How Much Training Is Enough? Low-Dose, High-Frequency Simulation Training and Maintenance of Competence in Neonatal Resuscitation.

INTRODUCTION: Facemask ventilation is a crucial, but challenging, element of neonatal resuscitation.In a previously reported study, instructor-led training using a novel neonatal simulator resulted in high-level ventilation competence for health care providers (HCPs) involved in newborn resuscitation. The aim of this study was to identify the optimal frequency and dose of simulation training to maintain this competence level. METHODS: Prospective observational study of HCPs training through 9 months. All training was logged. Overall ventilation competence scores were calculated for each simulation case, incorporating 7 skill elements considered important for effective ventilation.Overall scores and skill elements were analyzed by generalized linear mixed effects models using frequency (number of months of 9 where training occurred and total number of training sessions in 9 months) and dose (total number of cases performed) as predictors. Training loads (frequency + dose) predictive of high scores were projected based on estimated marginal probabilities of successful outcomes. RESULTS: A total of 156 HCPs performed 4348 training cases. Performing 5 or more sessions in 9 months predicted high global competence scores (>28/30). Frequency was the best predictor for 4 skill elements; success in maintaining airway patency and ventilation fraction was predicted by performing training in, respectively, 2 and 3 months of 9, whereas for avoiding dangerously high inflating pressures and providing adequate mask seal, 5 and 6 sessions, respectively, over the 9 months, predicted success. Skills reflecting global performance (successful resuscitation and valid ventilations) and ventilation rate were more dose-dependent. CONCLUSIONS: Training frequency is important in maintaining neonatal ventilation competence. Training dose is important for some skill elements. This offers the potential for individualized training schedules.

Newborn resuscitation timelines: Accurately capturing treatment in the delivery room.

OBJECTIVES: To evaluate the use of newborn resuscitation timelines to assess the incidence, sequence, timing, duration of and response to resuscitative interventions. METHODS: A population-based observational study conducted June 2019-November 2021 at Stavanger University Hospital, Norway. Parents consented to participation antenatally. Newborns ≥28 weeks' gestation receiving positive pressure ventilation (PPV) at birth were enrolled. Time of birth was registered. Dry-electrode electrocardiogram was applied as soon as possible after birth and used to measure heart rate continuously during resuscitation. Newborn resuscitation timelines were generated from analysis of video recordings. RESULTS: Of 7466 newborns ≥28 weeks' gestation, 289 (3.9%) received PPV. Of these, 182 had the resuscitation captured on video, and were included. Two-thirds were apnoeic, and one-third were breathing ineffectively at the commencement of PPV. PPV was started at median (quartiles) 72 (44, 141) seconds after birth and continued for 135 (68, 236) seconds. The ventilation fraction, defined as the proportion of time from first to last inflation during which PPV was provided, was 85%. Interruption in ventilation was most frequently caused by mask repositioning and auscultation. Suctioning was performed in 35% of newborns, in 95% of cases after the initiation of PPV. PPV was commenced within 60 s of birth in 49% of apnoeic and 12% of ineffectively breathing newborns, respectively. CONCLUSIONS: Newborn resuscitation timelines can graphically present accurate, time-sensitive and complex data from resuscitations synchronised in time. Timelines can be used to enhance understanding of resuscitation events in data-guided quality improvement initiatives.

Improvements in Obstetric and Newborn Health Information Documentation following the Implementation of the Safer Births Bundle of Care at 30 Facilities in Tanzania.

This paper examines changes in the completeness of documentation in clinical practice before and during the implementation of the Safer Births Bundle of Care (SBBC) project. This observational study enrolled parturient women with a gestation age of at least 28 weeks at the onset of labour. Data collectors extracted information from facility registers and then a central data manager summarised and reported weekly statistics. Variables of clinical significance for CQI were selected, and the proportion of non-documentation was analysed over time. A Pearson chi-square test was used to test for significant differences in non-documentation between the periods. Between 1 March 2021 and 31 July 2022, a total of 138,442 deliveries were recorded. Overall, 75% of all patient cases had at least one missing variable among the selected variables across both periods. A lack of variable documentation occurred more frequently at the district hospital level (81% of patient cases) and health centres (74%) than at regional referral hospitals (56%) (p < 0.001). Non-documentation decreased significantly from 79% to 70% after the introduction of the SBBC (p < 0.001). A tendency towards negative correlations was noted for most variables. We noted an increased attention to data quality and use which may have a positive impact on the completeness of documentation. However, halfway through the project's implementation, the completeness of documentation was still low. Our findings support the recommendation to establish short-spaced feedback loops of locally collected data using one data platform.

