee angles were smaller for choice bed height (p=0.03, 95% CI Lower=-12.14, Upper=-0.68 and p=0.05, 95% CI Lower=3.43, Upper=0.01, respectively). After 1 min and 45 s of chest compressions, mean wrist angles were smaller in the choice bed height condition (p = 0.01, 95% CI Lower=-9.20, Upper=-1.22), stride length decreased between the 30 s and 1 min 45 s marks of the chest compressions in the predetermined height condition (p=0.02)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate's birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and blood transfusion. Despite these benefits, clinicians typically cut the umbilical cord without delay in neonates requiring resuscitation and move them to a radiant warmer for further care; this effectively prevents these patients from receiving any benefits from DCC. This study evaluated the feasibility of a delayed cord clamping cart (DCCC) in low-risk neonates born via Cesarean section (CS). The DCCC is a small, sterile cart designed to facilitate neonatal resuscitation while the umbilical cord remains intact. The cart is cantilevered over the operating room (OR) table during a CS, allowing the patient to be placed onto it immediately after birth. For this study, a sample of 20 low-risk CS cases were chosen from the non-emergency Labor and Delivery surgical case list. The DCCC was utilized for 1 min of DCC in all neonates. The data collected included direct observation by research team members, recorded debriefings and surveys of clinicians as well as surveys of patients. Forty-four care team members participated in written surveys; of these, 16 (36%) were very satisfied, 12 (27%) satisfied, 13 (30%) neutral, and 3 (7%) were somewhat dissatisfied with use of the DCCC in the OR. Feedback was collected from all 20 patients, with 18 (90%) reporting that they felt safe with the device in use. This study provides support that utilizing a DCCC can facilitate DCC with an intact umbilical cord.

Newborn resuscitation requires a multidisciplinary team effort to deliver safe, effective and efficient care. California Perinatal Quality Care Collaborative's Simulating Success program was designed to help hospitals implement on-site simulation-based neonatal resuscitation training programs. Partnering with the Center for Advanced Pediatric and Perinatal Education at Stanford, Simulating Success engaged hospitals over a 15 month period, including three months of preparatory training and 12 months of implementation. The experience of the first cohort (Children's Hospital of Orange County (CHOC), Sharp Mary Birch Hospital for Women and Newborns (SMB) and Valley Children's Hospital (VCH)), with their site-specific needs and aims, showed that a multidisciplinary approach with a sound understanding of simulation methodology can lead to a dynamic simulation program. All sites increased staff participation. CHOC reduced latent safety threats measured during team exercises from 4.5 to two per simulation while improving debriefing skills. SMB achieved 100% staff participation by identifying unit-specific hurdles within in situ simulation. VCH improved staff confidence level in responding to neonatal codes and proved feasibility of expanding simulation across their hospital system. A multidisciplinary approach to quality improvement in neonatal resuscitation fosters engagement, enables focus on patient safety rather than individual performance, and leads to identification of system issues.

Extensive neonatal resuscitation is a high acuity, low-frequency event accounting for approximately 1% of births. Neonatal resuscitation requires an interprofessional healthcare team to communicate and carry out tasks efficiently and effectively in a high adrenaline state. Implementing a neonatal patient safety simulation and debriefing program can help teams improve the behavioral, cognitive, and technical skills necessary to reduce morbidity and mortality. In Simulating Success , a 15-month quality improvement (QI) project, the Center for Advanced Pediatric and Perinatal Education (CAPE) and California Perinatal Quality Care Collaborative (CPQCC) provided outreach and training on neonatal simulation and debriefing fundamentals to individual teams, including community hospital settings, and assisted in implementing a sustainable program at each site. The primary Aim was to conduct two simulations a month, with a goal of 80% neonatal intensive care unit (NICU) staff participation in two simulations during the implementation phase. While the primary Aim was not achieved, in-situ simulations led to the identification of latent safety threats and improvement in system processes. This paper describes one unit's QI collaborative experience implementing an in-situ neonatal simulation and debriefing program.

