A Description of Medications and Intravenous Fluids Used During Neonatal Transport by a Regional Pediatric Critical Care Team.

OBJECTIVE: This study aimed to describe the type and frequency of enteral and parenteral fluids and medications used during the transport of neonates by a regional pediatric critical care transport team. METHODS: We performed a retrospective analysis of neonates transported by a regional neonatal transport team affiliated with a level IV neonatal intensive care unit within a large care network between 2020 and 2021. Demographic and clinical data were collected from the electronic medical record. Standard frequency tabulation and summary statistics were used to report demographics, transport characteristics, and fluid and medication use; results were then stratified by preterm (37 weeks) and term births. RESULTS: In the 628 included transports, more term than preterm infants received at least 1 fluid or medication (53% vs. 43%, respectively). The most commonly administered medications were antibiotics (ampicillin and gentamicin), prostaglandin, and opiates (morphine sulfate and fentanyl). In addition, term infants received more analgesic medications, antimicrobials, and prostaglandin, whereas preterm infants received total parenteral nutrition more often. There were over 38 different medications provided on the transports studied. CONCLUSION: This study of a single transport team revealed that a wide variety of medications and fluids were used in the transport of neonates, with term infants receiving more medications than preterm infants. These data could be used by transport teams in making or updating their standardized medication lists or in creating simulations.

Virtual Reality Simulation in Pediatric Resuscitation for Pre-hospital Providers.

This technical report explored the feasibility and utility of virtual reality (VR) pediatric resuscitation simulations for pre-hospital providers during their scheduled shifts. To our knowledge, neither the pediatric resuscitation VR simulation nor the feasibility of in situ, on-shift training with VR had been previously evaluated in pre-hospital providers. VR headset was available at an urban city fire station for 10 days where a total of 60 pre-hospital providers were scheduled to work. Providers were made aware of the VR module but no formal demonstration was done. There were no facilitators. Participants filled out an anonymous retrospective pre- and post-survey using a five-point Likert scale, rating their confidence from "not confident" to "very confident" in recognizing and managing pediatric emergencies. We found that VR simulation for pediatric resuscitation was a feasible training tool to use in situ as 63% of the providers were able to use it on shift. Furthermore, self-reported confidence increased after the training where responses of "very confident" increased from 20% to 30% for emergency medical technicians and 55% to 63% for paramedics.

Finding Your Voice: A Large-Scale Nursing Training in Speaking up and Listening Skills.

BACKGROUND: Training in speaking up skills for nursing professionals provides the groundwork for promoting a culture of curiosity and inquiry. At the foundation of speaking up is psychological safety for team members to disagree, offer alternative ideas, and ask questions. METHOD: A large-scale training session, Finding Your Voice: Speaking Up & Listening Skills, was designed and delivered to 1,306 nurses at an academic medical center. RESULTS: Most participants reported that the session met the training goals (97%). There was an increase in participants' confidence in speaking up (pretraining 69% ± 19%; posttraining 73% ± 15%; p < .0001), and listening (pretraining 68% ± 19%; post-training 74% ± 15%; p < .0001). Leaders showed greater increases in confidence in listening and responding to nurses speaking up (leaders 5.6% vs. nonleaders 4.2%, p < .00001). CONCLUSION: Nurses benefited from an interactive educational experience by practicing strategies for speaking up and listening. [J Contin Educ Nurs. 2024;55(6):309-316.].

Increasing Realism and Variety of Virtual Patient Dialogues for Prenatal Counseling Education Through a Novel Application of ChatGPT: Exploratory Observational Study.

