"How Do I Prepare for This?" Patient Perspectives on Providers' Employment-related Support During Pregnancy.

BACKGROUND: Health care providers can offer employment-related support to pregnant patients by providing information about occupational risks and benefits, discussing adjustments, and/or completing paperwork to help patients obtain accommodations or benefits, but little research has examined whether and how this support is provided. METHODS: We conducted interviews with 20 adults who had been employed while pregnant within the 5 years preceding data collection. Eligible participants had low incomes, were hourly wage earners, or were employed in service or retail occupations. Applied thematic analysis was used to identify emergent themes. RESULTS: People who had been employed while pregnant described a range of experiences during that time, including physical and psychological demands from work, lack of access to appropriate accommodations, difficulties combining breastfeeding with work, and work-related challenges accessing health care. Participants described four primary roles that health care providers played: 1) completing paperwork needed to apply for benefits or receive work modification; 2) providing information about how to mitigate employment-related risks; 3) providing referrals to social or medical services; and 4) advocating for patients to ensure receipt of accommodations, resources, and information. Strategies identified by patients that could be enacted within health care to help them better navigate the work-pregnancy interface include increasing appointment flexibility, providing information about work-related risks and benefits programs and referrals to legal support, and helping providers to understand and support their patients' individual work-related concerns. CONCLUSIONS: Health care providers have a critical role to play in supporting employed pregnant people to achieve flexibility in managing their work and to be active participants in discussions about recommended workplace accommodations.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest.

Importance: Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival. Objective: To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA. Design, Setting, and Participants: This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023. Main Outcomes and Measure: Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose). Results: A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6). Conclusions and Relevance: In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Experiences and Communication Preferences in Pregnancy Care Among Patients With a Spanish Language Preference: A Qualitative Study.

OBJECTIVE: To explore Spanish-speaking patients' experiences and preferences regarding communication during pregnancy care with specific attention to language barriers. METHODS: Patients with a Spanish language preference who gave birth between July 2022 and February 2023 at an academic medical center were invited to participate in focus groups. Focus groups were held over Zoom, audio-recorded, transcribed in Spanish, translated into English, and reviewed for translation accuracy. Thematic analysis was conducted with deductive and inductive approaches. Three investigators double-coded all transcripts, and discrepancies were resolved through team consensus. RESULTS: Seven focus groups (27 total participants, range 2-6 per group) were held. Three key themes emerged regarding patient experiences and communication preferences when seeking pregnancy care: 1) language concordance and discordance between patients and clinicians are not binary-they exist on a continuum; 2) language-discordant care is common and presents communication challenges, even with qualified interpreters present; and 3) language discordance can be overcome with positive interpersonal dynamics between clinicians and patients. CONCLUSION: Our findings highlight the importance of relationship to overcome language discordance among patients with limited English proficiency during pregnancy care. These findings inform potential structural change and patient-clinician dyad interventions to better meet the communication needs of patients with limited English proficiency.

Identifying high cognitive load activities during simulated pediatric cardiac arrest using functional near-infrared spectroscopy.

Aim: To identify specific activities associated with high cognitive load during simulated pediatric out-of-hospital cardiac arrest (POHCA) resuscitation using physiological monitoring with functional near-infrared spectroscopy (fNIRS). Methods: We recruited teams of emergency medical services (EMS) responders from fire departments located throughout the Portland, OR metropolitan area to participate in POHCA simulations. Teams consisted of both paramedics and emergency medical technicians (EMTs), with one paramedic serving as the person in charge (PIC). The PIC was outfitted with the OctaMon to collect fNIRS signals from the prefrontal cortex. Signals reported changes in oxygenated and deoxygenated hemoglobin concentrations, which were used to determine moments of increased cognitive activity. Increased cognitive activity was determined by significant increases in oxygenated hemoglobin and decreases in deoxygenated hemoglobin. Significant changes in fNIRS signals were associated with specific concurrent clinical tasks recorded by two independent researchers using video review. Results: We recorded cognitive activity of EMS providers in 18 POHCA simulations. We found that a proportion of PIC's experienced relatively high cognitive load during medication administration, defibrillation, and rhythm checks compared to other events. Conclusion: EMS providers commonly experienced increased cognitive activity during key resuscitation tasks that were related to safely coordinating team members around calculating and administering medications, defibrillation, and rhythm and pulse checks. Understanding more about activities that require high cognitive demand can inform future interventions that reduce cognitive load.