Objective: This study aimed to investigate the use of simulation in neonatal-perinatal medicine (NPM) fellowship programs., Study Design: This was a cross-sectional survey of program directors (PDs) and simulation educators in Accreditation Council for Graduate Medical Education (ACGME) accredited NPM fellowship programs., Results: Responses were received from 59 PDs and 52 simulation educators, representing 60% of accredited programs. Of responding programs, 97% used simulation, which most commonly included neonatal resuscitation (94%) and procedural skills (94%) training. The time and scope of simulation use varied significantly. The majority of fellows (51%) received ≤20 hours of simulation during training. The majority of PDs (63%) wanted fellows to receive >20 hours of simulation. Barriers to simulation included lack of faculty time, experience, funding, and curriculum., Conclusion: While the majority of fellowship programs use simulation, the time and scope of fellow exposure to simulation experiences are limited. The creation of a standardized simulation curriculum may address identified barriers to simulation., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: There is limited research exploring the relationship between design and patient safety outcomes, especially in maternal and neonatal care. We employed design thinking methodology to understand how the design of labor and delivery units impacts safety and identified spaces and systems where improvements are needed., Study Design: Site visits were conducted at 10 labor and delivery units in California. A multidisciplinary team collected data through observations, measurements, and clinician interviews. In parallel, research was conducted regarding current standards and codes for building new hospitals., Results: Designs of labor and delivery units are heterogeneous, lacking in consistency regarding environmental factors that may impact safety and outcomes. Building codes do not take into consideration workflow, human factors, and patient and clinician experience. Attitude of hospital staff may contribute to improving safety through design. Three areas in need of improvement and actionable through design emerged: (1) blood availability for hemorrhage management, (2) appropriate space for neonatal resuscitation, and (3) restocking and organization methods of equipment and supplies., Conclusion: Design thinking could be implemented at various stages of health care facility building projects and during retrofits of existing units. Through this approach, we may be able to improve hospital systems and environmental factors., Competing Interests: Ms. Sherman, Ms. Hedli, Ms. Kristensen-Cabrera, Dr. Lipman, Mr. Schwandt, Dr. Lee, Ms. Sie, Dr. Halamek, and Dr. Austin report grants from Agency for Healthcare Research and Quality, during the conduct of the study., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Safety, effectiveness and efficiency are keys to performance in all high-risk industries; healthcare is no exception, and neonatal-perinatal medicine is one of the highest risk subspecialties within healthcare. Briefing, simulation and debriefing are methods used by professionals in high-risk industries to reduce the overall risk to life and enhance the safety of the human beings involved in receiving and delivering the services provided by those industries. Although relatively new to neonatal-perinatal medicine, briefing, simulation and debriefing are being practiced with increasing frequency and have become embedded in training exercises such as the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP). This chapter will define these terms and offer examples as to how they are used in high-risk activities including neonatal-perinatal medicine., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To determine the validity, reliability, feasibility and applicability of a neonatal intubation scoring instrument., Design: Prospective observational study., Setting: Simulation-based research and training centre (Center for Advanced Pediatric and Perinatal Education), California, USA., Subjects: Forty clinicians qualified for neonatal intubation., Interventions: Videotaped elective intubations on a neonatal patient simulator were scored by two independent raters. One rater scored the intubations twice. We scored the preparation of equipment and premedication, intubation performance, tube position/fixation, communication, number of attempts, duration and successfulness of the procedure., Main Outcome Measures: Intraclass correlation coefficients (ICC) were calculated for intrarater and inter-rater reliability. Kappa coefficients for individual items and mean kappa coefficients for all items combined were calculated. Construct validity was assessed with one-way analysis of variance using the hypothesis that experienced clinicians score higher than less experienced clinicians. The approximate time to score one intubation and the instrument's applicability in another setting were evaluated., Results: ICCs for intrarater and inter-rater reliability were 0.99 (95% CI 0.98 to 0.99) and 0.89 (95% CI 0.35 to 0.96), and mean kappa coefficients were 0.93 (95% CI 0.85 to 1.01) and 0.71 (95% CI 0.56 to 0.92), respectively. There were no differences between the more and less experienced clinicians regarding preparation, performance, communication and total scores. The experienced group scored higher only on tube position/fixation (p = 0.02). Scoring one intubation took approximately 15 min. Our instrument, developed in The Netherlands, could be readily applied in the USA., Conclusions: Our scoring instrument for simulated neonatal intubations appears to be reliable, feasible and applicable in another centre. Construct validity could not be established., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Neonatal resuscitation demands that healthcare professionals perform cognitive and technical tasks while working under time pressure as a team in order to provide efficient and effective care. Neonatal resuscitation teams simultaneously process and act upon multiple data streams, perform ergonomically challenging technical procedures, and coordinate their actions within a small physical space. An understanding and application of human factors and ergonomics science broadens the areas of need in resuscitation research, and will lead to enhanced technologies, systems, and work environments that support human limitations and maximize human performance during neonatal resuscitation.