BACKGROUND: Using virtual patients, facilitated by natural language processing, provides a valuable educational experience for learners. Generating a large, varied sample of realistic and appropriate responses for virtual patients is challenging. Artificial intelligence (AI) programs can be a viable source for these responses, but their utility for this purpose has not been explored. OBJECTIVE: In this study, we explored the effectiveness of generative AI (ChatGPT) in developing realistic virtual standardized patient dialogues to teach prenatal counseling skills. METHODS: ChatGPT was prompted to generate a list of common areas of concern and questions that families expecting preterm delivery at 24 weeks gestation might ask during prenatal counseling. ChatGPT was then prompted to generate 2 role-plays with dialogues between a parent expecting a potential preterm delivery at 24 weeks and their counseling physician using each of the example questions. The prompt was repeated for 2 unique role-plays: one parent was characterized as anxious and the other as having low trust in the medical system. Role-play scripts were exported verbatim and independently reviewed by 2 neonatologists with experience in prenatal counseling, using a scale of 1-5 on realism, appropriateness, and utility for virtual standardized patient responses. RESULTS: ChatGPT generated 7 areas of concern, with 35 example questions used to generate role-plays. The 35 role-play transcripts generated 176 unique parent responses (median 5, IQR 4-6, per role-play) with 268 unique sentences. Expert review identified 117 (65%) of the 176 responses as indicating an emotion, either directly or indirectly. Approximately half (98/176, 56%) of the responses had 2 or more sentences, and half (88/176, 50%) included at least 1 question. More than half (104/176, 58%) of the responses from role-played parent characters described a feeling, such as being scared, worried, or concerned. The role-plays of parents with low trust in the medical system generated many unique sentences (n=50). Most of the sentences in the responses were found to be reasonably realistic (214/268, 80%), appropriate for variable prenatal counseling conversation paths (233/268, 87%), and usable without more than a minimal modification in a virtual patient program (169/268, 63%). CONCLUSIONS: Generative AI programs, such as ChatGPT, may provide a viable source of training materials to expand virtual patient programs, with careful attention to the concerns and questions of patients and families. Given the potential for unrealistic or inappropriate statements and questions, an expert should review AI chat outputs before deploying them in an educational program.

The difficult neonatal airway.

Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.

Telesimulation for neonatal resuscitation training.

Telesimulation uses telecommunication and simulation to educate and assess remote learners, obviating the need for instructors or learners to travel off site. Telesimulation increases access to and convenience of simulation-based education for sites that do not have formal simulation centers, including rural/remote areas. Telesimulation is feasible, improves knowledge and skills, and is favorably received by learners and instructors. In general, telesimulation has been shown to be effective for neonatal resuscitation training, even in low- and middle-income countries. Post telesimulation debriefing, termed teledebriefing, requires many of the skills of in-person debriefing, and teledebriefing can optimize learning by exposing learners to content experts in geographically distant sites or from specialties not available locally. When implementing telesimulation for neonatal resuscitation training, key considerations include program design, telecommunication platform, pre-telesimulation preparation, and teledebriefing. Additional research is needed to identify whether lessons learned during telesimulation translate to clinical practice and impact patient outcomes.

Virtual simulations for neonatal education.

Virtual simulation (VS) education involves the use of virtual reality, augmented reality, mixed reality and screen-based platforms, collectively referred to as extended reality, to provide education and assessment. This novel simulation modality supports experiential learning and increases access to practice opportunities, supplementing manikin-based simulation. VS has been used successfully for neonatal resuscitation training in high and low resource settings. Virtual simulators can be used to objectively assess learner performance in neonatal resuscitation knowledge and skills. When implementing VS for neonatal resuscitation training, key considerations include matching learning objectives with suitable technology, pre-session preparation, supporting learners, and debriefing. Additional research is needed to evaluate the impact of VS applications on clinical practice and patient outcomes.

Quality Indices and Outcomes of a Neonatology Telerounding Program in a Level II Neonatal Intensive Care Unit: Single-Center Experience during the COVID-19 Pandemic.