Comparison of Resuscitation Quality in Simulated Pediatric and Adult Out-of-Hospital Cardiac Arrest.

Importance: Mortality from pediatric out-of-hospital cardiac arrest (OHCA) is high and has not improved in decades, unlike adult mortality. The low frequency of pediatric OHCA and weight-based medication and equipment needs may lead to lower quality of pediatric resuscitation compared with adults. Objective: To compare the quality of pediatric and adult resuscitation from OHCA in a controlled simulation environment and to evaluate whether teamwork, knowledge, experience, and cognitive load are associated with resuscitation performance. Design, Setting, and Participants: This cross-sectional in-situ simulation study was conducted between September 2020 and August 2021 in the metropolitan area of Portland, Oregon, and included engine companies from fire-based emergency services (EMS) agencies. Exposures: Participating EMS crews completed 4 simulation scenarios presented in random order: (1) adult female with ventricular fibrillation; (2) adult female with pulseless electrical activity; (3) school-aged child with ventricular fibrillation; and (4) infant with pulseless electrical activity. All patients were pulseless on EMS arrival. Data were captured by the research team in real time during the scenarios. Main outcomes and measures: The primary outcome was defect-free care, which included correct cardiopulmonary resuscitation depth, rate, and compression to ventilation ratio, time to bag-mask ventilation, and time to defibrillation, if applicable. Outcomes were determined by direct observation by an experienced physician. Secondary outcomes included additional time-based interventions and the use of correct medication doses and equipment size. We measured teamwork using the clinical teamwork scale, cognitive load with the National Aeronautics and Space Administration task load index (NASA-TLX), and knowledge using advanced life support resuscitation tests. Results: Among the 215 clinicians (39 crews) who participated in 156 simulations, 200 (93%) were male, and the mean (SD) age was 38.7 (0.6) years. No pediatric shockable scenario was defect free and only 5 pediatric nonshockable scenarios (12.8%) were defect free, while 11 (28.2%) adult shockable scenarios and 27 adult nonshockable scenarios (69.2%) were defect free. The mental demand subscale of the NASA-TLX was higher in the pediatric compared with the adult scenarios (mean [SD] pediatric score, 59.1 [20.7]; mean [SD] adult score, 51.4 [21.1]; P = .01). Teamwork scores were not associated with defect-free care. Conclusions and Relevance: In this simulation study of OHCA, resuscitation quality was significantly lower for pediatric than adult resuscitation. Mental demand may have been a contributor.

Measuring cognitively demanding activities in pediatric out-of-hospital cardiac arrest.

BACKGROUND: This methodological intersection article demonstrates a method to measure cognitive load in clinical simulations. Researchers have hypothesized that high levels of cognitive load reduce performance and increase errors. This phenomenon has been studied primarily by experimental designs that measure responses to predetermined stimuli and self-reports that reduce the experience to a summative value. Our goal was to develop a method to identify clinical activities with high cognitive burden using physiologic measures. METHODS: Teams of emergency medical responders were recruited from local fire departments to participate in a scenario with a shockable pediatric out-of-hospital cardiac arrest (POHCA) patient. The scenario was standardized with the patient being resuscitated after receiving high-quality CPR and 3 defibrillations. Each team had a person in charge (PIC) who wore a functional near-infrared spectroscopy (fNIRS) device that recorded changes in oxygenated and deoxygenated hemoglobin concentration in their prefrontal cortex (PFC), which was interpreted as cognitive activity. We developed a data processing pipeline to remove nonneural noise (e.g., motion artifacts, heart rate, respiration, and blood pressure) and detect statistically significant changes in cognitive activity. Two researchers independently watched videos and coded clinical tasks corresponding to detected events. Disagreements were resolved through consensus, and results were validated by clinicians. RESULTS: We conducted 18 simulations with 122 participants. Participants arrived in teams of 4 to 7 members, including one PIC. We recorded the PIC's fNIRS signals and identified 173 events associated with increased cognitive activity. [Defibrillation] (N = 34); [medication] dosing (N = 33); and [rhythm checks] (N = 28) coincided most frequently with detected elevations in cognitive activity. [Defibrillations] had affinity with the right PFC, while [medication] dosing and [rhythm checks] had affinity with the left PFC. CONCLUSIONS: FNIRS is a promising tool for physiologically measuring cognitive load. We describe a novel approach to scan the signal for statistically significant events with no a priori assumptions of when they occur. The events corresponded to key resuscitation tasks and appeared to be specific to the type of task based on activated regions in the PFC. Identifying and understanding the clinical tasks that require high cognitive load can suggest targets for interventions to decrease cognitive load and errors in care.

