NeoCheck: A New Checklist to Assess Performance during Newborn Life Support-A Validation Study.

BACKGROUND: The aim of this study was to design and validate a new checklist and standardized scenario for assessing providers' performance during Newborn Life Support (NLS). METHODS: We invited twelve experts in Neonatology to take part in a three-step Delphi process. They rated the importance of each item of a newly designed assessment tool to evaluate participants' performance during Newborn Life Support independently on a numeric rating scale from 1 to 5 (1 = lowest; 5 = highest) and were able to give additional comments. All items achieving a mean rating below four after the third round were deleted. For the reliability of the checklist, we calculated interrater reliability. RESULTS: Using a standardized Delphi process, we revised the initial checklist according to the experts' ratings and comments. The final assessment tool includes 38 items covering all relevant steps during NLS. The mean expert rating of all items was 4.40. Interrater reliability showed substantial agreement between the two raters in the first draft (κ = 0.80) as well as in the final draft of the checklist (κ = 0.73). CONCLUSION: We designed a feasible assessment tool for evaluating performance during NLS. We proved the checklist to be valid and reasonable using a Delphi validation process and calculating interrater reliability.

Recommendations of the Netzwerk Kindersimulation for the Implementation of Simulation-Based Pediatric Team Trainings: A Delphi Process.

BACKGROUND: Serious or life-threatening pediatric emergencies are rare. Patient outcomes largely depend on excellent teamwork and require regular simulation-based team training. Recommendations for pediatric simulation-based education are scarce. We aimed to develop evidence-based guidelines to inform simulation educators and healthcare stakeholders. METHODS: A modified three-round Delphi technique was used. The first guideline draft was formed through expert discussion and based on consensus (n = 10 Netzwerk Kindersimulation panelists). Delphi round 1 consisted of an individual and team revision of this version by the expert panelists. Delphi round 2 comprised an in-depth review by 12 external international expert reviewers and revision by the expert panel. Delphi round 3 involved a revisit of the guidelines by the external experts. Consensus was reached after three rounds. RESULTS: The final 23-page document was translated into English and adopted as international guidelines by the Swiss Society of Pediatrics (SGP/SSP), the German Society for Neonatology and Pediatric Intensive Care (GNPI), and the Austrian Society of Pediatrics. CONCLUSIONS: Our work constitutes comprehensive up-to-date guidelines for simulation-based team trainings and debriefings. High-quality simulation training provides standardized learning conditions for trainees. These guidelines will have a sustainable impact on standardized high-quality simulation-based education.

Living in a box: Understanding acoustic parameters in the NICU environment.

Background: In the last years, a significant body of scientific literature was dedicated to the noisy environment preterm-born infants experience during their admission to Neonatal Intensive Care Units (NICUs). Nonetheless, specific data on sound characteristics within and outside the incubator are missing. Therefore, this study aimed to shed light on noise level and sound characteristics within the incubator, considering the following domain: environmental noise, incubator handling, and respiratory support. Methods: The study was performed at the Pediatric Simulation Center at the Medical University of Vienna. Evaluation of noise levels inside and outside the incubator was performed using current signal analysis libraries and toolboxes, and differences between dBA and dBSPL values for the same acoustic noises were investigated. Noise level results were furthermore classed within previously reported sound levels derived from a literature survey. In addition, sound characteristics were evaluated by means of more than 70 temporal, spectral, and modulatory timbre features. Results: Our results show high noise levels related to various real-life situations within the NICU environment. Differences have been observed between A weighted (dBA) and unweighted (dBSPL) values for the same acoustic stimulus. Sonically, the incubator showed a dampening effect on sounds (less high frequency components, less brightness/sharpness, less roughness, and noisiness). However, a strong tonal booming component was noticeable, caused by the resonance inside the incubator cavity. Measurements and a numerical model identified a resonance of the incubator at 97 Hz and a reinforcement of the sound components in this range of up to 28 dB. Conclusion: Sound characteristics, the strong low-frequency incubator resonance, and levels in dBSPL should be at the forefront of both the development and promotion of incubators when helping to preserve the hearing of premature infants.