This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000->5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future., Competing Interests: The authors have declared that no competing interests exist.

Aim: American guidelines suggest that neonatal resuscitation be considered at 23 weeks of gestation, one week earlier than in the Netherlands, but how counselling practices differ at the threshold of viability is unknown. This pilot study compared prenatal periviability counselling in the two countries., Methods: In 2013, a cross-sectional survey was sent to 121 Dutch neonatologists as part of a nationwide evaluation of prenatal counselling. In this pilot study, the same survey was sent to a convenience sample of 31 American neonatologists in 2014. The results were used to compare the organisation, content and decision-making processes in prenatal counselling at 24 weeks of gestation between the two countries., Results: The survey was completed by 17 (55%) American and 77 (64%) Dutch neonatologists. American neonatologists preferred to meet with parents more frequently, for longer periods of time, and to discuss more intensive care topics, including long-term complications, than Dutch neonatologists. Neonatologists from both countries preferred shared decision-making when deciding whether to initiate intensive care., Conclusion: Neonatologists in the United States and the Netherlands differed in their approach to prenatal counselling at 24 weeks of gestation. Cross-cultural differences may play a role., (©2018 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Performance in the delivery of care to sick neonates in need of resuscitation has long been defined primarily in terms of the extent of the knowledge possessed and hands-on skill demonstrated by physicians and other healthcare professionals. This definition of performance in neonatal resuscitation is limited by its focus solely on the human beings delivering care and a perceived set of the requisite skills to do so. This manuscript will expand the definition of performance to include all of the skill sets that humans must use to resuscitate newborns as well as the often complex systems in which those humans operate while delivering that care. It will also highlight how the principles of human factors and ergonomics can be used to enhance human and system performance during patient care. Finally, it will describe the role of simulation and debriefing in the assessment of human and system performance., (© 2018 Published by Elsevier Ltd.)

Background: Pediatric fellows receive little palliative care (PC) education and have few opportunities to practice communication skills., Objective: In this pilot study, we assessed (1) the relative effectiveness of simulation-based versus didactic education, (2) communication skill retention, and (3) effect on PC consultation rates., Design: Thirty-five pediatric fellows in cardiology, critical care, hematology/oncology, and neonatology at two institutions enrolled: 17 in the intervention (simulation-based) group (single institution) and 18 in the control (didactic education) group (second institution). Intervention group participants participated in a two-day program over three months (three simulations and videotaped PC panel). Control group participants received written education designed to be similar in content and time., Measurements: (1) Self-assessment questionnaires were completed at baseline, post-intervention and three months; mean between-group differences for each outcome measure were assessed. (2) External reviewers rated simulation-group encounters on nine communication domains. Within-group changes over time were assessed. (3) The simulation-based site's PC consultations were compared in the six months pre- and post-intervention., Results: Compared to the control group, participants in the intervention group improved in self-efficacy (p = 0.003) and perceived adequacy of medical education (p < 0.001), but not knowledge (p = 0.20). Reviewers noted nonsustained improvement in four domains: relationship building (p = 0.01), opening discussion (p = 0.03), gathering information (p = 0.01), and communicating accurate information (p = 0.04). PC consultation rate increased 64%, an improvement when normalized to average daily census (p = 0.04)., Conclusions: This simulation-based curriculum is an effective method for improving PC comfort, education, and consults. More frequent practice is likely needed to lead to sustained improvements in communication competence.

The resuscitation of conjoined twins is a rare and complex clinical challenge. We detail how patient-specific, in situ simulation can be used to prepare a large, multidisciplinary team of health care professionals (HCPs) to deliver safe, efficient, and effective care to such patients. In this case, in situ simulation allowed an 18-person team to address the clinical and ergonomic challenges anticipated for this neonatal resuscitation. The HCPs trained together as an intact team in the actual delivery room environment to probe for human and system weaknesses prior to this unique delivery, and optimized communication, teamwork, and other behavioral skills as they prepared for the simultaneous resuscitation of two patients who were physically joined to one another., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality., Study Design: This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group., Results: Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death., Conclusion: Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.

