Gamified learning for resuscitation education: A systematic review.

Aim: To systematically review published literature to evaluate the impact of gamified learning on educational and clinical outcomes during life support education. Methods: This systematic review was conducted as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR). A search of PubMed, Embase, and Cochrane was conducted from inception until February 12, 2024. Studies examining incorporation of gamified learning were eligible for inclusion. Reviewers independently extracted data on study design and outcomes; appropriate risk of bias assessment tools were used across all outcomes. Results: 2261 articles were identified and screened, yielding sixteen articles (seven randomized trials, nine observational studies) which comprised the final review. No meta-analyses were conducted due to significant heterogeneity of intervention, population, and outcome. Only one study was found to have a low risk of bias; the remaining studies were found to have moderate to high risk. Fourteen studies were in healthcare providers and two were in laypersons. Most studies (11 of 16) examined the impact of a digital platform (computer or smartphone). Most (15 of 16) studies found a positive effect on at least one educational domain; one study found no effect. No included study found a negative effect on any educational domain. Conclusion: This systematic review found a very heterogeneous group of studies with low certainty evidence, all but one of which demonstrated a positive effect on one or more educational domains. Future studies should examine the underlying causes of improved learning with gamification and assess the resource requirements with implementation and dissemination of gamified learning.

Endotracheal Tube Size Adjustments Within Seven Days of Neonatal Intubation.

BACKGROUND AND OBJECTIVES: Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations. METHODS: Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups. RESULTS: Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89). CONCLUSIONS: For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized.

Increasing Realism and Variety of Virtual Patient Dialogues for Prenatal Counseling Education Through a Novel Application of ChatGPT: Exploratory Observational Study.

BACKGROUND: Using virtual patients, facilitated by natural language processing, provides a valuable educational experience for learners. Generating a large, varied sample of realistic and appropriate responses for virtual patients is challenging. Artificial intelligence (AI) programs can be a viable source for these responses, but their utility for this purpose has not been explored. OBJECTIVE: In this study, we explored the effectiveness of generative AI (ChatGPT) in developing realistic virtual standardized patient dialogues to teach prenatal counseling skills. METHODS: ChatGPT was prompted to generate a list of common areas of concern and questions that families expecting preterm delivery at 24 weeks gestation might ask during prenatal counseling. ChatGPT was then prompted to generate 2 role-plays with dialogues between a parent expecting a potential preterm delivery at 24 weeks and their counseling physician using each of the example questions. The prompt was repeated for 2 unique role-plays: one parent was characterized as anxious and the other as having low trust in the medical system. Role-play scripts were exported verbatim and independently reviewed by 2 neonatologists with experience in prenatal counseling, using a scale of 1-5 on realism, appropriateness, and utility for virtual standardized patient responses. RESULTS: ChatGPT generated 7 areas of concern, with 35 example questions used to generate role-plays. The 35 role-play transcripts generated 176 unique parent responses (median 5, IQR 4-6, per role-play) with 268 unique sentences. Expert review identified 117 (65%) of the 176 responses as indicating an emotion, either directly or indirectly. Approximately half (98/176, 56%) of the responses had 2 or more sentences, and half (88/176, 50%) included at least 1 question. More than half (104/176, 58%) of the responses from role-played parent characters described a feeling, such as being scared, worried, or concerned. The role-plays of parents with low trust in the medical system generated many unique sentences (n=50). Most of the sentences in the responses were found to be reasonably realistic (214/268, 80%), appropriate for variable prenatal counseling conversation paths (233/268, 87%), and usable without more than a minimal modification in a virtual patient program (169/268, 63%). CONCLUSIONS: Generative AI programs, such as ChatGPT, may provide a viable source of training materials to expand virtual patient programs, with careful attention to the concerns and questions of patients and families. Given the potential for unrealistic or inappropriate statements and questions, an expert should review AI chat outputs before deploying them in an educational program.

Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics.

