Infant heart-rate measurement and oxygen desaturation detection with a digital video camera using imaging photoplethysmography.

OBJECTIVE: To assess the feasibility of using an ordinary digital video camera to measure heart rate and detect oxygen desaturations in healthy infants. STUDY DESIGN: Heart rate and oxygen saturation were measured with a video camera by detecting small color changes in 28 infants' foreheads and compared with standard pulse oximetry measures. Multivariable regression examined the relationship between infant characteristics and heart-rate measurement precision. RESULTS: The average bias of camera heart-rate measures was -4.2 beats per minute (BPM) and 95% limits of agreement were ±43.8 BPM. Desaturations detected by camera were 75% sensitive (15/20) and had a positive predictive value of 20% (15/74). Lower birth-weight was independently correlated with more precise heart-rate measures (8.05 BPM per kg, [95% CI 0.764-15.3]). CONCLUSIONS: A digital video camera provides accurate but imprecise measures of infant heart rate and may provide a rough screening tool for oxygen desaturations.

Clinical Macrosystem Simulation Translates Between Organizations.

INTRODUCTION: Simulation has become an integral tool in healthcare facility redesign. Immersing clinical experts into their future environment has demonstrated benefits for transition planning. This study evaluates translation of a proven macrosystems testing protocol, TESTPILOT, to an organization with limited simulation experience. METHODS: An experienced TESTPILOT team guided Woman's Hospital Baton Rouge's simulation preparation for their new neonatal intensive care unit. Metrics included participant evaluations, latent safety threats (LST), and clinician surveys. Latent safety threats recorded during debriefings were addressed by workflow committees. Clinicians were surveyed at four time points for readiness and preparedness on 24 key processes. RESULTS: The local team invested nearly 750 hours into learning and implementing seven simulations that participants rated positively. Most of the 305 LST were minor issues. Surveys at baseline (42% of staff), postsim (18%), pretransition (26%), and postmove (29%) demonstrated strong internal consistency. System readiness lagged behind staff preparedness (P < 0.007); both were higher after simulations (P ≤ 0.001) but at no other interval. Critical laboratory notification, rounding structure, team coverage, and feedback were still evolving as of move day (P < 0.02). DISCUSSION: Macrosystems testing using simulation identifies LST, improves process, and prepares staff. The methodology is implementable in organizations with limited prior exposure. Woman's Hospital Baton Rouge accrued essential skills to model and orchestrate an immersive neonatal intensive care unit and then drive effective multidisciplinary debriefings. Staff immersed in the new environment began to articulate their jobs before moving in. The trajectory of system readiness improvement corroborated LST correction. Future research is needed to determine the extent of simulation required for different organizational structures.

Implementing a Neonatal Transport System With Simulation in Kosovo.

OBJECTIVE: Post-war Kosovar health care systems have reduced gaps in maternal and newborn health care. Coordinated neonatal transport programs may further improve survival and morbidities. METHODS: Transport care paradigms were tested using in situ (Kosovo) and ex situ (the United States) mobile immersive simulation. Patient demographics and outcomes were measured at the tertiary referral center. RESULTS: Four paired physician and nurse transport teams performed 7 simulated interfacility transports across Kosovo. In situ simulations revealed safety threats in facilities, ambulances, and team process. Ex situ observations reinforced roles and professionalism. For the first year after simulations, tertiary neonatal intensive care unit admissions were more premature (-2.4 weeks), smaller (-725 g), and out born (+12%). Mortality was higher (14.7% vs. 7.8%), hypothermia was lower (0.2% vs. 4.6%), and culture-positive sepsis was lower (15.7% vs. 42.9%). CONCLUSION: In situ augmented by ex situ simulation provided perspective and depth of understanding to implement a new care delivery paradigm. Simulations involving Kosovar health care providers across a network of facilities generated practical experience in nationwide neonatal transport, with temporal association to altered referral patterns at the tertiary care facility.

Seeking the best training model for difficult conversations in neonatology.