Objective: We describe health care simulation, designed primarily for training, and provide examples of how human factors experts can collaborate with health care professionals and simulationists-experts in the design and implementation of simulation-to use contemporary simulation to improve health care delivery., Background: The need-and the opportunity-to apply human factors expertise in efforts to achieve improved health outcomes has never been greater. Health care is a complex adaptive system, and simulation is an effective and flexible tool that can be used by human factors experts to better understand and improve individual, team, and system performance within health care., Method: Expert opinion is presented, based on a panel delivered during the 2014 Human Factors and Ergonomics Society Health Care Symposium., Results: Diverse simulators, physically or virtually representing humans or human organs, and simulation applications in education, research, and systems analysis that may be of use to human factors experts are presented. Examples of simulation designed to improve individual, team, and system performance are provided, as are applications in computational modeling, research, and lifelong learning., Conclusion: The adoption or adaptation of current and future training and assessment simulation technologies and facilities provides opportunities for human factors research and engineering, with benefits for health care safety, quality, resilience, and efficiency., Application: Human factors experts, health care providers, and simulationists can use contemporary simulation equipment and techniques to study and improve health care delivery., (© 2016, Human Factors and Ergonomics Society.)

Simulation can be an effective tool to facilitate the acquisition and maintenance of the cognitive, technical and behavioral skills necessary to carry out our mission in neonatology: the delivery of safe, effective and efficient care to our patients. Prominent examples of successful implementation of simulation within neonatology include the Neonatal Resuscitation Program, the International Pediatric Simulation Society, and the International Network for Simulation-Based Pediatric Innovation, Research and Education. Despite these successes much remains to be accomplished. Expanding simulation beyond technical skill acquisition, using simulated environments to conduct research into human and system performance, incorporating simulation into high-stakes skill assessments, embracing the expertise of the more extensive modeling and simulation community and, in general, applying simulation to healthcare with the same degree of gravitas with which it is deployed in other high-risk industries are all tasks that must be completed in order to achieve our mission., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The 2015 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) and International Liaison Committee on Resuscitation (ILCOR) resuscitation guidelines state, "It is still suggested that briefing and debriefing techniques be used whenever possible for neonatal resuscitation." Effective communication and reliable delivery of evidence-based best practices are critical aspects of the 2015 NRP guidelines. To promote optimal communication and best practice-focused checklists use during active neonatal resuscitation, the Readiness Bundle (RB) was integrated within the larger change package deployed in the California Perinatal Quality Care Collaborative's (CPQCC) 12-month Delivery Room Management Quality Improvement Collaborative., Methods: The RB consisted of (1) a checklist for high-risk neonatal resuscitations and (2) briefings and debriefings to improve teamwork and communication in the delivery room (DR). Implementation of the RB was encouraged, compliance with the RB was tracked monthly up through 6 months after the completion of the collaborative, and satisfaction with the RB was evaluated., Results: Twenty-four neonatal intensive care units (NICUs) participated in the CPQCCDR collaborative. Before the initiation of the collaborative, the elements of the RB were complied with in 0 of 740 reported deliveries (0%). During the 12-month collaborative, compliance with the RB improved to a median of 71%, which was surpassed in the 6-month period after the collaborative ended (80%). One-hundred percent of responding NICUs would recommend the RB to other NICUs working on improving DR management., Conclusions: The RB was rapidly adopted, with compliance sustained for 6 months after completion of the collaborative. Inclusion of the RB in the next generation of the NRP guidelines is encouraged.

Post-event debriefings are a foundational behavior of high performing teams. Despite the inherent value of post-event debriefings, the frequency with which they are used in neonatal care is extremely low. If post-event debriefings are so beneficial, why aren't they conducted more frequently? The reasons are many, but solutions are available. In this report, we provide practical advice on conducting post-event debriefing in neonatal care. In addition, we examine the perceived barriers to conducting post-event debriefings, and offer strategies to overcome them. Finally, we consider opportunities to foster a culture change within neonatal care which integrates debriefing as standard daily work. By establishing a safety culture in neonatal care that encourages and facilitates effective post-event debriefings, patient safety can be enhanced and clinical outcomes can be improved.