OBJECTIVE: The objective of this program evaluation was to describe the outcomes of daily neonatologist telerounding with the onsite advanced practice provider (APP) in a Level II neonatal intensive care unit (NICU), before and during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Bedside telerounding occurred with an onsite APP using a telehealth cart and paired Bluetooth stethoscope. Data collected by longitudinal and cross-sectional surveys and chart review before (May 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic were analyzed using descriptive statistics and thematic analysis. RESULTS: A total of 258 patients were admitted to the Level II NICU before (May 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic. Demographic characteristics and outcomes, including breastfeeding at discharge and length of stay were similar pre- and postonset of the COVID-19 pandemic. Postrounding surveys by 10 (response rate 83%) neonatologists indicated parents were present in 80 (77%) of rounds and video was at least somewhat helpful in 94% of cases. Cross-sectional survey responses of 23 neonatologists and APPs (response rate 62%) indicated satisfaction with the program. Common themes on qualitative analysis of open-ended survey responses were "need for goodness of fit" and "another set of eyes" and "opportunities for use." CONCLUSION: Daily telerounding with neonatologists and APPs in a Level II NICU supported neonatal care. Quality metrics and clinical outcomes are described with no differences seen before and during the COVID-19 pandemic. KEY POINTS: · Little is known about Level II NICU quality metrics and outcomes.. · Daily bedside telerounding with neonatologists and APPs is described.. · Telerounding supported neonatal care before and during the COVID-19 pandemic.. · Neonatologists found visual exam helpful in the majority of cases.. · No differences in NICU clinical outcomes were seen during the COVID-19 pandemic..

Neonatal Transport Safety Metrics and Adverse Event Reporting: A Systematic Review.

OBJECTIVE: Neonatal transports are an essential component of regionalized medical systems. Neonates who are unstable after birth require transport to a higher level of care by neonatal transport teams. Data on adverse events on neonatal transports are limited. The aim of this study was to identify, evaluate, and summarize the findings of all relevant studies on adverse events on neonatal transports. METHODS: We identified 38 studies reporting adverse events on neonatal transports from January 1, 2000, to December 31, 2019. The adverse events were distributed into 5 categories: vital sign abnormalities, laboratory value abnormalities, equipment challenges, system challenges, cardiopulmonary resuscitation, and transport-related mortality. RESULTS: Most of the evidence surrounds vital sign abnormalities during transport (n = 28 studies), with hypothermia as the most frequently reported abnormal vital sign. Fourteen studies addressed laboratory abnormalities, 12 reported on events related to equipment issues, and 4 reported on system issues that lead to adverse events on transport. Of the 38 included studies, 12 included mortality related to transport as an outcome, and 4 reported on cardiopulmonary resuscitation during transport. There were significant variations in samples, definitions of adverse events, and research quality. CONCLUSION: Adverse events during neonatal transport have been illuminated in various ways, with vital sign abnormalities most commonly explored in the literature. However, considerable variation in studies limits a clear understanding of the relative frequencies of each type of adverse event. The transport safety field would benefit from more efforts to standardize adverse event definitions, collect safety data prospectively, and pool data across larger care systems.

Evaluating the feasibility of a multicenter teleneonatology clinical effectiveness trial.

BACKGROUND: Our research consortium is preparing for a prospective multicenter trial evaluating the impact of teleneonatology on the health outcomes of at-risk neonates born in community hospitals. We completed a 6-month pilot study to determine the feasibility of the trial protocol. METHODS: Four neonatal intensive care units ("hubs") and four community hospitals ("spokes") participated in the pilot-forming four hub-spoke dyads. Two hub-spoke dyads implemented synchronous, audio-video telemedicine consultations with a neonatologist ("teleneonatology"). The primary outcome was a composite feasibility score that included one point for each of the following: site retention, on-time screening log completion, no eligibility errors, on-time data submission, and sponsor site-dyad meeting attendance (score range 0-5). RESULTS: For the 20 hub-spoke dyad months, the mean (range) composite feasibility score was 4.6 (4, 5). All sites were retained during the pilot. Ninety percent (18/20) of screening logs were completed on time. The eligibility error rate was 0.2% (3/1809). On-time data submission rate was 88.4% (84/95 case report forms). Eighty-five percent (17/20) of sponsor site-dyad meetings were attended by both hub and spoke site staff. CONCLUSIONS: A multicenter teleneonatology clinical effectiveness trial is feasible. Learnings from the pilot study may improve the likelihood of success of the main trial. IMPACT: A prospective, multicenter clinical trial evaluating the impact of teleneonatology on the early health outcomes of at-risk neonates born in community hospitals is feasible. A multidimensional composite feasibility score, which includes processes and procedures fundamental to completing a clinical trial, is useful for quantitatively measuring pilot study success. A pilot study allows the investigative team to test trial methods and materials to identify what works well or requires modification. Learnings from a pilot study may improve the quality and efficiency of the main effectiveness trial.