Prevalence of bradycardia in 4876 newborns in the first minute after birth and association with positive pressure ventilation: a population-based cross-sectional study.

OBJECTIVE: To determine the prevalence of bradycardia in the first minute after birth and association with positive pressure ventilation (PPV). METHOD: A population-based cross-sectional study was conducted from June 2019 to December 2021 at Stavanger University Hospital, Norway. Parents consented to participation during pregnancy, and newborns ≥28 weeks' gestation were included at birth. Heart rate (HR) was captured immediately after birth and continuously for the first minute(s). Time of birth was registered on a tablet. Provision of PPV was captured using video. RESULTS: Of 4876 included newborns, 164 (3.4%) did not breathe (two-thirds) or breathed ineffectively (one-third) and received PPV at birth. HR in the first minute had a wide distribution. The prevalence of first measured HR <100 and <60 beats/minute at median 16 s was 16.3% and 0.6%, respectively. HR increased in most cases. At 60 s, 3.7% had HR <100 beats/minute, of which 82% did not require PPV. In total, 25% of newborns had some registered HR <100 beats/minute during the first minute, of which 95% did not require PPV. Among newborns who received PPV, 76% and 62% had HR ≥100 beats/minute at 60 s and at start PPV, respectively. CONCLUSION: Bradycardia with HR <100 bpm in the first minute of life was frequent, but mostly self-resolved. Among the 4% of newborns that remained bradycardic at 60 s, only 20% received PPV. Two-thirds of resuscitated newborns had HR ≥100 beats/minute at start PPV. None of the ventilated newborns were breathing adequately at start PPV. TRIAL REGISTRATION NUMBER: NCT03849781.

Use of Suctioning during Newborn Resuscitation and Its Effects on Heart Rate in a Low-Resource Setting, Tanzania.

Suctioning of newborns immediately after birth, as part of delivery room resuscitation, is only recommended if the airway is obstructed. The aim of this study was to describe the use of suctioning during newborn resuscitation among survivors versus those who died within 3 days and potential suction-related heart rate responses and associations to newborn characteristics. This was a retrospective observational study from July 2013 to July 2016 in a referral hospital in rural Tanzania. Research assistants observed and documented all deliveries, newborn resuscitations were video-recorded, and newborn heart rates were captured with a dry-electrode electrocardiogram. Liveborn infants ≥34 weeks gestation who received ventilation and with complete datasets were eligible. All 30 newborns who died were included, and a total of 46 survivors were selected as controls. Videos were annotated and heart rate patterns were observed before and after the suction events. Suctioning was performed more frequently than recommended. No differences were found in suctioning characteristics between newborns who died versus those who survived. In 13% of suction events, a significant heart rate change (i.e., arrhythmia or brief/sustained >15% fall in heart rate) was observed in relation to suctioning. This represents a potential additional harm to already depressed newborns undergoing resuscitation.

Virtual reality simulation training in stroke thrombectomy centers with limited patient volume-Simulator performance and patient outcome.

BACKGROUND: Virtual reality simulation training may improve the technical skills of interventional radiologists when establishing endovascular thrombectomy at limited-volume stroke centers. The aim of this study was to investigate whether the technical thrombectomy performance of interventional radiologists improved after a defined virtual reality simulator training period. As part of the quality surveillance of clinical practice, we also assessed patient outcomes and thrombectomy quality indicators at the participating centers. METHODS: Interventional radiologists and radiology residents from three thrombectomy-capable stroke centers participated in a five months thrombectomy skill-training curriculum on a virtual reality simulator. The simulator automatically registered procedure time, the number of predefined steps that were correctly executed, handling errors, contrast volume, fluoroscopy time, and radiation dose exposure. The design was a before-after study. Two simulated thrombectomy cases were used as pretest and posttest cases, while seven other cases were used for training. Utilizing the Norwegian Stroke Register, we investigated clinical results in thrombectomy during the study period. RESULTS: Nineteen interventional radiologists and radiology residents participated in the study. The improvement between pretest and posttest cases was statistically significant for all outcome measures in both simulated cases, except for the contrast volume used in one case. Clinical patient outcomes in all three centers were well within the recommendations from multi-society consensus guidelines. CONCLUSION: Performance on the virtual reality simulator improved after training. Virtual reality simulation may improve the learning curve for interventional radiologists in limited-volume thrombectomy centers. No correlation alleged, the clinical data indicates that the centers studied performed thrombectomy in accordance with guideline-recommended standards.