Work as a social risk factor in pregnancy: A systematic review of screening practices related to working conditions and family leave among pregnant adults.

BACKGROUND: Paid family leave and working conditions are components of employment quality-a key social determinant of health across the life course, particularly during pregnancy. Increased research on prenatal social risk screening has not extended to employment quality. The objective of this systematic review was to identify prenatal screening practices and interventions in health care settings that address employment and working conditions as social risk factors among pregnant adults and to describe their properties and key findings. METHOD: We searched MEDLINE, PsychINFO, SocINDEX, EMBASE, and the SIREN Evidence and Resource Library for studies published through February 14, 2022. We selected multiple search terms related to four domains: (1) employment or working conditions; (2) screening; (3) health care settings; and (4) pregnancy or maternal health. RESULTS: Of the 2317 unique titles and abstracts that were potentially relevant, eight articles met all inclusion criteria and focused on pregnant populations. The content of identified screening practices varied substantially, highlighting the multiple ways employment is conceptualized as a potential risk factor. Few studies included multidimensional measures of employment to assess working conditions, which may be particularly relevant during pregnancy. CONCLUSIONS: Our review suggests that screening for employment as a social risk factor does not regularly occur in prenatal care. Although pragmatic properties of the screening tools we assessed are promising, tools seldom examine the multidimensional nature of work. Understanding the principal intent of screening for employment prenatally could provide greater opportunity to collect and interpret contextual factors that influence how both providers and patients respond to social risk.

Uncomfortable yet necessary: The impact of PPE on communication in emergency medicine.

BACKGROUND: The efficacy of pre-hospital emergency services is heavily dependent on the effective communication of care providers. This effective communication occurs between providers as part of a team and also among providers interacting with family members and patients. The COVID-19 pandemic introduced a number of communication challenges to emergency care, which are primarily linked to the increased use of personal protective equipment (PPE). OBJECTIVE: We sought to analyze the impacts of the COVID-19 pandemic on emergency medical service (EMS) workers and pre-hospital care delivery. METHODS: We conducted focus groups and one-on-one interviews with fire-based EMS first responders between September 2021 and 2022. Interviews included questions about job-related stress, EMS skills, work experiences and changes during COVID-19. Interviews were recorded, independently dual coded and analyzed for themes. RESULTS: Two hundred twenty-three first responders participated in 40 focus groups and 40 lead paramedics participated in individual interviews. We found that additional use of PPE was reported to have significantly impaired efficiency and perceptions of quality of care-among EMS team members and also between EMS workers and patients. EMS personnels also experienced on-scene hostility on arrival (from both families and other agencies). Extensive use of PPE muffles voices, obscures facial expressions and can cause team members to have difficulty recognizing and communicating with one another and can be a barrier to showing empathy and connecting with patients. Creative solutions such as putting a hand on someone's shoulder, wearing name tags on suits and explaining rationale for perceived delays were mentioned as methods to transcend these barriers. The appearance of providers in heavy PPE can be unsettling and create barriers to human connection, particularly for pediatric patients. CONCLUSION: Human connection is an important element of health-care delivery and healing. These findings shed light on new skills that are needed to initiate and maintain human connection in these times of PPE use, especially full-body PPE. Awareness of the communication and empathy barriers posed by PPE is the first step to improving provider-patient interactions in pre-hospital EMS. Additionally, 'communication-friendly' adaptations of PPE equipment may be an important area for future research and development in manufacturing and the health-care industry.

Training the next generation of learning health system scientists.