Aim: Current patterns of communication in high-risk clinical situations, such as resuscitation, are imprecise and prone to error. We hypothesized that the use of standardized communication techniques would decrease the errors committed by resuscitation teams during neonatal resuscitation., Methods: In a prospective, single-blinded, matched pairs design with block randomization, 13 subjects performed as a lead resuscitator in two simulated complex neonatal resuscitations. Two nurses assisted each subject during the simulated resuscitation scenarios. In one scenario, the nurses used nonstandard communication; in the other, they used standardized communication techniques. The performance of the subjects was scored to determine errors committed (defined relative to the Neonatal Resuscitation Program algorithm), time to initiation of positive pressure ventilation (PPV), and time to initiation of chest compressions (CC)., Results: In scenarios in which subjects were exposed to standardized communication techniques, there was a trend toward decreased error rate, time to initiation of PPV, and time to initiation of CC. While not statistically significant, there was a 1.7-second improvement in time to initiation of PPV and a 7.9-second improvement in time to initiation of CC., Conclusions: Should these improvements in human performance be replicated in the care of real newborn infants, they could improve patient outcomes and enhance patient safety., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

There are no national or international guidelines for the resuscitation of conjoined twins. We have described how the U.S. Neonatal Resuscitation Program algorithm can be modified for delivery room resuscitation of omphaloischiopagus conjoined twins. In planning for the delivery and resuscitation of these patients, we considered the challenges of providing cardiopulmonary support to preterm conjoined twins in face-to-face orientation and with shared circulation via a fused liver and single umbilical cord. We also demonstrate how in situ simulation can be used to prepare a large, multidisciplinary team of health care professionals to deliver safe, efficient, and effective care to such patients., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Aim: The Neonatal Resuscitation Program (NRP) algorithm serves as a guide to healthcare professionals caring for neonates transitioning to extrauterine life. Despite this, adherence to the algorithm is challenging, and errors are frequent. Information-dense, high-risk fields such as air traffic control have proven that formal classification of errors facilitates recognition and remediation. This study was performed to determine and characterize common deviations from the NRP algorithm during neonatal resuscitation., Methods: Audiovisual recordings of 250 real neonatal resuscitations were obtained between April 2003 and May 2004. Of these, 23 complex resuscitations were analyzed for adherence to the contemporaneous NRP algorithm and scored using a novel classification tool based on the validated NRP Megacode Checklist., Results: Seven hundred eighty algorithm-driven tasks were observed. One hundred ninety-four tasks were completed incorrectly, for an average error rate of 23%. Forty-two were errors of omission (28% of all errors) and 107 were errors of commission (72% of all errors). Many errors were repetitive and potentially clinically significant: failure to assess heart rate and/or breath sounds, improper rate of positive pressure ventilation, inadequate peak inspiratory and end expiratory pressures during ventilation, improper chest compression technique, and asynchronous PPV and CC., Conclusions: Errors of commission, especially when performing advanced life support interventions such as positive pressure ventilation, intubation, and chest compressions, are common during neonatal resuscitation and are sources of potential harm. The adoption of error reduction strategies capable of decreasing cognitive and technical load and standardizing communication - strategies common in other industries - should be considered in healthcare., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Interventions to improve pediatric trainee education in palliative care have been limited by a lack of reliable and valid tools for measuring effectiveness., Objective: We developed a questionnaire to measure pediatric fellows' self-efficacy (comfort), knowledge, and perceived adequacy of prior medical education. We measured the questionnaire's reliability and validity., Methods: The questionnaire contains questions regarding self-efficacy (23), knowledge (10), fellow's perceived adequacy of prior medical education (6), and demographics. The survey was developed with palliative care experts, and sent to fellows in U.S. pediatric cardiology, critical care, hematology/ oncology, and neonatal-perinatal medicine programs. Measures of reliability, internal consistency, and validity were calculated., Results: One hundred forty-seven fellows completed the survey at test and retest. The self-efficacy and medical education questionnaires showed high internal consistency of 0.95 and 0.84. The test-retest reliability for the Self-Efficacy Summary Score, measured by intraclass correlation coefficient (ICC) and weighted kappa, was 0.78 (item range 0.44-0.81) and 0.61 (item range 0.36-0.70), respectively. For the Adequacy of Medical Education Summary Score, ICC was 0.85 (item range 0.6-0.78) and weighted kappa was 0.63 (item range 0.47-0.62). Validity coefficients for these two questionnaires were 0.88 and 0.92. Fellows answered a mean of 8.8/10 knowledge questions correctly; percentage agreement ranged from 65% to 99%., Conclusions: This questionnaire is capable of assessing self-efficacy and fellow-perceived adequacy of their prior palliative care training. We recommend use of this tool for fellowship programs seeking to evaluate fellow education in palliative care, or for research studies assessing the effectiveness of a palliative care educational intervention.