Increase in Newborns Ventilated Within the First Minute of Life and Reduced Mortality After Clinical Data-Guided Simulation Training.

INTRODUCTION: Birth asphyxia-related deaths is a major global concern. Rapid initiation of ventilation within the "Golden Minute" is important for intact survival but reported to be challenging, especially in low-/middle-income countries. Helping Babies Breathe (HBB) is a simulation-based training program for newborn resuscitation. The aim of this HBB quality improvement (QI) intervention was to decrease time from birth to ventilation and document potential changes in perinatal outcomes. METHOD: Prospective observational QI study in a rural Tanzanian hospital, October 1, 2017, to August 31, 2021, first-year baseline, second-year QI/simulation intervention, and 2-year postintervention. Trained research assistants observed wide-ranging information from all births (N = 12,938). The intervention included monthly targeted HBB simulation training addressing documented gaps in clinical care, clinical debriefings, and feedback meetings. RESULTS: During the QI/simulation intervention, 68.5% nonbreathing newborns were ventilated within 60 seconds after birth compared with 15.8% during baseline and 42.2% and 28.9% during the 2 postintervention years (P < 0.001). Time to first ventilation decreased from median 101 (quartiles 72-150) to 55 (45-67) seconds (P < 0.001), before increasing to 67 (49-97) and 85 (57-133) seconds after intervention. More nonbreathing newborns were ventilated in the intervention period (12.9%) compared with baseline (8.5%) and the postintervention years (10.6% and 9.4%) (P < 0.001). Assumed fresh stillborns decreased significantly from baseline to intervention (3.2%-0.7%) (P = 0.013). CONCLUSIONS: This QI study demonstrates an increase in nonbreathing newborns being ventilated within the Golden Minute and a significant reduction in fresh stillborns after introduction of an HBB QI/simulation intervention. Improvements are partially reversed after intervention, highlighting the need for continuous simulation-based training and research into QI efforts essential for sustainable changes.

Incomplete Exhalation during Resuscitation-Theoretical Review and Examples from Ventilation of Newborn Term Infants.

BACKGROUND: Newborn resuscitation guidelines recommend positive pressure ventilation (PPV) for newborns who do not establish effective spontaneous breathing after birth. T-piece resuscitator systems are commonly used in high-resource settings and can additionally provide positive end-expiratory pressure (PEEP). Short expiratory time, high resistance, rapid dynamic changes in lung compliance and large tidal volumes increase the possibility of incomplete exhalation. Previous publications indicate that this may occur during newborn resuscitation. Our aim was to study examples of incomplete exhalations in term newborn resuscitation and discuss these against the theoretical background. METHODS: Examples of flow and pressure data from respiratory function monitors (RFM) were selected from 129 term newborns who received PPV using a T-piece resuscitator. RFM data were not presented to the user during resuscitation. RESULTS: Examples of incomplete exhalation with higher-than-set PEEP-levels were present in the recordings with visual correlation to factors affecting time needed to complete exhalation. CONCLUSIONS: Incomplete exhalation and the relationship to expiratory time constants have been well described theoretically. We documented examples of incomplete exhalations with increased PEEP-levels during resuscitation of term newborns. We conclude that RFM data from resuscitations can be reviewed for this purpose and that incomplete exhalations should be further explored, as the clinical benefit or risk of harm are not known.

Use of Pulse Oximetry during Resuscitation of 230 Newborns-A Video Analysis.