Measuring antenatal counseling skill with a milestone-based assessment tool: a validation study.

BACKGROUND: Antenatal counseling for parents in the setting of expected preterm delivery is an important component of pediatric training. However, healthcare professionals receive a variable amount and quality of formal training. This study evaluated and discussed validity of a practical tool to assess antenatal counseling skills and provide evaluative feedback: the Antenatal Counseling Milestones Scale (ACoMS). METHODS: Experts in antenatal counseling developed an anchored milestone-based tool to evaluate observable skills. Study participants with a range of antenatal counseling skills were recruited to participate in simulation of counseling sessions in person or via video with standardized patient actors presenting with preterm labor at 23 weeks' gestation. Two faculty observers scored each session independently using the ACoMS. Participants completed an ACoMS self-assessment, demographic, and feedback survey. Validity was measured with weighted kappas for inter-rater agreement, Kruskal-Wallis and Dunn's tests for milestone levels between degrees of expertise in counseling, and cronbach's alpha for item consistency. RESULTS: Forty-two participants completed observed counseling sessions. Of the 17 items included in the tool, 15 items were statistically significant with scores scaling with level of training. A majority of elements had fair-moderate agreement between raters, and there was high internal consistency amongst all items. CONCLUSION: This study demonstrates that the internal structure of the ACoMS rubric has greater than fair inter-rater reliability and high internal consistency amongst items. Content validity is supported by the scale's ability to discern level of training. Application of the ACoMS to clinical encounters is needed to determine utility in clinical practice.

Nonsurgical periodontal treatment during pregnancy and rates of preterm birth.

BACKGROUND: Periodontitis during pregnancy is associated with an increased risk of preterm birth (<37 weeks of gestation) or low birthweight (<2500 g) offspring. Beyond periodontal disease, the risk of preterm birth varies both by previous history of preterm birth and in association with social determinants prevalent among vulnerable and marginalized populations. This study hypothesized that the timing of periodontal treatment during pregnancy and/or social vulnerability measures modified the response to dental scaling and root planing for the treatment of periodontitis and prevention of preterm birth. OBJECTIVE: This study aimed to determine the association of timing of dental scaling and root planing for gravidae with a diagnosed periodontal disease on the rates of preterm birth or low birthweight offspring among subgroups or strata of gravidae as part of the Maternal Oral Therapy to Reduce Obstetric Risk randomized controlled trial. All participants in the study had clinically diagnosed periodontal disease and differed by the timing of the periodontal treatment (dental scaling and root planing at <24 weeks [per protocol] or after delivery) or by baseline characteristics. Although all participants met the well-accepted clinical criteria for periodontitis, not all participants acknowledged a priori that they had periodontal disease. STUDY DESIGN: This was a per-protocol analysis of data from 1455 participants of the Maternal Oral Therapy to Reduce Obstetric Risk trial evaluating dental scaling and root planing on the risk of preterm birth or low birthweight offspring. Adjusted multiple logistic regression to control for confounders was used to estimate associations comparing the timing of periodontal treatment in pregnancy to receiving treatment after pregnancy (referent control) on rates of preterm birth or low birthweight among subgroups of gravidae with known periodontal disease. Study analyses were stratified, and the associations with the following characteristics-body mass index, self-described race and ethnicity, household income, maternal education, recency of immigration, and self-acknowledgment of poor oral health, were explored. RESULTS: Dental scaling and root planing during the second or third trimester of pregnancy were associated with an increased adjusted odds ratio of preterm birth among those at the lower body mass index strata (18.5 to <25.0 kg/m2) (adjusted odds ratio, 2.21; 95% confidence interval, 1.07-4.98), but not among individuals who were overweight (body mass index of 25.0 to <30.0 kg/m2; adjusted odds ratio, 0.68; 95% confidence interval, 0.29-1.59) or obese (body mass index of ≥30 kg/m2; adjusted odds ratio, 1.26; 95% confidence interval, 0.65-2.49). There was no significant difference in pregnancy outcomes related to the other evaluated variables: self-described race and ethnicity, household income, maternal education, immigration status, or self-acknowledgment of poor oral health. CONCLUSION: In this per-protocol analysis of the Maternal Oral Therapy to Reduce Obstetric Risk trial, dental scaling and root planing had no preventive benefit against adverse obstetrical outcomes and were associated with increased odds of preterm birth among individuals at lower body mass index strata. There was no significant difference in the occurrence of preterm birth or low birthweight after dental scaling and root planing periodontitis treatment concerning other analyzed social determinants of preterm birth.

