Simulation in New Zealand: what have you done for me lately? New Zealand Association for Simulation in Healthcare (NZASH) white paper.

Medical simulation has become an integral aspect of modern healthcare education and practice. It has evolved to become an essential aspect of teaching core concepts and skills, common and rare presentations, algorithms and protocols, communication, interpersonal and teamworking skills and testing new equipment and systems. Simulation-based learning (SBL) is useful for the novice to the senior clinician. Healthcare is a complex adaptive system built from very large numbers of mutually interacting subunits (e.g., different professions, departments, equipment). These subunits generate multiple repeated interactions that have the potential to result in rich, collective behaviour that feeds back into the organisation. There is a unique opportunity in New Zealand with the formation of Te Whatu Ora - Health New Zealand and Te Aka Whai Ora - Maori Health Authority and the reorganisation of the healthcare system. This viewpoint is a white paper for the integration of SBL into our healthcare system. We describe our concerns in the current system and list our current capabilities. The way SBL could be implemented in pre- and post-registration phases of practice are explored as well as the integration of communication and culture. Interprofessional education has been shown to improve outcomes and is best done with an interprofessional simulation curriculum. We describe ways that simulation is currently used in our system and describe other uses such as quality improvement, safety and systems engineering and integration. The aim of this viewpoint is to alert Te Whatu Ora and Te Aka Whai Ora of the existing infrastructure of the simulation community in New Zealand and encourage them to invest in its future.

Examining the potential preventability of adverse fetal/neonatal outcomes associated with severe maternal morbidity.

BACKGROUND: Severe maternal morbidity (SMM) occurs in 1-2% of pregnancies. Despite the knowledge that a SMM event can contribute to poor fetal/neonatal outcomes, little is known about the preventability of these adverse outcomes. AIMS: To examine adverse fetal/neonatal outcomes associated with SMM to determine if these outcomes were potentially preventable. MATERIALS AND METHODS: A New Zealand national retrospective cohort study examining cases of SMM with an adverse fetal/neonatal outcome. Maternity and initial neonatal care were explored by multidisciplinary panels utilising a preventability tool to assess whether the fetal/neonatal harm was potentially preventable. Adverse fetal/neonatal outcomes were defined as fetal or early neonatal death, Apgar score <7 at five minutes, admission to neonatal intensive care unit or special care baby unit and neonatal encephalopathy. RESULTS: Of 85 cases reviewed, adverse fetal/neonatal outcome was deemed potentially preventable in 55.3% of cases (n = 47/85). Preventability was related to maternal antenatal/peripartum care (in utero) in 39% (n = 33/85), to initial neonatal care (ex utero) in 36% (n = 29/80), and to both maternal and neonatal care in 20% (16/80) of cases. Main contributors to potential preventability were factors related to healthcare providers, particularly lack of recognition of high risk, delayed or failure to diagnose, and delayed or inappropriate treatment. CONCLUSIONS: Multidisciplinary panels found that over half of adverse fetal/neonatal harm associated with SMM was potentially preventable. The novel approach of examining both maternal and neonatal care identifies opportunities to improve fetal/neonatal outcomes associated with SMM at multiple points on the perinatal continuum of care.

Macronutrient Composition of Donated Human Milk in a New Zealand Population.

BACKGROUND: A primary role of human donor milk banks is to provide pasteurized human milk for the sick and preterm infant populations and to support the mothers of these infants as they establish their own milk supply. The results of human milk pasteurization continue to be studied to provide information that enables optimal nutrition in this sick and preterm population. RESEARCH AIMS: The aims of our study were to determine macronutrient characteristics (fat, protein, carbohydrate) and energy content of human milk donated to the Christchurch Women's Hospital Human Milk Bank in New Zealand, and the influence of Holder pasteurization on this macronutrient composition. METHODS: This was a retrospective, pre/post pasteurization observational design to describe the macronutrient content within two groups of donors, mature preterm PDM (n = 13; 21%) and mature term PDM (n = 50; 79%). Sixty three samples of human milk donated to the human milk bank by 27 registered participants (mothers of preterm and term infants) were analyzed. This analysis took place July-September 2018 using a human milk analyzer before and after Holder pasteurization (62.5 °C for 30 min). RESULTS: Preterm milk contained on average 76 kcal/100 ml energy, 4.0 g/100 ml fat, 1.1 g/100 ml protein and 8.2 g/100 ml total carbohydrate; and mature term milk contained 68 kcal/100 ml energy, 3.5 g/100 ml fat, 0.8 g/100 ml protein and 7.9 g/100 ml total carbohydrate. Wide variation between single, donor-pooled samples was demonstrated and there was no major result of pasteurization. CONCLUSION: This research adds to the evidence regarding the macronutrient content of preterm and term milk and that these values are unaffected by Holder pasteurization. The variance in individual pooled donor human milk indicates the importance of determining the nutrient composition of donated milk to inform fortification procedures.

Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity.

BACKGROUND: While there is a global focus on severe maternal morbidity (SMM), less is known about the impact of SMM on fetal and neonatal outcomes. AIMS: To examine fetal/neonatal outcomes associated with SMM. MATERIALS AND METHODS: A national New Zealand (NZ) retrospective cohort study describing fetal/neonatal outcomes of all women with SMM admitted to a NZ Intensive Care Unit (ICU) or High Dependency Unit (HDU) in 2014. Adverse fetal/neonatal outcomes were defined as one or more of the following: fetal or early neonatal death, hypoxic ischaemic encephalopathy, Apgar score less than seven at five minutes, admission to Neonatal Intensive Care Unit or Special Care Baby Unit. RESULTS: There were 400 women with SMM admitted to NZ ICU/HDU units in 2014, and 395 (98.8%) had complete birth/pregnancy outcome information. Of these, 49.4% (195/395) were associated with an adverse fetal/neonatal outcome. Indigenous Maori women had a 30% higher rate of adverse fetal/neonatal outcome compared to NZ European women (63.7% and 48.9% respectively; relative risk = 1.30, 95% CI 1.04-1.64). Pre-eclampsia was associated with an adverse fetal/neonatal outcome in 67% (81/120). Perinatal-related mortality rate was 53.1 per 1000 total births compared to NZ perinatal mortality of 11.2 per 1000 total births for 2014. CONCLUSION: SMM events are associated with high rates of adverse fetal/neonatal outcomes with a higher burden of adverse events for Maori. Further research is needed to explore opportunities in maternal and neonatal care pathways to improve fetal/neonatal outcomes and address inequities.

Supporting mothers, protecting babies for long-term health: establishing a pasteurised human milk bank.

It is now very clear that early feeding practices have lifelong implications for an individual's health as well as economic and public health consequences. This article summarises some of the important reasons to prioritise breast milk feeding and introduces the Christchurch Neonatal Intensive Care Human Milk Bank. This Milk Bank was opened in 2014 to support babies and their families with the provision of pasteurised donor milk. The primary goals were to support mothers while they established their own milk supply, reduce exposure to parenteral nutrition and formula and reduce the risk of necrotising enterocolitis in this vulnerable population.

Mutations in the DNAH11 (axonemal heavy chain dynein type 11) gene cause one form of situs inversus totalis and most likely primary ciliary dyskinesia.

Primary ciliary dyskinesia (PCD; MIM 242650) is an autosomal recessive disorder of ciliary dysfunction with extensive genetic heterogeneity. PCD is characterized by bronchiectasis and upper respiratory tract infections, and half of the patients with PCD have situs inversus (Kartagener syndrome). We characterized the transcript and the genomic organization of the axonemal heavy chain dynein type 11 (DNAH11) gene, the human homologue of murine Dnah11 or lrd, which is mutated in the iv/iv mouse model with situs inversus. To assess the role of DNAH11, which maps on chromosome 7p21, we searched for mutations in the 82 exons of this gene in a patient with situs inversus totalis, and probable Kartagener syndrome associated with paternal uniparental disomy of chromosome 7 (patUPD7). We identified a homozygous nonsense mutation (R2852X) in the DNAH11 gene. This patient is remarkable because he is also homozygous for the F508del allele of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Sequence analysis of the DNAH11 gene in an additional 6 selected PCD sibships that shared DNAH11 alleles revealed polymorphic variants and an R3004Q substitution in a conserved position that might be pathogenic. We conclude that mutations in the coding region of DNAH11 account for situs inversus totalis and probably a minority of cases of PCD.

Mutations in DNAH5 cause primary ciliary dyskinesia and randomization of left-right asymmetry.

Primary ciliary dyskinesia (PCD, MIM 242650) is characterized by recurrent infections of the respiratory tract due to reduced mucociliary clearance and by sperm immobility. Half of the affected offspring have situs inversus (reversed organs), which results from randomization of left-right (LR) asymmetry. We previously localized to chromosome 5p a PCD locus containing DNAH5, which encodes a protein highly similar to the Chlamydomonas gamma-dynein heavy chain. Here we characterize the full-length 14-kb transcript of DNAH5. Sequence analysis in individuals with PCD with randomization of LR asymmetry identified mutations resulting in non-functional DNAH5 proteins.