Between 0.25% and 3% of admissions to the NICU, PICU, and PCICU receive cardiopulmonary resuscitation (CPR). Most CPR events occur in patients <1 year old. The incidence of CPR is 10 times higher in the NICU than at birth. Therefore, optimizing the approach to CPR in hospitalized neonates and infants is important. At birth, the resuscitation of newborns is performed according to neonatal resuscitation guidelines. In older infants and children, resuscitation is performed according to pediatric resuscitation guidelines. Neonatal and pediatric guidelines differ in several important ways. There are no published recommendations to guide the transition from neonatal to pediatric guidelines. Therefore, hospitalized neonates and infants can be resuscitated using neonatal guidelines, pediatric guidelines, or a hybrid approach. This report summarizes the current neonatal and pediatric resuscitation guidelines, considers how to apply them to hospitalized neonates and infants, and identifies knowledge gaps and future priorities. The lack of strong scientific data makes it impossible to provide definitive recommendations on when to transition from neonatal to pediatric resuscitation guidelines. Therefore, it is up to health care teams and institutions to decide if neonatal or pediatric guidelines are the best choice in a given location or situation, considering local circumstances, health care team preferences, and resource limitations.

Maternal COVID-19 Infection Associated with Fetal Systemic Inflammatory Complications in COVID-19-Negative Neonates: A Case-Series.

OBJECTIVE: This study aimed to examine fetal and neonatal inflammatory and neurologic complications associated with maternal coronavirus disease 2019 (COVID-19) infection. STUDY DESIGN: Case-series using a convenience sample of neonates cared for in a large referral-based children's hospital neonatal intensive care unit between September 2021 and May 2022. RESULTS: We identified seven neonates with exposure to maternal severe acute respiratory syndrome related coronavirus 2 (SARS-CoV-2) and a presentation consistent with inflammatory complications. All had some degree of neurologic injury with neuroimaging findings including restricted diffusion indicating injury in the white matter, cortex, deep gray structures, and splenium of the corpus callosum as well as intracranial hemorrhage. In addition, many infants had cytopenia and abnormal coagulation studies. Placental pathology, when available, revealed inflammation, clot with calcifications, and hematomas with associated infarcts. CONCLUSION: Neonates born to mothers with SARS-CoV-2, even when negative for the virus themselves, may have complications consistent with a systemic inflammatory syndrome. Placental pathology as well as neurologic imaging in infants with neurologic findings may help to support this diagnosis. KEY POINTS: · A systemic inflammatory response may cause illness in babies born to mothers with a history of COVID-19.. · Inflammatory markers and placental pathology are helpful in supporting this diagnosis.. · Consider neuroimaging in infants of mothers with a history of COVID-19 with neurologic findings..

The difficult neonatal airway.

Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized.

Competency-based assessment in neonatal simulation-based training.

Simulation is a cornerstone of training in neonatal clinical care, allowing learners to practice skills in a safe and controlled environment. Competency-based assessment provides a systematic approach to evaluating technical and behavioral skills observed in the simulation environment to ensure the learner is prepared to safely perform the skill in a clinical setting. Accurate assessment of competency requires the creation of tools with evidence of validity and reliability. There has been considerable work on the use of competency-based assessment in the field of neonatology. In this chapter, we review neonatal simulation-based training, examine competency-based assessment tools, explore methods to gather evidence of the validity and reliability, and review an evidence-based approach to competency-based assessment using simulation.

Association of full premedication on tracheal intubation outcomes in the neonatal intensive care unit: an observational cohort study.

OBJECTIVE: Evaluate the association of short-term tracheal intubation (TI) outcomes with premedication in the NICU. STUDY DESIGN: Observational single-center cohort study comparing TIs with full premedication (opiate analgesia and vagolytic and paralytic), partial premedication, and no premedication. The primary outcome is adverse TI associated events (TIAEs) in intubations with full premedication compared to those with partial or no premedication. Secondary outcomes included change in heart rate and first attempt TI success. RESULTS: 352 encounters in 253 infants (median gestation 28 weeks, birth weight 1100 g) were analyzed. TI with full premedication was associated with fewer TIAEs aOR 0.26 (95%CI 0.1-0.6) compared with no premedication, and higher first attempt success aOR 2.7 (95%CI 1.3-4.5) compared with partial premedication after adjusting for patient and provider characteristics. CONCLUSION: The use of full premedication for neonatal TI, including an opiate, vagolytic, and paralytic, is associated with fewer adverse events compared with no and partial premedication.

Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS.