Real-Time Intubation and Ventilation Feedback: A Randomized Controlled Simulation Study.

BACKGROUNDS: This study aimed to determine the best educational application of a respiratory function monitor and a video laryngoscope. METHODS: This study was a randomized controlled simulation-based trial, including 167 medical students. Participants had to execute ventilation and intubation maneuvers on a newborn manikin. Participants were randomized into 3 groups. In group A (no-access), the feedback devices were not visible but recording. In group B (supervisor-access), the feedback devices were visible to the supervisor only. In group C (full-access), both the participant and the supervisor had visual access. RESULTS: The two main outcome variables were the percentage of ventilations within the tidal volume target range (4-8mL/kg) and the number of intubation attempts. Group C achieved the highest percentage of ventilations within the tidal volume target range (full-access 63.6%, supervisor-access 51.0%, no-access 31.1%, P < .001) and the lowest mask leakage (full-access 34.9%, supervisor-access 46.6%, no-access 61.6%; A to B: P < .001, A to C: P < .001, B to C: P = .003). Overall, group C achieved superior ventilation quality regarding primary and secondary outcome measures. The number of intubation attempts until success was lowest in the full-access group (full-access: 1.29, supervisor-access: 1.77, no-access: 2.43; A to B: P = .001, A to C: P < .001, B to C: P = .015). CONCLUSIONS: Our findings confirm that direct visual access to feedback devices for supervisor and trainees alike considerably benefits outcomes and can contribute to the future of clinical education.

Provider Visual Attention Correlates With the Quality of Pediatric Resuscitation: An Observational Eye-Tracking Study.

Background: Eye-tracking devices are an innovative tool to understand providers' attention during stressful medical tasks. The knowledge about what gaze behaviors improve (or harm) the quality of clinical care can substantially improve medical training. The aim of this study is to identify gaze behaviors that are related to the quality of pediatric resuscitation. Methods: Forty students and healthcare providers performed a simulated pediatric life support scenario, consisting of a chest compression task and a ventilation task, while wearing eye-tracking glasses. Skill Reporter software measured chest compression (CC) quality and Neo Training software measured ventilation quality. Main eye-tracking parameters were ratio [the number of participants who attended a certain area of interest (AOI)], dwell time (total amount of time a participant attended an AOI), the number of revisits (how often a participant returned his gaze to an AOI), and the number of transitions between AOIs. Results: The most salient AOIs were infant chest and ventilation mask (ratio = 100%). During CC task, 41% of participants also focused on ventilation bag and 59% on study nurse. During ventilation task, the ratio was 61% for ventilation bag and 36% for study nurse. Percentage of correct CC rate was positively correlated with dwell time on infant chest (p = 0.044), while the overall CC quality was negatively correlated with dwelling outside of pre-defined task-relevant AOIs (p = 0.018). Furthermore, more dwell time on infant chest predicted lower leakage (p = 0.042). The number of transitions between AOIs was unrelated to CC parameters, but correlated negatively with mask leak during ventilations (p = 0.014). Participants with high leakage shifted their gaze more often between ventilation bag, ventilation mask, and task-irrelevant environment. Conclusion: Infant chest and ventilation mask are the most salient AOIs in pediatric basic life support. Especially the infant chest AOI gives beneficial information for the resuscitation provider. In contrast, attention to task-irrelevant environment and frequent gaze shifts seem to harm the quality of care.

Incidence of Post-extubation Stridor in Infants With Cuffed vs. Uncuffed Endotracheal Tube: A Retrospective Cohort Analysis.

