In Situ Simulation and Clinical Outcomes in Infants Born Preterm.

OBJECTIVE: To evaluate impact of a multihospital collaborative quality improvement project implementing in situ simulation training for neonatal resuscitation on clinical outcomes for infants born preterm. STUDY DESIGN: Twelve neonatal intensive care units were divided into 4 cohorts; each completed a 15-month long program in a stepped wedge manner. Data from California Perinatal Quality Care Collaborative were used to evaluate clinical outcomes. Infants with very low birth weight between 22 through 31 weeks gestation were included. Primary outcome was survival without chronic lung disease (CLD); secondary outcomes included intubation in the delivery room, delivery room continuous positive airway pressure, hypothermia (<36°C) upon neonatal intensive care unit admission, severe intraventricular hemorrhage, and mortality before hospital discharge. A mixed effects multivariable regression model was used to assess the intervention effect. RESULTS: Between March 2017 and December 2020, a total of 2626 eligible very low birth weight births occurred at 12 collaborative participating sites. Rate of survival without CLD at participating sites was 74.1% in March to August 2017 and 76.0% in July to December 2020 (risk ratio 1.03; [0.94-1.12]); no significant improvement occurred during the study period for both participating and nonparticipating sites. The effect of in situ simulation on all secondary outcomes was stable. CONCLUSIONS: Implementation of a multihospital collaborative providing in situ training for neonatal resuscitation did not result in significant improvement in survival without CLD. Ongoing in situ simulations may have an impact on unit practice and unmeasured outcomes.

Moms in the NICU: developing a pilot to engage and empower women who have delivered a prematurely born infant.

BACKGROUND: Mothers spend long hours at their preterm infant's bedside in the Neonatal Intensive Care Unit (NICU), giving clinicians the opportunity to engage mothers in caring for their own health. OBJECTIVE: To develop a NICU based intervention to reduce the risk of a future premature birth by engaging and empowering mothers to improve their own health and identify barriers to implementing their improvement. DESIGN: Development based on a framework of narrative discourse refined by the Quality Improvement Plan Do Study Act Approach. SETTING: Level II Stepdown Neonatal Intensive Care Unit. PARTICIPANTS: 14 mothers of preterm infants, ages 24-39 years. METHODS: A team of Maternal Fetal Medicine Physicians, obstetricians, neonatologists, neonatal nurses, and parents developed guidelines to elicit the mother's birth story, review the story with a clinical expert to fill in knowledge gaps, identify strategies to improve health to reduce the risk of future preterm birth, and facilitate mother developing an action plan with specific six week goals. A phone interview was designed to assess success and identify barriers to implementing their health plan. The protocol was modified as needed after each intervention to improve the interventions. RESULTS: "Moms in the NICU" toolkit is effective to guide any clinical facilitator to engage, identify health improvement strategies, and co-develop an individualized health plan and its take home summary reached stability after the 5th mother. Mothers reported experiencing reassurance, understanding, and in some cases, relief. Participants were enthusiastic to inform future quality improvement activities by sharing the six week barriers faced implementing their health plan. CONCLUSION: Engaging in the NICU provides an opportunity to improve mothers' understanding of potential factors that may be linked to preterm birth, and promote personally selected actions to improve their health and reduce the risk of a future preterm birth.

Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery.

OBJECTIVE: This study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean. METHODS: This study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped by specialty to identify reported areas of congestion and time spent, and to identify themes related to physical space of the OR and labor and delivery unit. RESULTS: Task analysis revealed complex interdependencies between specialties. Thirty task groupings requiring over 20 pieces of equipment were identified. Perceived areas of congestion and areas of time spent in the OR varied by clinical specialty. The following categories emerged as main challenges encountered during an emergency Cesarean: 1) size of physical space and equipment, 2) layout and orientation, and 3) patient transport. CONCLUSION: User insights on physical space and workflow processes during emergency Cesarean section at the institution studied revealed challenges related to getting the patients into the OR expediently and having space to perform tasks without crowding or staff injury. By utilizing human factors techniques, other institutions may build upon our findings to improve safety during emergency situations on labor and delivery.

A Feasibility Study of a Novel Delayed Cord Clamping Cart.

Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate's birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and blood transfusion. Despite these benefits, clinicians typically cut the umbilical cord without delay in neonates requiring resuscitation and move them to a radiant warmer for further care; this effectively prevents these patients from receiving any benefits from DCC. This study evaluated the feasibility of a delayed cord clamping cart (DCCC) in low-risk neonates born via Cesarean section (CS). The DCCC is a small, sterile cart designed to facilitate neonatal resuscitation while the umbilical cord remains intact. The cart is cantilevered over the operating room (OR) table during a CS, allowing the patient to be placed onto it immediately after birth. For this study, a sample of 20 low-risk CS cases were chosen from the non-emergency Labor and Delivery surgical case list. The DCCC was utilized for 1 min of DCC in all neonates. The data collected included direct observation by research team members, recorded debriefings and surveys of clinicians as well as surveys of patients. Forty-four care team members participated in written surveys; of these, 16 (36%) were very satisfied, 12 (27%) satisfied, 13 (30%) neutral, and 3 (7%) were somewhat dissatisfied with use of the DCCC in the OR. Feedback was collected from all 20 patients, with 18 (90%) reporting that they felt safe with the device in use. This study provides support that utilizing a DCCC can facilitate DCC with an intact umbilical cord.

What's in a Name? Enhancing Communication in the Operating Room with the Use of Names and Roles on Surgical Caps.

OBJECTIVE: A pilot study was conducted in a tertiary referral center to assess whether wearing caps labeled with providers' names and roles has an impact on communication in the operating room (OR). METHODS: Two obstetricians observed surgeries for name uses and missed communications. Following each case, all providers were given a short survey that queried their attitude about the use of labeled surgical caps, their ability to know the names and roles of other providers during a case, and the impact of scrub attire on identifying others. They were also asked to rate the ease of communication and their ability to recall name and roles of the personnel specific to the case. Patients were asked how they perceived the use of labeled caps by providers. RESULTS: Twenty scheduled cesarean deliveries were randomized to either labeled (10) or nonlabeled (10) surgical caps. A total of 129 providers participated in the study, with 117 providing responses to the survey. Providers reported knowing the names and roles of colleagues more often with labeled caps vs. nonlabeled caps (names: 77.8% vs. 55.0%, 95% confidence interval [CI] = 64.4%-88.0% vs. 41.6%-67.9%, p = 0.011; roles: 92.5% vs. 78.3%, 95% CI = 81.8%-98.0% vs. 65.8%-88.0%, p = 0.036). Name uses increased (43 vs. 34, p = 0.208), and missed communications decreased (16 vs. 20, p = 0.614) when labeled caps were worn. Providers and patients had an overwhelmingly positive response to labeled caps. CONCLUSION: This pilot study demonstrated that wearing labeled caps in the OR led to more frequent name uses and less frequent missed communications. Providers and patients embraced the concept of labeled caps and perceived wearing labeled caps as improving communication in the OR.