OBJECTIVE: To determine the relationship between number of attempts and adverse events during neonatal intubation. STUDY DESIGN: A retrospective study of prospectively collected data of intubations in the delivery room and NICU from the National Emergency Airway Registry for Neonates (NEAR4NEOS) in 17 academic centers from 1/2016 to 12/2019. We examined the association between tracheal intubation attempts [1, 2, and ≥3 (multiple attempts)] and clinical adverse outcomes (any tracheal intubation associated events (TIAE), severe TIAE, and severe oxygen desaturation). RESULTS: Of 7708 intubations, 1474 (22%) required ≥3 attempts. Patient, provider, and practice factors were associated with higher TI attempts. Increasing intubation attempts was independently associated with a higher risk for TIAE. The adjusted odds ratio for TIAE and severe oxygen desaturation were significantly higher in TIs with 2 and ≥3 attempts than with one attempt. CONCLUSION: The risk of adverse safety events during intubation increases with the number of intubation attempts.

Comparison of a dichotomous versus trichotomous checklist for neonatal intubation.

BACKGROUND: To compare validity evidence for dichotomous and trichotomous versions of a neonatal intubation (NI) procedural skills checklist. METHODS: NI skills checklists were developed utilizing an existing framework. Experts were trained on scoring using dichotomous and trichotomous checklists, and rated recordings of 23 providers performing simulated NI. Videolaryngoscope recordings of glottic exposure were evaluated using Cormack-Lehane (CL) and Percent of Glottic Opening scales. Internal consistency and reliability of both checklists were analyzed, and correlations between checklist scores, airway visualization, entrustable professional activities (EPA), and global skills assessment (GSA) were calculated. RESULTS: During rater training, raters gave significantly higher scores on better provider performance in standardized videos (both p < 0.001). When utilized to evaluate study participants' simulated NI attempts, both dichotomous and trichotomous checklist scores demonstrated very good internal consistency (Cronbach's alpha 0.868 and 0.840, respectively). Inter-rater reliability was higher for dichotomous than trichotomous checklists [Fleiss kappa of 0.642 and 0.576, respectively (p < 0.001)]. Sum checklist scores were significantly different among providers in different disciplines (p < 0.001, dichotomous and trichotomous). Sum dichotomous checklist scores correlated more strongly than trichotomous scores with GSA and CL grades. Sum dichotomous and trichotomous checklist scores correlated similarly well with EPA. CONCLUSIONS: Neither dichotomous or trichotomous checklist was superior in discriminating provider NI skill when compared to GSA, EPA, or airway visualization assessment. Sum scores from dichotomous checklists may provide sufficient information to assess procedural competence, but trichotomous checklists may permit more granular feedback to learners and educators. The checklist selected may vary with assessment needs.

Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS.

OBJECTIVE: We hypothesized that videolaryngoscope use for tracheal intubations would differ across NICUs, be associated with higher first attempt success and lower adverse events. STUDY DESIGN: Data from the National Emergency Airway Registry for Neonates (01/2015 to 12/2017) included intubation with direct laryngoscope or videolaryngoscope. Primary outcome was first attempt success. Secondary outcomes were adverse tracheal intubation associated events and severe desaturation. RESULTS: Of 2730 encounters (13 NICUs), 626 (23%) utilized a videolaryngoscope (3% to 64% per site). Videolaryngoscope use was associated with higher first attempt success (p < 0.001), lower adverse tracheal intubation associated events (p < 0.001), but no difference in severe desaturation. After adjustment, videolaryngoscope use was not associated with higher first attempt success (OR:1.18, p = 0.136), but was associated with lower tracheal intubation associated events (OR:0.45, p < 0.001). CONCLUSION: Videolaryngoscope use is variable, not independently associated with higher first attempt success but associated with fewer tracheal intubation associated events.

Faculty Development Approaches for Life Support Courses: A Scoping Review.