Considering Risks to Researchers and Staff in Low-Resource Settings during Public Health Crises: A Proposed Conceptual Model.

Human subjects research protections have historically focused on mitigating risk of harm and promoting benefits for research participants. In many low-resource settings (LRS), complex and often severe challenges in daily living, poverty, geopolitical uprisings, sociopolitical, economic, and climate crises increase the burdens of even minimal risk research. While there has been important work to explore the scope of ethical responsibilities of researchers and research teams to respond to these wider challenges and hidden burdens in global health research, less attention has been given to the ethical dilemmas and risk experienced by frontline researcher staff as they perform research-related activities in LRS. Risks such as job insecurity, moral distress, infection, or physical harm can be exacerbated during public health crises, as recently highlighted by the COVID-19 pandemic. We highlight the layers of risk research staff face in LRS and present a conceptual model to characterize drivers of this risk, with particular attention to public health crises. A framework by which funders, institutions, principal investigators, and/or research team leaders can systematically consider these additional layers of risk to researchers and frontline staff is an important and needed addition to routine research proposals and protocol review.

Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study.

OBJECTIVE: Evaluate the association of short-term tracheal intubation (TI) outcomes with premedication in the NICU. STUDY DESIGN: Observational single-center cohort study comparing TIs with full premedication (opiate analgesia and vagolytic and paralytic), partial premedication, and no premedication. The primary outcome is adverse TI associated events (TIAEs) in intubations with full premedication compared to those with partial or no premedication. Secondary outcomes included change in heart rate and first attempt TI success. RESULTS: 352 encounters in 253 infants (median gestation 28 weeks, birth weight 1100 g) were analyzed. TI with full premedication was associated with fewer TIAEs aOR 0.26 (95%CI 0.1-0.6) compared with no premedication, and higher first attempt success aOR 2.7 (95%CI 1.3-4.5) compared with partial premedication after adjusting for patient and provider characteristics. CONCLUSION: The use of full premedication for neonatal TI, including an opiate, vagolytic, and paralytic, is associated with fewer adverse events compared with no and partial premedication.

Provider Perspectives on the Acceptability, Appropriateness, and Feasibility of Teleneonatology.

OBJECTIVE: We aimed to measure provider perspectives on the acceptability, appropriateness, and feasibility of teleneonatology in neonatal intensive care units (NICUs) and community hospitals. STUDY DESIGN: Providers from five academic tertiary NICUs and 27 community hospitals were surveyed using validated implementation measures to assess the acceptability, appropriateness, and feasibility of teleneonatology. For each of the 12 statements, scale values ranged from 1 to 5 (1 = strongly disagree; 5 = strongly agree), with higher scores indicating greater positive perceptions. Survey results were summarized, and differences across respondents assessed using generalized linear models. RESULTS: The survey response rate was 56% (203/365). Respondents found teleneonatology to be acceptable, appropriate, and feasible. The percent of respondents who agreed with each of the twelve statements ranged from 88.6 to 99.0%, with mean scores of 4.4 to 4.7 and median scores of 4.0 to 5.0. There was no difference in the acceptability, appropriateness, and feasibility of teleneonatology when analyzed by professional role, years of experience in neonatal care, or years of teleneonatology experience. Respondents from Level I well newborn nurseries had greater positive perceptions of teleneonatology than those from Level II special care nurseries. CONCLUSION: Providers in tertiary NICUs and community hospitals perceive teleneonatology to be highly acceptable, appropriate, and feasible for their practices. The wide acceptance by providers of all roles and levels of experience likely demonstrates a broad receptiveness to telemedicine as a tool to deliver neonatal care, particularly in rural communities where specialists are unavailable. KEY POINTS: · Neonatal care providers perceive teleneonatology to be highly acceptable, appropriate, and feasible.. · Perceptions of teleneonatology do not differ based on professional role or years of experience.. · Perceptions of teleneonatology are especially high in smaller hospitals with well newborn nurseries..