Aim: Studies have shown that healthcare professionals (HCPs) display a 16-55% error rate in adherence to the Neonatal Resuscitation Program (NRP) algorithm. The aim of this study was to evaluate adherence to the Neonatal Resuscitation Program algorithm by subjects working from memory as compared to subjects using a decision support tool that provides auditory and visual prompts to guide implementation of the Neonatal Resuscitation Program algorithm during simulated neonatal resuscitation., Methods: Healthcare professionals (physicians, nurse practitioners, obstetrical/neonatal nurses) with a current NRP card were randomized to the control or intervention group and performed three simulated neonatal resuscitations. The scenarios were evaluated for the initiation and cessation of positive pressure ventilation (PPV) and chest compressions (CC), as well as the frequency of FiO2 adjustment. The Wilcoxon rank sum test was used to compare a score measuring the adherence of the control and intervention groups to the Neonatal Resuscitation Program algorithm., Results: Sixty-five healthcare professionals were recruited and randomized to the control or intervention group. Positive pressure ventilation was performed correctly 55-80% of the time in the control group vs. 94-95% in the intervention group across all three scenarios (p<0.0001). Chest compressions were performed correctly 71-81% of the time in the control group vs. 82-93% in the intervention group in the two scenarios in which they were indicated (p<0.0001). FiO2 was addressed three times more frequently in the intervention group compared to the control group (p<0.001)., Conclusions: Healthcare professionals using a decision support tool exhibit significantly fewer deviations from the Neonatal Resuscitation Program algorithm compared to those working from memory alone during simulated neonatal resuscitation., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: There is little evidence to compare the effectiveness of large collaborative quality improvement versus individual local projects., Methods: This was a prospective pre-post intervention study of neonatal resuscitation practice, comparing 3 groups of nonrandomized hospitals in the California Perinatal Quality Care Collaborative: (1) collaborative, hospitals working together through face-to-face meetings, webcasts, electronic mailing list, and data sharing; (2) individual, hospitals working independently; and (3) nonparticipant hospitals. The collaborative and individual arms participated in improvement activities, focusing on reducing hypothermia and invasive ventilatory support., Results: There were 20 collaborative, 31 individual, and 44 nonparticipant hospitals caring for 12,528 eligible infants. Each group had reduced hypothermia from baseline to postintervention. The collaborative group had the most significant decrease in hypothermia, from 39% to 21%, compared with individual hospital efforts of 38% to 33%, and nonparticipants of 42% to 34%. After risk adjustment, the collaborative group had twice the magnitude of decrease in rates of newborns with hypothermia compared with the other groups. Collaborative improvement also led to greater decreases in delivery room intubation (53% to 40%) and surfactant administration (37% to 20%)., Conclusions: Collaborative efforts resulted in larger improvements in delivery room outcomes and processes than individual efforts or nonparticipation. These findings have implications for planning quality improvement projects for implementation of evidence-based practices., (Copyright © 2014 by the American Academy of Pediatrics.)

Objective: Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists., Methods: We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation., Results: American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues., Conclusions: Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.

This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.

The Neonatal Resuscitation Program (NRP) consists of an algorithm and curriculum to train healthcare professionals to facilitate newborn infants' transition to extrauterine life and to provide a standardized approach to the care of infants who require more invasive support and resuscitation. This review discusses the most recent update of the NRP algorithm and recommended guidelines for the care of newly born infants. Current challenges in training and assessment as well as the importance of ergonomics in the optimization of human performance are discussed. Finally, it is recommended that in order to ensure high-performing resuscitation teams, members should be selected and retained based on objective performance criteria and frequent participation in realistic simulated clinical scenarios.