Outcomes after delivery room positive pressure ventilation in late preterm and term infants.

Objectives: Characterize short-term outcomes of late preterm and term infants who received positive pressure ventilation in the delivery room and compare these with infants who did not receive resuscitation at birth. Study Design: Single center retrospective cohort study of infants born between 35 0/7 and 41 6/7 weeks' gestation in 2019. Baseline characteristics and outcomes of infants who received positive pressure ventilation were compared with controls who did not receive delivery room ventilation. The primary outcome was neonatal intensive care unit admission; secondary outcomes included multiple hospital morbidities and interventions. Results: Among 202 infants who received delivery room positive pressure ventilation, 77 (38.1%) received ≤1 min, and 125 (61.9%) received >1 min of positive pressure ventilation. Neonatal intensive care unit admission directly following resuscitation was more common in the ventilation cohort (33%) compared with controls (1.5%), p ≤ 0.0001. After initial admission to the newborn nursery, intensive care unit transfer rates were similar in the positive pressure ventilation cohort (4%) and controls (5%). Antibiotic exposure, hypoxic ischemic encephalopathy, respiratory support in the neonatal intensive care unit, and pneumothorax were more common in the ventilation cohort. The composite outcome of any post-delivery complication occurred in 45% of positive pressure ventilation-exposed infants, compared to 15.8% of control infants (<0.0001); this was more common following >1 min (52.8%) than ≤1 min positive pressure ventilation (32.5%), p = 0.002. Conclusion: Post-delivery complications are common following delivery room positive pressure ventilation, emphasizing the need for post-resuscitation monitoring in either the neonatal intensive care unitor newborn nursery setting.

The Hidden Impact of Neonatology Boot Camp: A Qualitative Study.

INTRODUCTION: Simulation-based boot camps have been evaluated by fellows as an effective way to learn, to improve self-confidence, and to prepare for new responsibilities. However, existing studies do not explore how boot camps may contribute to other critical aspects of trainee development. Our objective was to use qualitative research methodology to characterize trainees' experiences of boot camp and its impact on their professional development. METHODS: This study used a phenomenological framework to explore fellows' experience of boot camp. Semistructured phone interviews were conducted with first-year neonatology fellows after attending the Regional Neonatology Boot Camp. Interviews were transcribed and coded for themes. The authors continually evaluated the coding categories in an iterative process until consensus was reached. RESULTS: Seventy-seven first-year neonatal-perinatal medicine fellows representing 16 fellowship programs participated in the Regional Neonatology Boot Camp in 2016 and 2017. Fifteen fellows from 10 institutions were interviewed before reaching thematic saturation. Five themes were identified: introspection about starting fellowship, learning to lead and communicate, gaining reassurance from the shared experience, understanding the fellow role, and developing future identity as a neonatologist. CONCLUSIONS: Participation in boot camp enhances fellows' professional identity formation (PIF) by incorporating key aspects of socialization, including role models and mentors, a variety of experiential learning, and opportunities for conscious self-reflection. In designing future boot camp experiences, educators should integrate these elements into the curriculum to support PIF and explicitly state PIF as a learning objective.

Pivot and Persist: A Technical Report on Adapting an Existing Multi-Institutional Bootcamp to a Hybrid Platform.

The coronavirus disease 2019 (COVID-19) pandemic has disrupted most in-person simulation training, including established simulation-based medical bootcamps. These sessions are important for the preparation of new trainees to think critically about common clinical scenarios, practice technical skills, and optimize leadership, teamwork, and communication. Having the opportunity to hone these skills in a safe environment is instrumental for the development of trainees' confidence and professional identity formation, and may contribute to patient safety. When the annual New England/Mid-Atlantic regional first-year neonatology fellows' bootcamp was jeopardized by COVID restrictions, we implemented a novel approach to adapt the existing in-person format and curriculum for large-scale hybrid delivery. The resultant two-day session was well-received by both participants and facilitators. Important lessons from this experience, including adaptions to the curriculum, schedule, simulation interface and hybrid platform, are relevant to educators seeking to conduct large-scale virtual simulation-based educational sessions.

Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn.

Introduction: The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. Methods: This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. Results: The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. Discussion: This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

Corrective steps to enhance ventilation in the delivery room.

OBJECTIVE: The clinical impact of ventilation corrective steps for delivery room positive pressure ventilation (PPV) is not well studied. We aimed to characterise the performance and effect of ventilation corrective steps (MRSOPA (Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase and Alternative airway)) during delivery room resuscitation of preterm infants. DESIGN: Prospective observational study of delivery room PPV using video and respiratory function monitor recordings. SETTING: Tertiary academic delivery hospital. PATIENTS: Preterm infants <32 weeks gestation. MAIN OUTCOME MEASURE: Mean exhaled tidal volume (Vte) of PPV inflations before and after MRSOPA interventions, categorised as inadequate (<4 mL/kg); appropriate (4-8 mL/kg), or excessive (>8 mL/kg). Secondary outcomes were leak (>30%) and obstruction (Vte <1 mL/kg), and infant heart rate. RESULTS: There were 41 corrective interventions in 30 infants, with a median duration of 15 (IQR 7-29) s. The most frequent intervention was a combination of Mask/Reposition and Suction/Open. Mean Vte was inadequate before 16/41 interventions and became adequate following 6/16. Mean Vte became excessive after 6/41 interventions. Mask leak, present before 13/41 interventions, was unchanged after 4 and resolved after 9. Obstruction was present before five interventions and was subsequently resolved only once. MRSOPA interventions introduced leak in two cases and led to obstruction in one case. The heart rate was <100 beats per minute before 31 interventions and rose to >100 beats per minute after 14/31 of these. CONCLUSIONS: Ventilation correction interventions improve tidal volume delivery in some cases, but lead to ineffective or excessive tidal volumes in others. Mask leak and obstruction can be induced by MRSOPA manoeuvres.

Reducing Variation in the Management of Apnea of Prematurity in the Intensive Care Nursery.

BACKGROUND: Premature infants have bradycardia and/or desaturation events due to apnea of prematurity that resolve as the infants mature. Despite American Academy of Pediatrics guidelines recommending a standard "event-free" period before discharge, length of observation in our Intensive Care Nursery was variable. By June 2018, for infants born <36 weeks' gestation in the Intensive Care Nursery, we aimed to standardize time to discharge after the last documented event at 5 days, when the baseline mean was 3.6 days (range 0-6 days). METHODS: A quality-improvement team used the Model for Improvement. Plan-do-study-act cycles improved nursing documentation of events and standardized discharge criteria after consensus on operational definitions. The outcome measure was days to discharge after last documented event. Process measures included percentage of events documented completely and correctly in the electronic medical record. Balancing measure was length of stay after 36 weeks' corrected gestational age. We used statistical process control. RESULTS: The baseline event watch ranged from 0 to 6 days. After defining significant events, documentation expectations, and consensus on a 5-day "watch" before discharge, the event watch range narrowed with a mean that shifted from 3.6 to 4.8 days on X-bar S statistical process control chart. Completeness of documentation increased from 38% to 63%, and documentation of significant events increased from 38% to 88%. Length of stay after 36 weeks' corrected gestational age was unchanged, and nursing satisfaction improved. CONCLUSIONS: We found decreasing variation in the management of apnea of prematurity while simultaneously improving staff satisfaction. Next steps include revising electronic medical record flowsheets and spread to network NICUs.