Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial.

OBJECTIVE: To assess if simulation-based just-in-time training (JITT, short video and simulation) is superior to video training (5-minute video) in acquiring skill in neonatal endotracheal intubation (ETI). STUDY DESIGN: A Canadian multicenter randomized trial recruited junior residents who performed neonatal ETI from July 2017 to June 2021. The primary outcomes were overall and first attempt ETI success rate. Secondary outcomes included number of attempts, duration of attempts, ETI-related complications, and residents' confidence level. Statistical analysis included generalized estimating equations, mixed model analysis, Mann-Whitney test, and χ² tests. RESULTS: Sixty-five residents performed 139 ETI. The overall success rate was similar for both groups (67% vs 70%, P = .71). However, the first attempt success rate was higher for the simulation-based JITT group (54% vs 41%, P = .035). The mean duration of attempts was shorter (35 [SD, 9] vs 62 [SD, 9] seconds, P = .048) and the median number of attempts had a tendency to be lower for the simulation-based JITT group (1 [IQR, 1; 1] vs 1 [IQR, 1; 2], P = .02). There were more mucosal trauma events in the simulation-based JITT group (P = .02). Residents in both groups reported similar confidence level in performing ETI. CONCLUSIONS: Compared with video training, simulation-based JITT for neonatal ETI did not improve overall success rate. However, simulation-based JITT improved first attempt success rate and decreased the number and the duration of ETI attempts. With its positive clinical impact, simulation-based JITT can become an educational adjunct to neonatal ETI training for residents. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02809924.

Advanced neonatal procedural skills: a simulation-based workshop: impact and skill decay.

BACKGROUND: Trainees aiming to specialize in Neonatal Perinatal Medicine (NPM), must be competent in a wide range of procedural skills as per the Royal College of Canada. While common neonatal procedures are frequent in daily clinical practice with opportunity to acquire competence, there are substantial gaps in the acquisition of advanced neonatal procedural skills. With the advent of competency by design into NPM training, simulation offers a unique opportunity to acquire, practice and teach potentially life-saving procedural skills. Little is known on the effect of simulation training on different areas of competence, and on skill decay. METHODS: We designed a unique simulation-based 4-h workshop covering 6 advanced procedures chosen because of their rarity yet life-saving effect: chest tube insertion, defibrillation, exchange transfusion, intra-osseus (IO) access, ultrasound-guided paracentesis and pericardiocentesis. Direct observation of procedural skills (DOPS), self-perceived competence, comfort level and cognitive knowledge were measured before (1), directly after (2), for the same participants after 9-12 months (skill decay, 3), and directly after a second workshop (4) in a group of NPM and senior general pediatric volunteers. RESULTS: The DOPS for all six procedures combined for 23 participants increased from 3.83 to 4.59. Steepest DOPS increase pre versus post first workshop were seen for Defibrillation and chest tube insertion. Skill decay was evident for all procedures with largest decrease for Exchange Transfusion, followed by Pericardiocentesis, Defibrillation and Chest Tube. Self-perceived competence, comfort and cognitive knowledge increased for all six procedures over the four time points. Exchange Transfusion stood out without DOPS increase, largest skill decay and minimal impact on self-assessed competence and comfort. All skills were judged as better by the preceptor, compared to self-assessments. CONCLUSIONS: The simulation-based intervention advanced procedural skills day increased preceptor-assessed directly observed procedural skills for all skills examined, except exchange transfusion. Skill decay affected these skills after 9-12 months. Chest tube insertions and Defibrillations may benefit from reminder sessions, Pericardiocentesis may suffice by teaching once. Trainees' observed skills were better than their own assessment. The effect of a booster session was less than the first intervention, but the final scores were higher than pre-intervention. TRIAL REGISTRATION: Not applicable, not a health care intervention.

Mortality and Morbidity rounds in neonatology: Providers' experiences and perspectives.

AIM: To describe how Canadian level III neonatal intensive care units (NICU) organise mortality and morbidity rounds (M&MR) and explore clinicians' perspectives. METHODS: This questionnaire study, including open-ended questions, examined the following domains: (1) M&MR format, (2) ethical issues and (3) limitations and perceived effectiveness. RESULTS: Sixteen out of twenty (80%) level III NICUs participated. All deaths and 64% of morbidities were discussed. M&MR occurred monthly (69%) with 3-5 patients discussed hourly (63%) and usually (75%) physician led. Wide variations of practice between centres existed for practical issues, such as administrative support and attendance. 44% of centres allowed nurses to participate. Goals reported by participants were also heterogeneous: reducing medical error (56%), educational (50%), improving communication (44%) and peer review (23%). Practical barriers were time (75%) and lack of resources/structure (25%). Four main themes were as follows: the role of M&MR, the ongoing blame culture, communication issues and the distinction between mortality and morbidity. CONCLUSION: Goals and format of M&MR vary widely. M&MR remains physician-centric, where the blame culture still endures. Neonatal M&MR models should be adapted to the modern NICU to ensure the M&MR stays relevant. It could also benefit from lessons learned in quality improvement.

Using internal and external reviewers can help to optimise neonatal mortality and morbidity conferences.