Background: Endotracheal intubation is a common procedure in Neonatal Intensive Care. While cuffed endotracheal tubes (ETT) are the standard of care in adults and children, their use in infants is controversial. The aim of this study was to compare the incidence of post-extubation stridor between uncuffed and cuffed ETTs in infants. We further evaluated the safety of cuffed ETTs in infants with a bodyweight between 2 and 3 kg and performed baseline analysis on development of subglottic stenosis. Methods: In this retrospective study, we screened all infants admitted to two NICUs of the Medical University of Vienna between 2012 and 2019.The study cohort was screened twice: In the first screening we selected all infants who underwent the first intubation when attaining a bodyweight >2 kg (but <6 kg) to analyze the incidence of post-extubation stridor and only considered the first intubation of each included infant. Post-extubation stridor was defined as the administration of either epinephrine aerosol or any corticosteroid within 6 h post-extubation. In the second screening we searched for all infants diagnosed with acquired severe subglottic stenosis during the study period regardless their bodyweight and numbers of intubations. Results: A total of 389 infants received at least one intubation during the study period. After excluding infants who underwent the first intubation below a bodyweight of 2 kg, 271 infants remained for final analysis with an average gestational age of 38.7 weeks at the time of intubation. Among those, 92 (33.9%) were intubated with a cuffed and 179 (66.1%) with an uncuffed ETT. Seven infants (2.6%) developed a clinically significant stridor: five of those were intubated with a cuffed and two with an uncuffed ETT (71.4 vs. 28.6%, p = 0.053). All of them had a bodyweight >3 kg at the time of intubation. Infants who developed subglottic stenosis were more often intubated with an uncuffed ETT. Conclusion: In this study, no difference in the incidence of post-extubation stridor between cuffed and uncuffed ETTs in infants with a bodyweight from 2 to 6 kg could be found. The use of uncuffed ETTs does not exhibit higher risk for the acquired subglottic stenosis in this cohort.

Visual attention during pediatric resuscitation with feedback devices: a randomized simulation study.

BACKGROUND: The aim of this study was to investigate the effect of feedback devices on visual attention and the quality of pediatric resuscitation. METHODS: This was a randomized cross-over simulation study at the Medical University of Vienna. Participants were students and neonatal providers performing four resuscitation scenarios with the support of feedback devices randomized. The primary outcome was the quality of resuscitation. Secondary outcomes were total dwell time (=total duration of visit time) on areas of interest and the workload of participants. RESULTS: Forty participants were analyzed. Overall, chest compression (P < 0.001) and ventilation quality were significantly better (P = 0.002) when using a feedback device. Dwell time on the feedback device was 40.1% in the ventilation feedback condition and 48.7% in the chest compression feedback condition. In both conditions, participants significantly reduced attention from the infant's chest and mask (72.9 vs. 32.6% and 21.9 vs. 12.7%). Participants' subjective workload increased by 3.5% (P = 0.018) and 8% (P < 0.001) when provided with feedback during a 3-min chest compression and ventilation scenario, respectively. CONCLUSIONS: The quality of pediatric resuscitation significantly improved when using real-time feedback. However, attention shifted from the manikin and other equipment to the feedback device and subjective workload increased, respectively. IMPACT: Cardiopulmonary resuscitation with feedback devices results in a higher quality of resuscitation and has the potential to lead to a better outcome for patients. Feedback devices consume attention from resuscitation providers. Feedback devices were associated with a shift of visual attention to the feedback devices and an increased workload of participants. Increased workload for providers and benefits for resuscitation quality need to be balanced for the best effect.

Impact of a Multifactorial Educational Training on the Management of Preterm Infants in the Central-Eastern European Region.