BACKGROUND: European guidelines recommend the use of pulse oximetry (PO) during newborn resuscitation, especially when there is a need for positive pressure ventilation or supplemental oxygen. The objective was to evaluate (i) to what extent PO was used, (ii) the time and resources spent on the application of PO, and (iii) the proportion of time with a useful PO signal during newborn resuscitation. METHODS: A prospective observational study was conducted at Stavanger University Hospital, Norway, between 6 June 2019 and 16 November 2021. Newborn resuscitations were video recorded, and the use of PO during the first ten minutes of resuscitation was recorded and analysed. RESULTS: Of 7466 enrolled newborns, 289 (3.9%) received ventilation at birth. The resuscitation was captured on video in 230 cases, and these newborns were included in the analysis. PO was applied in 222 of 230 (97%) newborns, median (quartiles) 60 (24, 58) seconds after placement on the resuscitation table. The proportion of time used on application and adjustments of PO during ongoing ventilation and during the first ten minutes on the resuscitation table was 30% and 17%, respectively. Median two healthcare providers were involved in the PO application. Video of the PO monitor signal was available in 118 (53%) of the 222 newborns. The proportion of time with a useful PO signal during ventilation and during the first ten minutes on the resuscitation table was 5% and 35%, respectively. CONCLUSION: In total, 97% of resuscitated newborns had PO applied, in line with resuscitation guidelines. However, the application of PO was time-consuming, and a PO signal was only obtained 5% of the time during positive pressure ventilation.

Healthcare Workers' Perceptions on the "SaferBirths Bundle of Care": A Qualitative Study.

Background: SaferBirths Bundle of Care (SBBC) is a package of innovative clinical and training tools coupled with low-dose high-frequency simulation-based on-job training guided by local data. This bundle of care is a new initiative being implemented in 30 health facilities from five regions of Tanzania aiming at improving birth outcomes. Objective: To assess the perception of healthcare workers and facility leaders on the "SaferBirths Bundle of Care" towards saving women's and newborns' lives at birth. Method: We used a qualitative approach using focused group discussion (FGD) and individual interviews. A total of 21 FGD and 43 individual interviews were conducted between August and November 2022. In total, 94 midwives and 12 doctors were involved, some of whom were in leadership roles. The framework method for the analysis of qualitative data was used for analysis. Results: Healthcare workers and facility leaders received the bundle well and regarded it as effective in saving lives and improving healthcare provision. Five themes emerged as facilitators to the acceptance of the bundle: (1) the bundle is appropriate to our needs, (2) the training modality and data use fit our context, (3) use of champions and periodic mentorship, (4) learning from our mistakes, and (5) clinical and training tools are of high quality but can be further improved. Conclusion: The relevance of SaferBirths Bundle of Care in addressing maternal and perinatal deaths, the quality and modality of training, and the culture that enhances learning from mistakes were among the facilitators of the acceptability of the SBBC. A well-accepted intervention has huge potential for bringing the intended impact in health provision.

Neurodevelopmental Outcome at 6 Months Following Neonatal Resuscitation in Rural Tanzania.

Early bag-mask ventilation (BMV) administered to non-breathing neonates at birth in the presence of birth asphyxia (interruption of placental blood flow) has reduced neonatal mortality by up to 50% in low- and middle-income countries. The neurodevelopmental outcome of neonates receiving BMV remains unknown. Using the Malawi Developmental Assessment Tool (MDAT), infants who received BMV at birth were assessed at 6 months, evaluating gross motor, fine motor, language and social skills. A healthy cohort with no birth complications was assessed with the same tool for comparison. Mean age-adjusted MDAT z-scores were not significantly different between the groups. The number of children having developmental delay defined as a z-score ≤ -2 was significantly higher in the resuscitated cohort for the fine motor and language domain and overall MDAT z-score. The prevalence of clinical seizures post discharge was significantly higher in the resuscitated group and was associated with neurodevelopmental delay. Infants with developmental delay or seizures were more likely to have a 5 min Apgar < 7 and a longer duration of BMV. Most children receiving BMV at birth are developing normally at 6 months. Still, there are some children with impaired development among resuscitated children, representing a subgroup of children who may have suffered more severe asphyxia.

Fetal to Neonatal Heart Rate Transition during Normal Vaginal Deliveries: A Prospective Observational Study.

