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

Simulation in neonatal care: towards a change in traditional training?

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

Neonatal Intensive Care Unit (NICU) Management during Treatment for Type 1 Retinopathy of Prematurity and Eye Outcomes

Introduction: Retinopathy of prematurity (ROP) is caused by abnormal retinal blood vessel development in premature infants and requires treatment of severe Type 1 disease to prevent ophthalmic complications such as scarring, retinal detachment, and blindness. However, even with treatment, many become blind or are affected by myopia, strabismus, or visual impairment. Currently, there are no published guidelines for NICU medical management during laser treatment for Type 1 ROP. The purpose of this study was to evaluate NICU care during ROP laser treatment and determine eye outcomes associated with treatment circumstances in order to better prevent medical and ophthalmic complications. Methods: We historically reviewed neonates with Type 1 ROP treated between January 2009 and June 2015 at Children’s National Medical Center (CNMC) which is a Level IV NICU.1 For infants receiving their first laser treatment at CNMC, we assessed demographics, intubation requirements, treatment duration, median time to return to respiratory and feeding baselines, and eye outcomes at ≥6 months of follow-up. Incidence of grade 3 or 4 intraventricular hemorrhage (IVH), hydrocephalus, sepsis anytime prior to treatment, necrotizing enterocolitis (NEC), and bronchopulmonary dysplasia (BPD) were noted as indicators of medical disease burden. Results: Of the 51 infants reviewed, 2 were excluded due to first treatments at other hospitals. Six others were excluded because they received anti-VEGF injection as ROP treatment. For the 43 infants treated with laser, mean age at treatment was 37.0±2.7 weeks (range 32.0-42.4), gestational age was 24.1±1.6 weeks, and birth weight was 684.5±284.7g. Incidence of sepsis anytime prior to the procedure was high at 88% (38), with BPD at 86% (37), NEC at 42% (18), and grade 3 or 4 IVH at 23% (10). Nine infants (21%) were intubated at baseline (base-ETI), 10 (23%) were electively intubated before laser (elect-ETI), 3 (7%) required urgent intubation during treatment due to respiratory distress (urg-ETI), and 21 (49%) received no intubation (no-ETI). Treatment duration for no-ETI was shorter (0.8 hours) than all intubated groups (base-ET 1.0, pre-ET 1.4, urg-ETI 2.0). Return to respiratory and feeding baselines were markedly prolonged for elect-ETI at median 90.0 hours and 75.0 hours, respectively, compared to base-ETI (16.8, 3.0), urg-ETI (51.7, 30.0), and no-ETI (11.0, 5.9) (Figures 1 and 2). Eye outcomes included macular scar (14%), retinal detachment (8%), legal blindness (17%), and strabismus (28%) with elect-ETI having poorest outcomes (20%, 30%, 40%, 40%, respectively). Discussion: For extremely low-birth-weight infants with Type 1 ROP, elect-ETI prolonged return to respiratory and feeding baselines, and eye outcomes were poorest for this group. In contrast, urg-ETI was associated with shorter return to baselines despite increased procedure duration. Given these surprising findings, there may be cause to avoid elective intubation for laser treatment when neonates are stable as longer ventilation can lead to respiratory morbidity and delayed feeding in this population of infants with an already high disease burden

Addressing caregiver mental health in the neonatal ICU

PURPOSE OF REVIEW: The neonatal ICU (NICU) setting is a unique opportunity to not only detect major changes in caregiver mental health through universal perinatal mood and anxiety disorder (PMAD) screening but also intervene with specialized support. We review evidence for addressing caregiver mental health in the NICU, explore current guidelines and models for integrated behavioural health programmes, and describe challenges specific to NICUs, particularly in standalone paediatric hospitals. RECENT FINDINGS: Parents of infants admitted to the NICU are at an increased risk for developing PMADs at rates well above the general postpartum community. Select NICUs within the United States and internationally have recognized the importance of having an embedded psychologist to address caregiver PMADs. However, organizational structures within paediatric healthcare systems are not equipped to manage the logistical, ethical, legal and practical needs of comprehensive caregiver mental health programmes. SUMMARY: To properly address caregiver mental health in NICU settings, clinical and administrative teams must work together to ensure seamless service provision. Systems that facilitate the development of unique parent medical records at the onset of paediatric care are likely to significantly reduce potential liability risks and solve several challenges related to caregiver-focused mental health support in the NICU. VIDEO ABSTRACT: http://links.lww.com/MOP/A70

Tracheal Aspirate Cultures in Intubated Neonates: A Descriptive Epidemiological Cohort Study