Introduction: The learning health system (LHS) aligns science, informatics, incentives, stakeholders, and culture for continuous improvement and innovation. The Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Institute designed a K12 initiative to grow the number of LHS scientists. We describe approaches developed by 11 funded centers of excellence (COEs) to promote partnerships between scholars and health system leaders and to provide mentored research training. Methods: Since 2018, the COEs have enlisted faculty, secured institutional resources, partnered with health systems, developed and implemented curricula, recruited scholars, and provided mentored training. Program directors for each COE provided descriptive data on program context, scholar characteristics, stakeholder engagement, scholar experiences with health system partnerships, roles following program completion, and key training challenges. Results: To date, the 11 COEs have partnered with health systems to train 110 scholars. Nine (82%) programs partner with a Veterans Affairs health system and 9 (82%) partner with safety net providers. Clinically trained scholars (n = 87; 79%) include 70 physicians and 17 scholars in other clinical disciplines. Non-clinicians (n = 29; 26%) represent diverse fields, dominated by population health sciences. Stakeholder engagement helps scholars understand health system and patient/family needs and priorities, enabling opportunities to conduct embedded research, improve outcomes, and grow skills in translating research methods and findings into practice. Challenges include supporting scholars through roadblocks that threaten to derail projects during their limited program time, ranging from delays in access to data to COVID-19-related impediments and shifts in organizational priorities. Conclusions: Four years into this novel training program, there is evidence of scholars' accomplishments, both in traditional academic terms and in terms of moving along career trajectories that hold the potential to lead and accelerate transformational health system change. Future LHS training efforts should focus on sustainability, including organizational support for scholar activities.

Characterization of teamwork and guideline compliance in prehospital neonatal resuscitation simulations.

Aim: Neonatal cardiopulmonary arrests are rare but serious events. There is limited information on compliance to best-practice guidelines due to rarity, but deviations can have dire consequences. This research aimed to characterize compliance with and deviations from Neonatal Resuscitation Program (NRP) guidelines and their association with teamwork. Methods: We observed Emergency Medical Service (EMS) teams responding to standardized neonatal resuscitation simulations following a precipitous home delivery. A Clinical expert evaluated teamwork during simulations using the Clinical Teamwork Scale (CTS™). A neonatologist evaluated technical performance in blinded video review according to NRP guidelines. We report the types, counts, and severity of observed deviations. Logistic regression tested the association of CTS™ factors with the occurrence of deviations. Results: Forty-five (45) teams of 265 EMS personnel from fire and transport agencies participated in the simulations. Eighty-seven percent (39/45) of teams were rated as having good teamwork according to CTS™. Nearly all teams (44 of 45) delayed or did not perform one or more of the initial steps of dry, warm, or stimulate; delayed bag-valve mask ventilation (BVM); or performed continuous compressions instead of the recommended 3:1 compression-to-ventilation ratio. Logistic regression revealed an 82% (p < 0.04) decrease in the odds of airway errors for each level of improvement in teams' decision-making. Conclusion: Drying, warming, and stimulating, and ventilation tailored to the physiologic needs of infants continue to be top priorities in neonatal care for out-of-hospital settings. EMS teamwork is good and higher quality of decision-making appears to decrease the odds of ventilation errors.

A chart review tool to systematically assess the safety of prehospital care for children with out-of-hospital cardiac arrest.

Objective: Create an easy-to-use pediatric out-of-hospital cardiac arrest (OHCA)-specific chart review tool to reliably detect severe adverse safety events (ASEs) in the prehospital care of children with OHCA. Methods: We revised our previously validated pediatric prehospital adverse event detection system (PEDS) tool, used to evaluate ASEs in the prehospital care of children during emergent calls, to create an OHCA-specific chart review tool. We developed decision support for reviewers, reviewer training, and a dedicated section for chart data abstraction. We randomly selected 28 charts for independent review by 2 expert reviewers who determined the presence or absence of a severe ASE for each care episode and identified the domain of care and preventability for each ASE. We calculated inter-rater agreement in the assessment of the presence or absence of a severe ASE using Gwet's first-order agreement coefficient (AC1). Results: The PEDS-OHCA chart review tool has 6 sections, with a minimum of 70 and maximum of 667 total possible fields. We found inter-rater agreement of 0.83 (95% confidence interval, 0.63-0.99) between our 2 reviewers for the overall detection of a severe ASE and an average time to complete of 8 minutes (range, 2-25 minutes). Inter-rater agreement in the detection of a severe ASE in each individual domain ranged from 0.36 to 0.96. Conclusions: The PEDS-OHCA is the first chart review tool to systematically evaluate the safety and quality of EMS care for children with OHCA. This tool may help improve understanding of the quality of EMS care for children with OHCA, which is essential to improving outcomes.

"It Would Have Been Nice to Have a Choice": Barriers to Contraceptive Decision-making among Women with Disabilities.

