Neonatal Simulation Program: A 5 Years Educational Journey From Qatar.

We describe the process of implementation, adaptation, expansion and some related clinical intuitional impacts of the neonatal simulation program since its launch in 2016 in a non-simulation neonatal unit. The team has developed 6 types of curricula: 1 full-day course and 5 half-day workshops. A total of 35 free of charge simulation courses/workshops were conducted, 32 in Qatar and 3 abroad with a total of 799 diverse participants. There was a steady increase in the overall success rate of PICC insertion from 81.7% (309/378) to 97.6% (439/450) across 3 years (P < 0.0001). The first attempt PICC insertion success rate has been also increased from 57.7% (218/378) to 66.9% (301/450) across 3 years. The mean duration of PICC insertion has been improved from 39.7 ± 25 to 34.9 ± 12.4 min after implementing the program (P = 0.33). The mean duration of the LISA catheter insertion at the beginning of the workshop was 23.5 ± 15.9 compared to 12.1 ± 8.5 s at the end of the workshop (P = 0.001). When it came to clinical practise in real patients by the same participants, the overall LISA catheter insertion success rate was 100% and the first attempt success rate was 80.4%. The mean duration of LISA catheter insertion in real patients was 26.9 ± 13.9 s compared to the end of the workshop (P = 0.001). The mean duration of the endotracheal intubation at the beginning of the workshop was 12.5 ± 9.2 compared to 4.2 ± 3.8 s at the end of the workshop (P = 0.001). In real patients, the first-attempt intubation success rate has been improved from 37/139 (26.6%) in the first year to 141/187 (75.5%) in the second year after the program implementation (P = 0.001). The mean duration of successful endotracheal intubation attempts has been improved from 39.1 ± 52.4 to 20.1 ± 9.9 s (P = 0.78). As per the participants, the skills learned in the program sessions help in protecting neonates from potential harm and improve the overall neonatal outcome. Implementing a neonatal simulation program is a promising and feasible idea. Our experience can be generalised and replicated in other neonatal care institutions.

Neonatal visits to the pediatric emergency center and its implications on postnatal discharge practices in qatar.

BACKGROUND: An early discharge from postnatal policy has been practiced at Women's Hospital, Hamad Medical Corporation. AIM: This observational cohort study was conducted to evaluate the effect of early postnatal discharge practice on neonatal morbidity in the State of Qatar. SETTING AND DESIGN: This is a data-based cohort study. All neonates ≤28 days visiting the Pediatric Emergency Centers (PEC) were evaluated for the need for re-hospitalization, referral for clinic appointments, or observation at the PEC setting. MATERIALS AND METHODS: Differences in outcome rates were compared in neonates who visited in the first 24 hours postnatal discharge (2-3 days of life) and those who visited after the third day of life. STATISTICAL ANALYSIS: Crude differences in incidence rate assessed by χ(2) or Fisher exact test were applicable. RESULTS: Of 3528 PEC visits for 1915 neonates, 1.7% required admission (3.1% of neonates), 8.4% were observed, 1.1% were referred to a clinic, and the remaining were discharged home. There was no significant difference in re-hospitalization rates of neonates visiting PEC in the first 3 days and those visiting at a later age (OR 0.78, 95% CL 0.19-3.23, P=1). However, early presentations to PEC was more likely to result in periods of observation (OR 1.88, 95% CL 1.17-3.04, P=0.01), or clinic referral (OR 4.96, 95% CL 2.16-11.38, P=0.001) when compared to older neonates. Moreover, those who presented early were significantly more likely to revisit any of the PECs with in the 28 days period (OR 3.20, 95% CL 2.17-4.97, P<0.0001). CONCLUSION: These results clearly demonstrate the need for a structured early post-discharge follow-up service that addresses the needs of all neonates and their families. The results, however, do not provide sufficient evidence that delaying postnatal discharges for apparently healthy neonates will provide significant health benefits to these neonates and their families.

Gestational age specific neonatal survival in the State of Qatar (2003-2008) - a comparative study with international benchmarks.