BACKGROUND: Considerable variability in antibiotic prescribing practices in neonatal intensive care units (NICUs) and increasing knowledge about the adverse consequences of antibiotic exposure in neonates highlights the need for a better understanding of antibiotic prescribing practices. Antibiotic prescribing practices related to positive tracheal aspirate culture results, which could represent either colonization or invasive infection, is unknown. METHODS: We conducted a retrospective cohort study of intubated neonates admitted to Children’s National Health System (CNHS) who had one or more tracheal aspirate cultures sent May to December 2016. Data collected through chart review included changes in vital signs, secretion characteristics, ventilator settings, oxygen requirement, white blood cell count, C-reactive protein (CRP), and chest x-ray results in the 48 hours preceding tracheal aspirate culture order. Outcome measures collected include duration of antibiotic therapy, hospital and NICU length of stay, ventilator days, discharge on respiratory support, recurrence of respiratory infection, bronchopulmonary dysplasia, colonization with multidrug-resistant organism (MDRO), and mortality. Clinical factors present in those with an identified pathogen were compared with those without, using chi squared for dichotomous and t-test for continuous variables. RESULTS: We identified 51 intubated neonates who met inclusion criteria; 43 (84%) were preterm with median gestation 28 weeks (IQR 25-31). Median birth weight was 1140 g (IQR 744-2360) and 47% were female. A pathogen was identified in 37% of isolates. S. aureus (7) was the most frequently isolated pathogen, followed by K. pneumoniae (5) and Enterobacter spp (4). Hemodynamic instability and abnormal laboratory values were the common clinical factors in the 48 hours preceding cultures. Antibiotics were prescribed for 45 (88%) neonates with a median of 14 days (IQR 6-16). The most frequently prescribed antibiotics were vancomycin (67%) and gentamicin (63%). Those with respiratory culture positive for a pathogen had a higher odds of having had change in respiratory secretion characteristics (OR 14.3; 95% CI 1.3-130.9) and increase in oxygen requirement (OR 4.1; 95% CI 1.0-16.6). CONCLUSIONS: Although most neonates are treated with antibiotics, fewer than half of respiratory cultures identified a pathogen. Those with an identified pathogen were more likely to have changes in respiratory secretion characteristics and increased oxygen requirement

Laryngeal Mask Airway Clinical Use and Training: A Survey of North American Neonatal Health Care Professionals

OBJECTIVE: The aim of this study was to explore North American neonatal health care professionals\u27 (HCPs) experience, confidence, skill, and training with the laryngeal mask airway (LMA). STUDY DESIGN: This was a cross-sectional survey. RESULTS: The survey was completed by 2,159 HCPs from Canada and the United States. Seventy nine percent had no clinical experience with the LMA, and less than 20% considered the LMA an alternative to endotracheal intubation (EI). The majority had received LMA training; however, 28% of registered nurses, 18% of respiratory therapists, 17% of physicians, and 12% of midwives had never inserted an LMA in a mannequin. Less than a quarter of respondents agreed that the current biennial Neonatal Resuscitation Program instruction paradigm is sufficient for LMA training. All groups reported low confidence and skill with LMA insertion, and compared with all other groups, the respiratory therapists had the highest reported confidence and skill. CONCLUSION: This survey study, which is the first of its kind to include midwives, demonstrates that neonatal HCPs lack experience, confidence, skill, and training with the LMA, rarely use the device, and in general, do not consider the LMA as an alternative to EI. These findings contribute to, and support the findings of previous smaller studies, and in conjunction with the diminishing opportunities for EI, highlight the need for programs to emphasize the importance of the LMA for neonatal airway management and prioritize regular LMA training, with focus that parallels the importance placed on the skills of EI and mask ventilation. KEY POINTS: · Lack of training for laryngeal mask airway use in neonatal resuscitation.. · Neonatal health care professionals rarely use the laryngeal mask airway as an alternate airway device.. · Neonatal health care professionals lack confidence and skill with the laryngeal mask airway.

Medical Diagnoses and Associated Characteristics of Neonatal Intensive Care Unit Infants Enrolled in the Giving Parents Support Study

Background: Children’s National Health System (CNHS) has a number of research studies being performed in the Neonatal Intensive Care Unit (NICU), including Giving Parents Support (GPS), a randomized controlled trial of parent navigation after NICU discharge. As a Level IV NICU, CNHS provides care to the sickest infants with a wide range of medical complexity. Objective: To describe the medical diagnoses and associated characteristics of NICU infants enrolled in GPS. Methods: Participants in the GPS study were enrolled from January 2016 to February 2017, and no infants were excluded due to diagnostic criteria. Approximately 300 infants were enrolled, and medical diagnoses were collected from the Children’s Hospitals Neonatal Database and classified by organ system; data was provided on 86% of GPS infants (n=257). Associated characteristics, such as infant sex and gestational age (GA), were obtained via chart review. Diagnoses belonging to preterm (\u3c37 weeks GA) and term (37+ weeks GA) infants were categorized separately. Results: Most infants were male (68%), full-term (55%), and diagnosed with at least one respiratory condition (58%); the majority of those in the latter group (83%) had respiratory distress syndrome (RDS). [KF1] [MC2] Of the 115 premature infants reviewed, 12% were diagnosed with bronchopulmonary dysplasia (BPD), 9% were diagnosed with intraventricular hemorrhage, 2% were diagnosed with periventricular leukomalacia, and 13% were diagnosed with necrotizing enterocolitis. Of the 142 term infants reviewed, 5% were diagnosed with hypoxic-ischemic encephalopathy (HIE) and 11% were diagnosed with seizure. Less than 1% of term infants received extracorporeal membrane oxygenation. Conclusion: Medical diagnoses among GPS infants were variable, although most had a respiratory diagnosis of RDS. The most common diagnosis among preterm and term infants was BPD and seizure, respectively