Documentation of fetal to neonatal heart rate (HR) transition is limited. The aim of the current study was to describe HR changes from one hour before to one hour after normal vaginal deliveries. We conducted a prospective observational cohort study in Tanzania from 1 October 2020 to 30 August 2021, including normal vaginal deliveries with normal neonatal outcomes. HR was continuously recorded from one hour before to one hour after delivery, using the Moyo fetal HR meter, NeoBeat newborn HR meter, and the Liveborn Application for data storage. The median, 25th, and 75th HR percentiles were constructed. Overall, 305 deliveries were included. Median (interquartile range; IQR) gestational age was 39 (38-40) weeks and birthweight was 3200 (3000-3500) grams. HR decreased slightly during the last 60 min before delivery from 136 (123,145) to 132 (112,143) beats/minute. After delivery, HR increased within one minute to 168 (143,183) beats/min, before decreasing to around 136 (127,149) beats/min at 60 min after delivery. The drop in HR in the last hour of delivery reflects strong contractions and pushing. The rapid increase in initial neonatal HR reflects an effort to establish spontaneous breathing.

"Safer Births Bundle of Care" Implementation and Perinatal Impact at 30 Hospitals in Tanzania-Halfway Evaluation.

Safer Births Bundle of Care (SBBC) consists of innovative clinical and training tools for improved labour care and newborn resuscitation, integrated with new strategies for continuous quality improvement. After implementation, we hypothesised a reduction in 24-h newborn deaths, fresh stillbirths, and maternal deaths by 50%, 20%, and 10%, respectively. This is a 3-year stepped-wedged cluster randomised implementation study, including 30 facilities within five regions in Tanzania. Data collectors at each facility enter labour and newborn care indicators, patient characteristics and outcomes. This halfway evaluation reports data from March 2021 through July 2022. In total, 138,357 deliveries were recorded; 67,690 pre- and 70,667 post-implementations of SBBC. There were steady trends of increased 24-h newborn and maternal survival in four regions after SBBC initiation. In the first region, with 13 months of implementation (n = 15,658 deliveries), an estimated additional 100 newborns and 20 women were saved. Reported fresh stillbirths seemed to fluctuate across time, and increased in three regions after the start of SBBC. Uptake of the bundle varied between regions. This SBBC halfway evaluation indicates steady reductions in 24-h newborn and maternal mortality, in line with our hypotheses, in four of five regions. Enhanced focus on uptake of the bundle and the quality improvement component is necessary to fully reach the SBBC impact potential as we move forward.

Newborns requiring resuscitation: Two thirds have heart rate ≥100 beats/minute in the first minute after birth.

AIM: The aim was to study the prevalence of bradycardia at birth in newborns requiring positive pressure ventilation (PPV), distribution of first measured heart rate (HR), changes in HR before start of PPV and HR response to PPV. METHODS: A population-based study including newborns ≥30 weeks' gestation receiving PPV at birth. HR was captured immediately after birth and continuously throughout resuscitation using the dry-electrode ECG device NeoBeat. Time of birth was registered in the Liveborn app. Provision of PPV was captured by video. RESULTS: We included 98 newborns receiving PPV at birth. Among newborns with HR measured within 60 s after birth, median (quartiles) first HR was 112 (84, 149) bpm recorded 19 (14, 37) s after birth, of which 33% had first HR <100 and 10% had first HR <60 bpm respectively. First HR was widely distributed. Median HR at start PPV 69 s after birth was 129 bpm. In newborns with an initial low HR, HR typically remained low for 20 s of PPV before increasing rapidly over the next 20-30 s. CONCLUSIONS: First measured HR was ≥100 bpm in two thirds of newborns receiving PPV. In bradycardic infants, HR did not increase until after 20 s of PPV.

Simulation-based team-training in acute stroke: Is it safe to speed up?