Background: Differences in management and outcomes of extremely preterm infants have been reported across European countries. Implementation of standardized guidelines and interventions within existing neonatal care facilities can improve outcomes of extremely preterm infants. This study evaluated whether a multifactorial educational training (MET) course in Vienna focusing on the management of extremely preterm infants had an impact on the management of extremely preterm infants in Central-Eastern European (CEE) countries. Methods: Physicians and nurses from different hospitals in CEE countries participated in a two-day MET in Vienna, Austria with theoretical lectures, bedside teaching, and simulation trainings. In order to evaluate the benefit of the workshops, participants had to complete pre- and post-workshop questionnaires, as well as follow-up questionnaires three and twelve months after the MET. Results: 162 participants from 15 CEE countries completed the two-day MET at our department. Less invasive surfactant administration (LISA) was only used by 39% (63/162) of the participants. After the MET, 80% (122/152) were planning to introduce LISA, and 66% (101/152) were planning to introduce regular simulation training, which was statistically significantly increased three and twelve months after the MET. Thirty-six percent and 57% of the participants self-reported improved outcomes three and twelve months after the MET, respectively. Conclusion: Our standardized training in Vienna promoted the implementation of different perinatal concepts including postnatal respiratory management using LISA as well as regular simulation trainings at the participants' home departments. Moreover, our MET contributed to dissemination of guidelines, promoted best-practice, and improved self-reported outcomes.

NeoAct: A Randomized Prospective Pilot Study on Communication Skill Training of Neonatologists.

Background: This randomized interventional study evaluated the impact of a 1-day experiential communication skills training on neonatologists' performance in doctor-parents-communication. Methods: 17 neonatologists with different levels of professional experience from the Medical University of Vienna were randomized into one of two study groups: The intervention group (IG) as opposed to the control group (CG) participated in a 1-day experiential communication training. Eight weeks after the training, participants' communication skills were assessed during an objective structured clinical examination (OSCE). Neonatologists were assessed in a simulated conversation by how effectively they performed when conveying complex health-related information to parents of ill infants. Participants in the control group (CG) were assessed first during the OSCE and received their communication training later on. Self-assessment questionnaires before and after the workshop and OSCE were completed. Results: The study determined that neonatologists in the IG subjectively perceived that their competence level regarding their communication skills had increased after the workshop, while this was not reflected by their performance during the OSCE assessment. Discussion: A 1-day experiential communication skills training significantly increased physicians' self-evaluation concerning their communicative competence. This perceived competence did not manifest itself in increased communication skills during the OSCE. Conclusion: Repeated training is needed.

The association between shift patterns and the quality of hand antisepsis in a neonatal intensive care unit: An observational study.

BACKGROUND: Healthcare-associated infections represent a major burden in neonatal intensive care units. Hand antisepsis is the most important tool for prevention, however, compliance among healthcare workers remains low. OBJECTIVES: To prospectively evaluate the influence of different work shifts (extended working hours, night shifts) on the quality of healthcare workers' hand antisepsis. DESIGN: Observational study. SETTINGS: Two equivalent "Level III" neonatal intensive care units at the University Hospital Vienna, Austria. PARTICIPANTS: Seventy healthcare workers, 46 nurses and 24 physicians. METHODS: The Semmelweis Scanner, an innovative training device assessing the quality of hand antisepsis with an ultraviolet dye labelled alcohol-based hand rub, was employed to collect data on the hand surface coverage achieved during hand antisepsis of participants. It provides visual feedback of appropriately versus inappropriately disinfected areas of the hand and can also be used for the objective quantification of hand surface coverage with the hand rub. Measurements were performed before and after 12.5 h (h) day and night shifts (nurses), as well as before and after regular 8 h day shifts and extended 25 h shifts (physicians). To avoid any bias caused by residual ultraviolet marker, scans had to be separated by 24 h periods. Primary outcome was the hand surface coverage with the hand rub: Hand scans were categorized as "passed" if an appropriate quality of hand hygiene, defined as a minimum 97% coverage of hand surface, was achieved. A generalized mixed model was used to analyse the data accounting for repeated measurements. RESULTS: Seventy healthcare workers performed a total of 485 scans. Nineteen scans had to be excluded, resulting in 466 scans for further analyses. A difference in the predicted probability of achieving appropriate hand antisepsis was found between the beginning and end of extended shifts: In physicians, adequate hand antisepsis was remarkably reduced after 25 h shifts (predicted probability 99.4% vs 78.8%), whereas there was no relevant difference between the beginning and end of 8 h day shifts (92.2% vs 97.3%). In nurses, a relevant difference was found between the beginning and end of 12.5 h day shifts (88.6% vs 73.6%). This difference was not found for 12.5 h night shifts. The most frequently missed area on the hands was the right dorsum. CONCLUSION: The quality of hand antisepsis of healthcare workers in neonatal intensive care units may be associated with long working hours.