AIM: This study determined whether there was a difference in the conclusions reached by neonatologists in morbidity and mortality conferences based on their level of involvement in a case. METHODS: All neonatal deaths occurring between August 2014 and September 2015 at the neonatal intensive care unit of Sainte-Justine Hospital, Montreal, Quebec, Canada, were reviewed by internal physicians involved in the case and external physicians who were not. The reviewers were asked to identify positive and negative clinical practice items and provide written recommendations. These were classified into eight categories and compared for each case. RESULTS: During the study, 55 patients died leading to 110 reviews and a total of 590 positive and negative items. Most items were in the communication (25.2%), ethical decision-making (16.7%) and clinical management (14.8%) categories. Both the internal and external reviewers were in agreement 48.5% of the time for positive items and 44.8% for negative items. There were 242 written recommendations, which differed significantly among the internal and external reviewers. CONCLUSION: Reviews of neonatal deaths by two independent reviewers, internal physicians and external physicians, led to different positive and negative practice items and recommendations. This could allow for a richer discussion and improve recommendations for patient care.

Does ECG monitoring affect resuscitation for neonates with pulseless electrical activity in the delivery room? A simulated, pilot, crossover randomised trial.

OBJECTIVE: To evaluate whether ECG monitoring impacts resuscitative steps during simulated neonatal resuscitation in the setting of pulseless electrical activity (PEA) in the delivery room. DESIGN: This pilot, crossover randomised controlled trial recruited providers in teams of three who participated in two simulation scenarios (PEA with and without ECG monitoring). Teams were randomised to one scenario and then crossed over. All sessions were video-recorded. The primary outcome was time to pulse check once the manikin was programmed to become pulseless. The secondary outcomes were total pulse checks, time to positive pressure ventilation, intubation, chest compressions and administration of epinephrine, and teams' quotes and behaviours during resuscitation. The primary outcome was analysed using Kaplan-Meier survival curve. The secondary outcomes were compared with Wilcoxon signed-rank test. The quotes were analysed using content analysis with pattern coding. RESULTS: Eighty-two healthcare providers were approached and 30 consented (10 teams). The mean time to check the pulse once the manikin was pulseless was 38.5 s (SD 30.1) without ECG vs 88.1 s (SD 46.1) with ECG (p<0.01). There was a significantly decreased number of pulse checks with the ECG compared with without (p<0.01). Time to intubation, chest compressions, start of positive pressure ventilation and epinephrine administration was not different between the groups. Quotes/behaviours revealed false reassurance and over-reliance on ECG monitoring, repeated pulse check errors and troubleshooting behaviours. CONCLUSIONS: ECG monitoring in simulated neonatal resuscitation results in delayed recognition of a pulseless state, decreased number of pulse checks and a possible false sense of security. Simulated resuscitation clinical endpoints are unaffected.

Atypical Presentation and Evolution of Necrotizing Enterocolitis as a PIK3CA Pathological Variant.

Activating mutation of PIK3CA is linked with cases of overgrowth syndromes and belongs to the PIK3CA-related overgrowth spectrum (PROS). Mutations in this gene are associated with vascular malformations, brain abnormalities, and an increased risk for certain tumors. We report the case of a newborn girl, preterm at 34 weeks of gestation, referred to our center for atypical necrotizing enterocolitis (NEC). At laparotomy, the appearance of the intestinal tract was described as puffy, cauliflower-like with a dark purplish coloration. Subsequently, the colostomy was described as having a consistent proliferative appearance. Medical treatment with sirolimus resulted in minimal improvement. There are no reported cases in the literature of association between NEC and PIK3CA mutation. It is possible that PIK3CA mutation, including the related vascular anomalies, plays a role in the pathogenesis of NEC with this condition.

Learning Neonatal Intubation Using the Videolaryngoscope: A Randomized Trial on Mannequins.

INTRODUCTION: The use of the videolaryngoscope (VL) facilitates intubation in adults and children, but experience in neonates is scarce. The objective of this study was to compare the VL with the classic laryngoscope (CL) in acquiring the skill of neonatal endotracheal intubation (ETI) and evaluate transferability of skill from VL to CL. We hypothesize that, on a neonatal mannequin, the VL will be superior to the CL with regard to success rate and that the skill will be transferred from VL to CL. METHODS: A randomized controlled trial was held at Sainte-Justine Hospital's simulation center. Third- and fourth-year medical students were randomized into group A, which used VL for the first phase and CL for the second phase, and group B, which used CL for both phases. Each subject performed 9 ETI on 3 simulated neonatal airways in each phase. RESULTS: Thirty-four students performed 612 intubations. Success in group A was higher than in group B in the first phase of the study (96.5% vs. 84.6%, P < 0.001). During phase 2, group A's success did not change significantly (91.7% vs. 96.5%, P = 0.07). Time to successful intubation was longer using the VL (27.6 vs. 15.6 seconds, P < 0.001), but there was no difference in phase 2 (12.5 vs. 10.2 seconds, P = 0.24). There were no esophageal intubations using the VL. CONCLUSIONS: Success rate of ETI on mannequins was improved, and esophageal intubations decreased while learning ETI using the VL compared with the CL. Once ETI is learned on mannequins using the VL, this skill is transferrable to the CL.