BACKGROUND: In acute ischemic stroke (AIS), rapid treatment with intravenous thrombolysis (IVT) is crucial for good clinical outcome. Weekly simulation-based team-training of the stroke treatment team was implemented, resulting in faster treatment times. The aim of this study was to assess whether this time reduction led to a higher proportion of stroke mimics (SMs) among patients who received IVT for presumed AIS, and whether these SM patients were harmed by intracranial hemorrhage (ICH). METHODS: All suspected AIS patients treated with IVT between January 1, 2015 and December 31, 2020 were prospectively registered. In 2017, weekly in situ simulation-based team-training involving the whole stroke treatment team was introduced. To analyze possible unintended effects of simulation training, the proportion of SMs among patients who received IVT for presumed AIS were identified by clinical and radiological evaluation. Additionally, we identified the extent of symptomatic ICH (sICH) in IVT-treated SM patients. RESULTS: From 2015 to 2020, 959 patients were treated with IVT for symptoms of AIS. After introduction of simulation training, the proportion of patients treated with IVT who were later diagnosed as SMs increased significantly (15.9% vs. 24.4%, p = .003). There were no ICH complications in the SM patients treated before, whereas two SM patients suffered from asymptomatic ICH after introduction of simulation training (p = 1.0). When subgrouping SMs into prespecified categories, only the group diagnosed with peripheral vertigo increased significantly (2.5% vs. 8.6%, p < .001). CONCLUSIONS: Simulation training of the acute stroke treatment team was associated with an increase in the proportion of patients treated with IVT for a suspected AIS who were later diagnosed with peripheral vertigo. The proportion of other SM groups among IVT-treated patients did not change significantly. No sICH was detected in IVT-treated SM patients.

Newborn resuscitation simulation training and changes in clinical performance and perinatal outcomes: a clinical observational study of 10,481 births.

BACKGROUND: Annually, 1.5 million intrapartum-related deaths occur; fresh stillbirths and early newborn deaths. Most of these deaths are preventable with skilled ventilation starting within the first minute of life. Helping Babies Breathe is an educational program shown to improve simulated skills in newborn resuscitation. However, translation into clinical practice remains a challenge. The aim was to describe changes in clinical resuscitation and perinatal outcomes (i.e., fresh stillbirths and 24-h newborn deaths) after introducing a novel simulator (phase 1) and then local champions (phase 2) to facilitate ongoing Helping Babies Breathe skill and scenario simulation training. METHODS: This is a 3-year prospective before/after (2 phases) clinical observational study in Tanzania. Research assistants observed all deliveries from September 2015 through August 2018 and recorded labor/newborn information and perinatal outcomes. A novel simulator with automatic feedback to stimulate self-guided skill training was introduced in September 2016. Local champions were introduced in October 2017 to motivate midwives for weekly training, also team simulations. RESULTS: The study included 10,481 births. Midwives had practiced self-guided skill training during the last week prior to a real newborn resuscitation in 34% of cases during baseline, 30% in phase 1, and 71% in phase 2. Most real resuscitations were provided by midwives, increasing from 66% in the baseline, to 77% in phase 1, and further to 83% in phase 2. The median time from birth to first ventilation decreased between baseline and phase 2 from 118 (85-165) to 101 (72-150) s, and time pauses during ventilation decreased from 28 to 16%. Ventilations initiated within the first minute did not change significantly (13-16%). The proportion of high-risk deliveries increased during the study period, while perinatal mortality remained unchanged. CONCLUSIONS: This study reports a gradual improvement in real newborn resuscitation skills after introducing a novel simulator and then local champions. The frequency of trainings increased first after the introduction of motivating champions. Time from birth to first ventilation decreased; still, merely 16% of newborns received ventilation within the first minute as recommended. This is a remaining challenge that may require more targeted team-scenario training and quality improvement efforts to improve.

Suctioning of clear amniotic fluid at birth: A systematic review.

Context: Upper airway suctioning at birth was considered standard procedure and is still commonly practiced. Negative effects could exceed benefits of suction. Question: In infants born through clear amniotic fluid (P) does suctioning of the mouth and nose (I) vs no suctioning (C) improve outcomes (O). Data sources: Information specialist conducted literature search (12th September 2021, re-run 17th June 2022) using Medline, Embase, Cochrane Databases, Database of Abstracts of Reviews of Effects, and CINAHL. RCTs, non-RCTs and observational studies with a defined selection strategy were included. Unpublished studies, reviews, editorials, animal and manikin studies were excluded. Data extraction: Two authors independently extracted data, risk of bias was assessed using the Cochrane ROB2 and ROBINS-I tools. Certainty of evidence was assed using the GRADE framework. Review Manager was used to analyse data and GRADEPro to develop summary of evidence tables. Meta-analyses were performed if ≥2 RCTs were available. Outcomes: Primary: assisted ventilation. Secondary: advanced resuscitation, oxygen supplementation, adverse effects of suctioning, unanticipated NICU admission. Results: Nine RCTs (n = 1096) and 2 observational studies (n = 418) were identified. Two RCTs (n = 280) with data concerns were excluded post-hoc. Meta-analysis of 3 RCTs, (n = 702) showed no difference in primary outcome. Two RCTs (n = 200) and 2 prospective observational studies (n = 418) found lower oxygen saturations in first 10 minutes of life with suctioning. Two RCTs (n = 200) showed suctioned newborns took longer to achieve target saturations. Limitations: Certainty of evidence was low or very low for all outcomes. Most studies selected healthy newborns limiting generalisability and insufficient data was available for planned subgroup analyses. Conclusions: Despite low certainty evidence, this review suggests no clinical benefit from suctioning clear amniotic fluid from infants following birth, with some evidence suggesting a resulting desaturation. These finding support current guideline recommendations that this practice is not used as a routine step in birth. Funding: The International Liaison Committee on Resuscitation provided access to software platforms, an information specialist and teleconferencing. Clinical Trial Registration: This systematic review was registered with the Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/prospero/) (identifier: CRD42021286258).