Randomised simulation trial found an association between rescuers' height and weight and chest compression quality during paediatric resuscitation.

AIM: Our aim was to examine the relationship between rescuers' anthropometric data and chest compression quality during paediatric resuscitation training. METHODS: This study focused on 224 medical students (53% women) who performed 2 minutes of paediatric resuscitation at the Medical University of Vienna, Austria: 116 on a baby manikin and 108 on an adolescent manikin. Skill Reporter software measured chest compression quality by recording compression depth, frequency, hand position and complete recoil. The participants' height, weight and body mass index (BMI) were recorded. RESULTS: Participants with a lower BMI achieved higher total chest compression scores on both the baby and adolescent manikins than participants with a higher BMI. The latter were more likely to exceed the correct compression depth and not achieve complete chest recoil in the adolescent manikin. When it came to the baby manikin, the female participants achieved better chest recoil and the males achieved a higher number of compressions at the correct rate. Males also achieved better chest recoil with the adolescent manikins. Being tall only correlated with incomplete recoil in the adolescent manikin. CONCLUSION: The results indicate that anthropometric variables were associated with chest compression quality in paediatric patients and should be considered by future education programmes.

Eye-tracking during simulation-based neonatal airway management.

BACKGROUND: Eye-tracking devices help to understand provider behavior during medical tasks. The aim of this study was to assess participants' gaze behavior and usability of eye-tracking glasses during airway management in a simulated neonatal resuscitation. METHODS: This study was an observational simulation-based study. The team member assigned to airway management wore head-mounted eye-tracking glasses. Main outcome measures were airway providers' gaze, dwell time (total amount of time a participant fixates certain areas of interest), and usability of eye-tracking glasses. RESULTS: Data from 13 participants were included. There were significant differences in dwell time during the scenario (p < 0.001), with participants spending twice as much time on the newborn and instruments as on the monitor and other staff. Participants spent about 25% more time focusing on another provider while the provider was inserting the umbilical vein catheter than in all other times of interest (intervals of time with meaningful events) (p = 0.04). The use of the glasses was perceived easy and not disturbing. CONCLUSIONS: Eye-tracking glasses enhance our understanding of providers' gaze and perspective during simulated neonatal airway management. Future studies will better characterize the ideal use in real situations.

Effects of Feedback on Chest Compression Quality: A Randomized Simulation Study.

OBJECTIVES: Our aim for this study was to test whether visual and verbal feedback compared with instructor-led feedback improve the quality of pediatric cardiopulmonary resuscitation (CPR). METHODS: There were 653 third-year medical students randomly assigned to practice pediatric CPR on 1 of 2 manikins (infant and adolescent; n = 344 and n = 309, respectively). They were further randomly assigned to 1 of 3 feedback groups: The instructor feedback (IF) group (n = 225) received traditional, instructor-led feedback without any additional feedback device. The device feedback (DF) group (n = 223) received real-time visual feedback from a feedback device. The instructor and device feedback (IDF) group (n = 205) received verbal feedback from an instructor who continuously reviewed the trainees' performance using the feedback device. After the training, participants' CPR performance was assessed on the same manikin while no feedback was being provided. RESULTS: For the primary outcome of total compression score, participants in the DF and IDF groups performed similarly, with both groups showing scores significantly (P < .001) better than those of the IF group. The same findings held for correct hand position and the proportion of complete release. For compression rate, the DF group was at the higher end of the guideline for 100 to 120 chest compressions per minute compared with the IF and IDF groups (both P < .001). No effect of feedback on compression depth was found. CONCLUSIONS: Chest compression performance significantly improved with both visual and verbal feedback compared with instructor-led feedback. Feedback devices should be implemented during pediatric resuscitation training to improve resuscitation performance.