Use of neonatal simulation models to assess competency in bag-mask ventilation.

OBJECTIVE: Providing adequate bag-mask ventilation (BMV) is an essential skill for neonatal resuscitation. Often this skill is learned using simulation manikins. Currently, there is no means of measuring the adequacy of ventilation in simulated scenarios. Thus, it is not possible to ascertain proficiency. The first aim of this study was to measure the pressure generated during BMV as performed by providers with different skill levels and measure the impact of different feedback mechanisms. The second aim was to measure the pressure volume characteristics of two neonatal manikins to see how closely they reflect newborn lung mechanics. STUDY DESIGN: In Phase I to achieve the first aim, we evaluated BMV skills in different level providers including residents (n=5), fellows (n=5), neonatal nurse practitioners (n=5) and neonatologists (n=5). Each provider was required to provide BMV for 2-min epochs on the SimNewB (Laerdal), which had been instrumented to measure pressure-volume characteristics. In sequential 2-min epochs, providers were given different feedback including chest-wall movement alone compared to manometer plus chest-wall movement or chest-wall movement plus manometer plus laptop lung volume depiction. In Phase II of the study we measured pressure-volume characteristics in instrumented versions of the SimNewB (Laerdal) and NeoNatalie (Laerdal). RESULTS: In Phase I, all providers are compared with the neonatologists. All measurements of tidal volume (Vt) are below the desired 5 ml kg(-1). The greatest difference in Vt between the neonatologists and other providers occurs when only chest-wall movement is provided. A linear relationship is noted between Vt and PIP for both SimNewB and NeoNatalie. The compliance curves are not 'S-shaped' and are different between the two models (P<0.001). CONCLUSION: Phase I of this study demonstrates that the SimNewB with the feedback of chest-wall movement alone was the best method of distinguishing experienced from inexperienced providers during simulated BMV. Therefore this is likely to be the best method to ascertain proficiency. Phase II of the study shows that the currently available neonatal simulation manikins do not have pressure-volume characteristics that are reflective of newborn lung mechanics, which can result in suboptimal training.

A model for assessing and improving drug abuse treatment resource use in inner-city areas.

While the field of drug use research has grown increasingly sophisticated theoretically and methodologically, there continues to be a need to improve our understanding of how drug abuse treatment programs relate to the communities they serve. In addressing this need, the present paper develops a research model, incorporating systems theory concepts, which provides a framework for evaluating how the relationships of drug abuse treatment programs to various consumer and community interest groups affect their performance.

Overview of the Community Mental Health Centers Program from an evaluation perspective.

The 18-year Community Mental Health Center (CMHC) Program of the National Institute of Mental Health (NIMH) was a complex and ambitious social experiment. This review identifies nine of the major goals of the program and examines available evaluative information on how well each was achieved. The most significant achievements of the program include increasing the quantity and range of public mental health services. Equality of access to services was also improved but all inequities were not removed. Problems continue to exist in funding services on the basis of need, in providing services to chronic clients, and in coordinating services. Prevention efforts suffered from uncertainties and perhaps overly optimistic expectations. The achievements of the program are currently threatened by third-party reimbursement mechanisms, the loss of federal leadership and oversight, and the loss of a community orientation in public mental health services. A great deal can be learned from the achievements and the shortfalls of the CMHC program that may be useful in state and federal mental health planning.

Accountability revisited: the arrival of client outcome evaluation.

In the past few years, "accountability" for public mental health programs has become differentiated in the minds of not only program evaluators, but also program managers and funders, including state and local-level legislators. Increasingly, these officials are becoming concerned with more than just the numbers and targets of services delivered, and the cost involved, and are looking for evidence of positive outcome or impact on clients to justify program implementation and maintenance. This represents a significant move beyond the two accountability models that most recently seemed to be the focus of most formal accountability efforts--performance measurement and quality assurance. Pressures for implementing these two alternatives seem to have been reduced somewhat by the new federal Administration, but even prior to its advent there had been a rapid escalation in awareness of and concern for client outcome measurement among important audiences, including state and local mental health policy-makers and the U.S. Congress. This presents a major new opportunity and challenge for program evaluators at this new accountability focus continues to gather momentum.

Awareness, use, and consequences of evaluation data in a community mental health center.

A major aspect of the effort of the Mental Health Systems Evaluation Project of the Northwest Denver Community Health Center's has involved studying the utilization of program evaluation data by community mental health center managers and clinicians. The intent of this effort was twofold: to assess the impact of program evaluation feedback in the community mental health center per se; and to investigate factors that influenced this impact. The impact of such input was assessed initially at the level of "subjective utility." Later attempts involved more extended or interactive forms of input and impact assessment. Basic findings to date suggest that program evaluation data are most likely to have impact when directed at the managers most closely involved with the service at issue, and when presented, preferably simply and personally, in ways that insure an understanding of the data and its implications by those receiving it.