OBJECTIVES: We hypothesize that a formal simulation curriculum prepares neonatology fellows for difficult conversations better than traditional didactics. METHODS: Single-center neonatology fellowship graduates from 1999 to 2013 were sent a retrospective web-based survey. Some had been exposed to a Difficult Conversations curriculum (simulation group), others had not (no simulation group). The simulation group participated in one workshop annually, consisting of lecture, simulation, and debriefing. Scenarios were customized to year of training. Epoch comparisons were made between the simulation and no simulation groups. RESULTS: Self-rated baseline effectiveness at discussing difficult topics was not different. The simulation group reported more supervised family meetings and feedback after fellow-led meetings. Simulations were rated very positively. The simulation group reported increased comfort levels. Strategic pause and body positioning were specific communication skills more frequently acquired in the simulation group. In both groups, the highest ranked contributors to learning were mentor observation and clinical practice. In the simulation group, simulation and debriefing outranked didactics or other experiences. CONCLUSIONS: Simulation-based workshops improve communication skills in high stakes conversations. However, they do not substitute for mentor observation and experience. Establishing a structured simulation-based difficult conversations curriculum refines vital communication skills necessary for the high stakes conversations neonatologists direct in clinical practice.

In situ simulation for systems testing in newly constructed perinatal facilities.

Macro-systems simulation is a methodology to assess existing services and support major culture shift to a new healthcare environment. Given credible local precedent, simulation can be effective for orienting staff, identifying process gaps and enabling their refinement prior to the transition. Select strategies enable staged process translation in an intensive care unit without exposing patients to potential risk. Orchestrating immersive, realistic in-situ simulations minimizes surprises at transition and enhances patient satisfaction. Such endeavors substantially elevate the perception of the value of simulation within an institution.

Influence of clinical status on the association between plasma total and unbound bilirubin and death or adverse neurodevelopmental outcomes in extremely low birth weight infants.

OBJECTIVES: To assess the influence of clinical status on the association between total plasma bilirubin and unbound bilirubin on death or adverse neurodevelopmental outcomes at 18-22 months corrected age in extremely low birth weight infants. METHOD: Total plasma bilirubin and unbound bilirubin were measured in 1101 extremely low birth weight infants at 5 +/- 1 days of age. Clinical criteria were used to classify infants as clinically stable or unstable. Survivors were examined at 18-22 months corrected age by certified examiners. Outcome variables were death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss, and death prior to follow-up. For all outcomes, the interaction between bilirubin variables and clinical status was assessed in logistic regression analyses adjusted for multiple risk factors. RESULTS: Regardless of clinical status, an increasing level of unbound bilirubin was associated with higher rates of death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss and death before follow-up. Total plasma bilirubin values were directly associated with death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss, and death before follow-up in unstable infants, but not in stable infants. An inverse association between total plasma bilirubin and death or cerebral palsy was found in stable infants. CONCLUSIONS: In extremely low birth weight infants, clinical status at 5 days of age affects the association between total plasma bilirubin and death or adverse neurodevelopmental outcomes at 18-22 months of corrected age. An increasing level of UB is associated a higher risk of death or adverse neurodevelopmental outcomes regardless of clinical status. Increasing levels of total plasma bilirubin are directly associated with increasing risk of death or adverse neurodevelopmental outcomes in unstable, but not in stable infants.

Effects of sample dilution, peroxidase concentration, and chloride ion on the measurement of unbound bilirubin in premature newborns.

OBJECTIVES: To assess the effects of sample dilution, peroxidase concentration, and chloride ion (Cl(-)) on plasma unbound bilirubin (B(f)) measurements made using a commercial peroxidase methodology (UB Analyzer) in a study population of ill, premature newborns. DESIGN AND METHODS: B(f) was measured with a UB Analyzer in 74 samples at the standard 42-fold sample dilution and compared with B(f) measured at a 2-fold sample dilution using a FloPro Analyzer. B(f) was measured at two peroxidase concentrations to determine whether the peroxidase steady state B(f) (B(fss)) measurements were significantly less than the equilibrium B(f) (B(feq)), in which case it was necessary to calculate B(feq) from the two B(fss) measurements. B(f) was also measured before and after adding 100 mmol/L Cl(-) to the UB Analyzer assay buffer. RESULTS: B(feq) at the 42-fold dilution was nearly 10-fold less than but it correlated significantly with B(feq) at the 2-fold dilution (mean 8.2+/-5.2 nmol/L versus 73.5+/-70 nmol/L, respectively, p<0.0001; correlation r=0.6). The two UB Analyzer B(fss) measurements were significantly less than B(feq) in 42 of 74 (57%) samples, and Cl(-) increased B(feq) in 66 of 74 (89%) samples by a mean of 82+/-67%. CONCLUSIONS: B(fss) measured by the UB Analyzer at the standard 42-fold sample dilution using assay buffer without Cl(-) and a single peroxidase concentration is significantly less than the B(feq) in undiluted plasma. Accurate B(f) measurements can be made only in minimally diluted serum or plasma.