OBJECTIVE: To analyze and compare the current gestational age specific neonatal survival rates between Qatar and international benchmarks. STUDY DESIGN: An analytical comparative study. PLACE AND DURATION OF STUDY: Women's Hospital, Hamad Medical Corporation, Doha, Qatar, from 2003-2008. METHODOLOGY: Six year's (2003-2008) gestational age specific neonatal mortality data was stratified for each completed week of gestation at birth from 24 weeks till term. The data from World Health Statistics by WHO (2010), Vermont Oxford Network (VON, 2007) and National Statistics United Kingdom (2006) were used as international benchmarks for comparative analysis. RESULTS: A total of 82,002 babies were born during the study period. Qatar's neonatal mortality rate (NMR) dropped from 6/1000 in 2003 to 4.3/1000 in 2008 (p < 0.05). The overall and gestational age specific neonatal mortality rates of Qatar were comparable with international benchmarks. The survival of < 27 weeks and term babies was better in Qatar (p=0.01 and p < 0.001 respectively) as compared to VON. The survival of > 32 weeks babies was better in UK (p=0.01) as compared to Qatar. The relative risk (RR) of death decreased with increasing gestational age (p < 0.0001). Preterm babies (45%) followed by lethal chromosomal and congenital anomalies (26.5%) were the two leading causes of neonatal deaths in Qatar. CONCLUSION: The current total and gestational age specific neonatal survival rates in the State of Qatar are comparable with international benchmarks. In Qatar, persistently high rates of low birth weight and lethal chromosomal and congenital anomalies significantly contribute towards neonatal mortality.

Twin-twin transfusion syndrome: a population-based study.

OBJECTIVE: To study the incidence and mortality and morbidity rates of twin-twin transfusion syndrome in a complete population-based cohort in Nova Scotia. METHODS: A population-based cohort study of all monochorionic diamniotic twin pregnancies of 20 weeks of gestation or longer born to Nova Scotia (Canada) residents between 1988 and 2000 was examined. The effect of gestational age adjustment and birth weight discordancy of more than 20% on mortality and 1-year survival was studied. Other outcomes studied included birth depression, respiratory distress syndrome, chronic lung disease, interventricular hemorrhage, periventricular leukomalacia, acute renal failure, and congestive heart failure. RESULTS: Of 404 monochorionic-diamniotic twin pregnancies examined, 48 were identified with twin-twin transfusion syndrome. Total mortality rates per pregnancy were significantly greater in the twin-twin transfusion syndrome group than in the remainder of our monochorionic diamniotic population (P < .01). However, when adjusted for gestational age, mortality failed to achieve statistical significance. Similarly, no differences were noted for 1-year survival and other outcomes of liveborn infants after gestational age adjustment. Discordance in birth weight predicted a higher incidence of morbid outcomes per pregnancy, but this effect was lost after gestational age adjustment. CONCLUSION: Increased morbidity and mortality of twins with twin-twin transfusion syndrome is likely to be due to a higher incidence of preterm birth. Birth weight discordancy was not found to be an independent predictor of mortality after controlling for gestational age and twin-twin transfusion syndrome.

Does the risk of cerebral palsy increase or decrease with increasing gestational age?

BACKGROUND: It is generally accepted that the risk of cerebral palsy decreases with increasing gestational age of live born infants. However, recent studies have shown that cerebral palsy often has prenatal antecedents including congenital malformations, vascular insults and maternal infection. Cerebral palsy is therefore better viewed as occurring among fetuses, rather than among infants. We explored the epidemiologic implications of this change in perspective. METHODS: We used recently published data from Shiga Prefecture, Japan and from North-East England to examine the pattern of gestational age-specific rates of cerebral palsy under these alternative perspectives. We first calculated gestational age-specific rates of cerebral palsy as per convention, by dividing the number of cases of cerebral palsy identified among live births within any gestational age category by the number of live births in that gestational age category. Under the alternative formulation, we calculated gestational age-specific rates of cerebral palsy by dividing the number of cases of cerebral palsy identified among live births within any gestational age category by the number of fetuses who were at risk of being born at that gestation and being afflicted with cerebral palsy. RESULTS: Under the conventional formulation, cerebral palsy rates decreased with increasing gestational age from 63.9 per 1,000 live births at <28 weeks gestation to 0.9 per 1,000 live births at 37 or more weeks gestation. When fetuses were viewed as potential candidates for cerebral palsy, cerebral palsy rates increased with increasing gestational age from 0.08 per 1,000 fetuses at risk at <28 weeks gestation to 0.9 per 1,000 fetuses at risk at 37 or more weeks gestation. CONCLUSIONS: The fetuses-at-risk approach is the appropriate epidemiologic formulation for calculating the gestational age-specific rate of cerebral palsy from a causal perspective. It shows that the risk of cerebral palsy increases as gestational duration increases. This compelling view of cerebral palsy risk may help refocus research aimed at understanding and preventing cerebral palsy.