The aim of this scoping review initiated by the Education, Implementation and Teams Task Force of the International Liaison Committee on Resuscitation was to identify faculty development approaches to improve instructional competence in accredited life support courses. We searched PubMed, Ovid Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials to identify studies published from January 1, 1966 to December 31, 2021 on approaches to improve faculty development for life support courses. Data on participant characteristics, interventions, design, and outcomes of included studies were extracted. Of the initially identified 10 310 studies, we included 20 studies (5 conference abstracts, 1 short communication, 14 full-length articles). Among them, 12 studies aimed to improve instructors/candidates' teaching ability in basic life support courses. A wide variety of interventions were identified. The interventions were categorized into 4 themes: instructor qualification/training (n=9), assessment tools (n=3), teaching skills enhancement (n=3), and additional courses for instructors (n=5). Most studies showed that these interventions improved specific teaching ability or confidence of the instructors and learning outcomes in different kinds of life support courses. However, no studies addressed clinical outcomes of patients. In conclusion, the faculty development approaches for instructors are generally associated with improved learning outcomes for participants, and also improved teaching ability and self-confidence of the instructors. It is encouraged that local organizations implement faculty development programs for their teaching staff of their accredited resuscitation courses. Further studies should explore the best ways to strengthen and maintain instructor competency, and define the cost-effectiveness of various different faculty development strategies.

Special consideration in neonatal resuscitation.

Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.

Telecoaching Improves Positive Pressure Ventilation Performance During Simulated Neonatal Resuscitations.

Introduction: Positive pressure ventilation (PPV) is a critical skill for neonatal resuscitation. We hypothesized that telecoaching would improve PPV performance in neonatal providers during simulated neonatal resuscitations. Setting: Level IV neonatal intensive care unit (NICU). Methods: This prospective crossover study included 14 experienced NICU nurses and respiratory therapists who performed PPV on a mannequin that recorded parameters of ventilation efficiency. Participants were randomized to practice independently (control) or with live feedback from a remote facilitator through audiovisual connection (intervention) and then switched to the opposite group. Participants' mask leak percentage, ventilation rates, and pressure delivery were analyzed. Results: The primary outcome of mask leak percentage was significantly increased in the telecoaching group (19% [interquartile range {IQR} 14-59.25] vs. 100% [IQR 88-100] leak, p = 0.0001). The secondary outcome of peak inspiratory pressure (PIP) delivery was also increased (median 27.6 [IQR 23.5-34.7] vs. 23.3 [IQR 19.1-32.8] cmH2O, p < 0.001). Differences in ventilation rates were not statistically significant (55 vs. 58 breaths/min, p = 0.51). Conclusion: Participants demonstrated better PPV performance during telecoaching with less mask leak. The intervention group also had higher measured peak inspiratory pressures. Telecoaching may be a feasible method to provide real-time feedback to health care providers during simulated neonatal resuscitations. Hypothesis: Neonatal providers who receive telecoaching during simulated resuscitations will perform PPV more effectively than those who do not receive telecoaching.

The Global Healthcare Simulation Economy: A Scoping Review.

Healthcare simulation is a technique that creates a situation or environment that allows persons to experience a representation of a real health care event for the purpose of practice, learning, evaluation, or gaining an understanding of systems or human actions. The use of healthcare simulation has grown rapidly over the last decade. In this review, we describe the global healthcare simulation economy. We reviewed the literature describing the global healthcare simulation economy using four research databases (Google Scholar, MEDLINE, Embase, and EconLit) as well as alternative sources. The specific aims were to examine the major economic themes facing the healthcare simulation economy. We found that the global healthcare simulation market is segmented based on product & services, fidelity, end-user, and geography. The market has experienced new player entry over the last few years, with most businesses focused in North America, Europe, and Asia-Pacific. The global healthcare simulation market is expected to reach between $3.19 and $7.7 billion by 2027, with a compound annual growth rate of 14.6% to 17.8%. Political and trade issues between America and China may increase the cost of goods in the short term. There are no global regulations on the use of healthcare simulation for training, licensing, or certification. Therefore, individual countries, states, and healthcare specialties establish individual regulations. We conclude that the major economic issues facing the global healthcare simulation economy include market segmentation, the entry of new players, and differential global growth. These factors, plus recent political and trade issues, and lack of regulations, could impact decision-making.

Validity Evidence for a Novel, Comprehensive Bag-Mask Ventilation Assessment Tool.