INTRODUCTION: Engaging in contraceptive decisions is an important part of reproductive health for women and other people with the capacity for pregnancy. However, not all individuals capable of pregnancy have equal access to information and/or opportunities to make fully informed decisions. The goal of this study was to understand barriers women with disabilities experience around contraceptive decision-making and whether these differ based on type of disability. METHODS: We conducted focus groups with 17 reproductive age adult women (aged 18-45 years). Focus groups were homogenous with regard to disability type and consisted of one group for each of the following disability categories: 1) physical disability, 2) intellectual and developmental disabilities, 3) blind or low vision, and 4) Deaf users of American Sign Language. Data were collected in the Portland, Oregon, metropolitan area during 2016-2017. We analyzed focus group transcripts using content analysis. RESULTS: Barriers to informed contraceptive decision-making emerged in five main thematic areas: 1) lack of information in accessible formats, 2) incomplete information about contraceptive side effects, 3) limited clinician knowledge and relevant research specific to the care of women with disabilities, 4) taboos around discussing sexual activity, and 5) limited opportunities for shared contraceptive decision-making. CONCLUSIONS: Women with disabilities faced numerous barriers to contraceptive decision-making. Although the barriers differed somewhat by disability type, many barriers were consistent across groups, suggesting commonalities associated with the experience of disability in the context of contraceptive decision-making. Increased attention to the reproductive health needs of people with disabilities is important for improving health care equity and quality.

The Effects of Leadership Curricula With and Without Implicit Bias Training on Graduate Medical Education: A Multicenter Randomized Trial.

PURPOSE: To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians. METHOD: This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer. RESULTS: One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome. CONCLUSIONS: Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

PROTOCOL: Conflict of interest issues when engaging stakeholders in health and healthcare guideline development: a systematic review.

This is the protocol for a Campbell systematic review. The overall objective of this study is to gather and summarize the existing literature on conflict of interest issues when engaging stakeholders in guideline development.

Experiences of Women With Disabilities in Accessing and Receiving Contraceptive Care.

OBJECTIVE: To conduct an initial exploration of the experiences of women with different types of disability when they attempt to obtain contraceptive care. DESIGN: Multiple-category focus group design. SETTING: Multiple community sites. PARTICIPANTS: Seventeen women with disabilities of reproductive age. METHODS: We purposively sampled women with different types of disability and conducted four focus groups organized by disability type: physical disability, intellectual and developmental disability, blind or low vision, and deaf or hard of hearing. We used a semistructured focus group guide to elicit participants' positive and negative experiences with contraceptive care. We analyzed focus group transcripts using content analysis. RESULTS: Participants identified challenges to obtaining high-quality contraceptive care in three main thematic areas: Accessibility and Accommodations, Clinician Attitudes, and Health Insurance. Participants with physical disabilities encountered inaccessible clinic rooms and examination tables, and those with sensory disabilities or intellectual and developmental disability described inaccessible clinic forms and information. Participants from multiple disability groups described negative attitudes of health care providers and health insurance limitations. CONCLUSION: As described by our participants, the processes and infrastructure of contraceptive care were based on an assumption of an able-bodied norm. Reliance on such a norm, for example, offering a paper pamphlet to a blind woman, is not helpful and can be harmful to women with disabilities. Increased attention to the reproductive health care needs of women with disabilities is important for improving health care equity and quality.

Characterizing prehospital response to neonatal resuscitation.

OBJECTIVE: To evaluate performance of initial steps of newborn resuscitation according to the American Heart Association and American Academy of Pediatrics' Neonatal Resuscitation Program (NRP) guidelines in the prehospital setting. STUDY DESIGN: Observational study of 265 paramedics and Emergency Medical Technicians (EMTs) from 45 EMS teams recruited from public fire and private transport agencies in a major metropolitan area. Participants completed a baseline questionnaire assessing demographics, experience, and comfort in caring for children. Simulations were conducted April 2015 to March 2016. Technical performance was evaluated by blinded video review. NRP actions were assessed using a structured performance tool. RESULTS: Two hundred sixty-five EMS providers responded to survey questions and participated in simulations. In total, 16% reported feeling very or extremely comfortable caring for children <30 days of age (vs. 71% for children aged 12-18 years). Among 45 EMS teams participating in simulations, 22% (n = 10) dried, 18% (n = 8) stimulated, and 2% (n = 1) warmed within 30 s from arrival and 11% (n = 5) provided BMV within 60 s from arrival, as recommended by NRP. All teams provided BMV. Eighty-eight percent bagged below NRP rate recommendations and 96% bagged with tidal volume exceeding guidelines. Looking over the entire 10-min simulation for ever performing measures, 73% started to dry the baby within a median of 51 (range 0-539) seconds from arrival, 38% started to stimulate the baby within a median of 34 s (range 0-181), and 44% started to warm the baby within a median 291 s (range 27-575 s). CONCLUSIONS: These data from field simulations suggest NRP steps recommended for the first minute after birth are seldom performed in a timely manner and suggests opportunities for improvement.