Exploring health service preparation for the COVID-19 crisis utilizing simulation-based activities in a Norwegian hospital: a qualitative case study.

INTRODUCTION: The first wave of the COVID-19 pandemic caused stress in healthcare organizations worldwide. Hospitals and healthcare institutions had to reorganize their services to meet the demands of the crisis. In this case study, we focus on the role of simulation as part of the pandemic preparations in a large hospital in Norway. The aim of this study is to explore hospital leaders' and simulation facilitators' expectations of, and experiences of utilizing simulation-based activities in the preparations for the COVID-19 pandemic. METHODS: This is a qualitative case study utilizing semi-structured in-depth interviews with hospital leaders and simulation facilitators in one large hospital in Norway. The data were sorted under three predefined research topics and further analyzed by inductive, thematic analysis according to Braun and Clarke within these pre-defined topics. RESULTS: Eleven members of the hospital leadership and simulation facilitators were included in the study. We identified four themes explaining why COVID-19 related simulation-based activities were initiated, and perceived consequences of the activities; 1) a multifaceted method like simulation fitted a multifaceted crisis, 2) a well-established culture for simulation in the hospital was crucial for scaling up simulation-based activities during the crisis, 3) potential risks were outweighed by the advantages of utilizing simulation-based activities, and finally 4) hospital leaders and simulation facilitators retrospectively assessed the use of simulation-based activities as appropriate to prepare for a pandemic crisis. CONCLUSIONS: The hospital leadership's decision to utilize simulation-based activities in preparing for the COVID-19 crisis may be explained by many factors. First, it seems that many years of experience with systematic use of simulation-based activities within the hospital can explain the trust in simulation as a valuable tool that were easy to reach. Second, both hospital leaders and simulation facilitators saw simulation as a unique tool for the optimization of the COVID-19 response due to the wide applicability of the method. According to hospital leaders and simulation facilitators, simulation-based activities revealed critical gaps in training and competence levels, treatment protocols, patient logistics, and environmental shortcomings that were acted upon, suggesting that institutional learning took place.

Neonatal Resuscitation Skill-Training Using a New Neonatal Simulator, Facilitated by Local Motivators: Two-Year Prospective Observational Study of 9000 Trainings.

Globally, intrapartum-related complications account for approximately 2 million perinatal deaths annually. Adequate skills in neonatal resuscitation are required to reduce perinatal mortality. NeoNatalie Live is a newborn simulator providing immediate feedback, originally designed to accomplish Helping Babies Breathe training in low-resource settings. The objectives of this study were to describe changes in staff participation, skill-training frequency, and simulated ventilation quality before and after the introduction of "local motivators" in a rural Tanzanian hospital with 4000-5000 deliveries annually. Midwives (n = 15-27) were encouraged to perform in situ low-dose high-frequency simulation skill-training using NeoNatalie Live from September 2016 through to August 2018. Frequency and quality of trainings were automatically recorded in the simulator. The number of skill-trainings increased from 688 (12 months) to 8451 (11 months) after the introduction of local motivators in October 2017. Staff participation increased from 43% to 74% of the midwives. The quality of training performance, measured as "well done" feedback, increased from 75% to 91%. We conclude that training frequency, participation, and performance increased after introduction of dedicated motivators. In addition, the immediate constructive feedback features of the simulator may have influenced motivation and training quality performance.