OBJECTIVE: To develop a comprehensive competency assessment tool for pediatric bag-mask ventilation (pBMV) and demonstrate multidimensional validity evidence for this tool. STUDY DESIGN: A novel pBMV assessment tool was developed consisting of 3 components: a 22-item-based checklist (trichotomized response), global rating scale (GRS, 5-point), and entrustment assessment (4-point). Participants' performance in a realistic simulation scenario was video-recorded and assessed by blinded raters. Multidimensional validity evidence for procedural assessment, including evidence for content, response-process, internal structure, and relation to other variables, was assessed. The scores of each scale were compared with training level. Item-based checklist scores also were correlated with GRS and entrustment scores. RESULTS: Fifty-eight participants (9 medical students, 10 pediatric residents, 18 critical care/neonatology fellows, 21 critical care/neonatology attendings) were evaluated. The pBMV tool was supported by high internal consistency (Cronbach α = 0.867). Inter-rater reliability for the item-based checklist component was acceptable (r = 0.65, P < .0001). The item-based checklist scores differentiated between medical students and other providers (P < .0001), but not by other trainee level. GRS and entrustment scores significantly differentiated between training levels (P < .001). Correlation between skill item-based checklist and GRS was r = 0.489 (P = .0001) and between item-based checklist and entrustment score was r = 0.52 (P < .001). This moderate correlation suggested each component measures pBMV skills differently. The GRS and entrustment scores demonstrated moderate inter-rater reliability (0.42 and 0.46). CONCLUSIONS: We established evidence of multidimensional validity for a novel entrustment-based pBMV competence assessment tool, incorporating global and entrustment-based assessments. This comprehensive tool can provide learner feedback and aid in entrustment decisions as learners progress through training.

Part 5: Essentials of Neonatal-Perinatal Medicine Fellowship: evaluation of competence and proficiency using Milestones.

The Accreditation Council for Graduate Medical Education (ACGME) Pediatric Subspecialty Milestone Project competencies are used for Neonatal-Perinatal Medicine (NPM) fellows. Milestones are longitudinal markers that range from novice to expert (levels 1-5). There is no standard approach to the required biannual evaluation of fellows by fellowship programs, resulting in significant variability among programs regarding procedural experience and exposure to pathology during clinical training. In this paper, we discuss the opportunities that Milestones provide, potential strategies to address challenges, and future directions.

Resuscitation 2020: Proceedings From the NeoHeart 2020 International Conference.

Resuscitation guidelines are developed and revised by medical societies throughout the world. These guidelines are increasingly based on evidence from preclinical and clinical research. The International Liaison Committee on Resuscitation reviews evidence for each resuscitation practice and provides summary consensus statements that inform resuscitation guideline committees. A similar process is used for different populations including neonatal, pediatric, and adult resuscitation. The NeoHeart 2020 Conference brought together experts in resuscitation to discuss recent evidence and guidelines for resuscitation practices. This review summarizes the main focus of discussion from this symposium.

Milestone Level Changes From Residency to Fellowship: A Multicenter Cohort Study.

BACKGROUND: A vital element of the Next Accreditation System is measuring and reporting educational Milestones. Little is known about changes in Milestones levels during the transition from residency to fellowship training. OBJECTIVE: Evaluate the Accreditation Council for Graduate Medical Education (ACGME) Milestones' ability to provide a linear trajectory of professional development from general pediatrics residency to neonatal-perinatal medicine (NPM) fellowship training. METHODS: We identified 11 subcompetencies that were the same for general pediatrics residency and NPM fellowship. We then extracted the last residency Milestone level and the first fellowship Milestone level for each subcompetency from the ACGME's Accreditation Data System on 89 subjects who started fellowship training between 2014 and 2018 at 6 NPM fellowship programs. Mixed-effects models were used to examine the intra-individual changes in Milestone scores between residency and fellowship after adjusting for the effects of the individual programs. RESULTS: A total of 1905 subcompetency Milestone levels were analyzed. The average first fellowship Milestone levels were significantly lower than the last residency Milestone levels (residency, mean 3.99 [SD = 0.48] vs fellowship 2.51 [SD = 0.56]; P < .001). Milestone levels decreased by an average of -1.49 (SD = 0.65) from the last residency to the first fellowship evaluation. Significant differences in Milestone levels were seen in both context-dependent subcompetencies (patient care and medical knowledge) and context-independent subcompetencies (professionalism). CONCLUSIONS: Contrary to providing a linear trajectory of professional development, we found that Milestone levels were reset when trainees transitioned from general pediatrics residency to NPM fellowship.