Evaluating pediatric advanced life support in emergency medical services with a performance and safety scoring tool.

INTRODUCTION: Pediatric out-of-hospital cardiac arrests (P-OHCA) are infrequent, have low survival rates, and often have poor neurologic outcomes. Recent evidence indicates that high-performance emergency medical service (EMS) care can improve outcomes. OBJECTIVES: To evaluate Pediatric Advanced Life Support (PALS) guideline performance in the out of hospital setting and introduce an easy-to-use tool that scores guideline compliance and patient safety. METHODS: We observed EMS teams responding to standardized pediatric resuscitation simulations. Teams were dispatched to a mock assisted living home for a choking 6-year-old with a complex medical history. The child manikin was presented as unconscious and apneic, with bradycardic pulse. Teams were expected to monitor vitals; initiate airway management and cardiopulmonary resuscitation (CPR); and establish vascular access and administer epinephrine based on PALS guidelines. We developed a tool to score the quality of care for critical tasks and had a clinical expert evaluate technical performance using blinded video review. RESULTS: We observed 34 EMS teams providing care in P-OHCA simulations. Teams were proficient at assessing vitals, using correct-sized equipment, intubation, and confirmation of tube placement. Teams were delayed in initiating positive pressure ventilation (PPV) and chest compressions. Many teams (53%) deviated from guidelines in chest compressions with 17 (50%) performing continuous compressions before establishing an advanced airway and one (3%) not performing compressions. Similarly, 20 (59%) teams deviated from medication guidelines with 12 (35%) failing to administer epinephrine, six (18%) underdosing, and two (6%) overdosing by more than 20%. CONCLUSION: EMS teams were successful in selecting the appropriate equipment but delayed initiating ventilations in a child with severe bradycardia. We also noted frequent use of continuous chest CC rather than the AHA recommended 15:2 ratio. We developed a scoring tool with time-based criteria that can be used to assess guideline compliance, individual performance, and/or educational effectiveness.

Retention Strategies for Medications for Opioid Use Disorder in Adults: A Rapid Evidence Review.

OBJECTIVES: Although medications for opioid use disorder (MOUD) save lives, treatment retention remains challenging. Identification of interventions to improve MOUD retention is of interest to policymakers and researchers. On behalf of the Agency for Healthcare Research and Quality, we conducted a rapid evidence review on interventions to improve MOUD retention. METHODS: We searched MEDLINE and the Cochrane Library from February 2009 through August 2019 for systematic reviews and randomized trials of care settings, services, logistical support, contingency management, health information technology (IT), extended-release (XR) formulations, and psychosocial interventions that assessed retention at least 3 months. RESULTS: Two systematic reviews and 39 primary studies were included; most did not focus on retention as the primary outcome. Initiating MOUD in soon-to-be-released incarcerated people improved retention following release. Contingency management may improve retention using antagonist but not agonist MOUD. Retention with interventions integrating medical, psychiatric, social services, or IT did not differ from in-person treatment-as-usual approaches. Retention was comparable with XR- compared to daily buprenorphine formulations and conflicting with XR-naltrexone monthly injection compared to daily buprenorphine. Most psychosocial interventions did not improve retention. DISCUSSION: Consistent but sparse evidence supports criminal justice prerelease MOUD initiation, and contingency management interventions for antagonist MOUD. Integrating MOUD with medical, psychiatric, social services, delivering through IT, or administering via XR-MOUD formulations did not worsen retention. Fewer than half of the studies we identified focused on retention as a primary outcome. Studies used different measures of retention, making it difficult to compare effectiveness. Additional inquiry into the causes of low retention would inform future interventions.Registration: PROSPERO: CRD42019134739.