Perspectives of medical students on simulation-based training: the Nigerian experience.

Introduction: simulation-based education (SBE) is becoming more prevalent in higher education. However, little is known of the perceptions of medical students towards this training approach. The objective of this study was to explore the perceptions of Nigerian medical students on manikin-based and virtual simulation training. Methods: in January 2019, a paper-based 25-item survey on simulation-based training was administered to a convenience sample of 120 medical students in the 4th year (400 level) and final year (600 level). Data were analysed using descriptive statistics, Pearson´s chi square, and the Fisher´s Exact test. Results: a total of 95 surveys were completed (RR 79%). Respondents were mostly 21-30 years 95 (81%) and about half were female 60 (51%). Under half of 600 level students 22 (38%) reported receiving simulation-based training in Basic Life Support. A lack of curriculum 27 (28%), instructors trained in simulation education 31 (33%) and funding 52 (55%) were perceived as challenges to manikin-based simulation. Lack of awareness was the greatest single challenge to online simulation 50 (53%). A majority of medical students 181 (96%) owned smartphones, but only 3% (n=3) of respondents had experienced a virtual reality (VR) simulation. If facilities were available, 99% of respondents would recommend the use of online simulation. Conclusion: there is an opportunity for increased exposure to simulation-based training during undergraduate medical education in Nigeria. Instruction in simulation methods for clinical lecturers in medical schools would increase awareness of the potential advantages of simulation-based training and access for medical students to simulation education.

Neonatal Vital Sign Trajectories and Risk Factors During Transport Within a Regional Care Network.

OBJECTIVE: The aim of this study was to characterize vital sign abnormalities, trajectories, and related risk factors during neonatal transport. METHODS: We performed a retrospective analysis of neonates transported within a US regional care network in 2020 to 2021. Demographic and clinical data were collected from electronic records. Group-based trajectory modeling was applied to identify groups of neonates who followed distinct vital sign trajectories during transport. Patients with conditions likely to impact the assessed vital were excluded. Risk factors for trajectories were examined using modified Poisson regression models. RESULTS: Of the 620 neonates in the study, 92% had one abnormal systolic blood pressure (SBP) measure, approximately half had an abnormal heart rate (47%) or temperature (56%), and 28% had an abnormal oxygen saturation measure during transport. Over half (53%) were in a low and decreasing SBP trajectory, and 36% were in a high and increasing heart rate trajectory. Most infants ≤ 28 weeks postmenstrual age had 2 or more concerning vital sign trajectories during transport. CONCLUSION: Abnormal vital signs were common during neonatal transport, and potentially negative trajectories in heart rate and SBP were more common than temperature or oxygen saturation. Transport teams should be trained and equipped to detect concerning trends and respond appropriately while en route.

Evaluation of a Program to Reduce Infant Mortality Risk Factors in Central Indiana.

The purpose of the program WeCare was to provide a personalized approach to addressing the wide array of psycho-social-cultural-fiscal needs to reduce risk factors for infant mortality (IM) by supporting maternal and infant health through health coaching by community health workers (CHWs). A prospective cohort study of 1,513 women from highest risk ZIP codes for IM in central Indiana were followed over three years. The WeCare program focused on training and deploying CHWs to provide evidence-based, patient-centered social care and support to pregnant and postpartum women and tracked outcomes in health risk categories (mental health, nutrition, safe sleep, breastfeeding) targeted for behavioral change. The low birth weight rate among program participants was lower (8.9%) than Marion County's rate (10%) (p=0.23) with statistically significant improvement in many risk behaviors. Despite limitations, the personalized coaching provided by the CHWs provided an effective, practical approach to maternal and child health disparities.