A Network Approach to Neonatal Palliative Care Education: Impact on Knowledge, Efficacy, and Clinical Practice.

More than 80 000 babies are admitted to specialist neonatal units in the United Kingdom every year, with approximately 2109 neonatal deaths a year; 98% in hospital. A common element in guidance and pathways to facilitate the provision of palliative care to infants and their families is the importance of good education and training to develop high-quality staff and services. This article presents a mixed-methods, sequential, explanatory design evaluation of 1 day palliative care education workshops delivered using a network-wide approach to multidisciplinary professionals. Workshops were delivered by healthcare professionals and bereaved parents and evaluated using questionnaires, adapted for neonatal staff from standardized measures, and follow-up interviews. The workshop content and shared learning approach resulted in significant improvements in participant's knowledge, attitude, self-beliefs and confidence in neonatal palliative care, enhanced awareness of services, and improved links between professionals. Participants cascaded their learning to their teams and provided examples of changes in their clinical practice following the workshop. Parent stories were identified as a very powerful component of the training, with lasting impact on participants. Formal, integrated palliative care education programs for perinatal and neonatal staff and longitudinal research into the impact on practice and the experience received by families are needed.

How stressful is the Newborn Life Support airway test? An observational study.

Objectives: To determine whether there is a significant stress response to the Newborn Life Support airway test (NLSAT) among healthcare professionals in the UK. Design: Quantitative study measuring both stress and anxiety of candidates on Newborn Life Support (NLS) courses measuring salivary cortisol levels along with validated anxiety questionnaires (State Trait Anxiety Inventory). Setting: UK NLS course centres. Participants: 80 healthcare professionals (nurses, doctors and midwives) on NLS courses. Interventions: Stress levels measured (cortisol swabs and State-Trait Anxiety Inventory (STAI)) at baseline, immediately before and 20 min after starting the NLSAT. Results: Cortisol measurements failed to detect any significant rise in stress levels as a result of the NLSAT. Significant anxiety was induced by the NLSAT based on STAI scores. STAI scores rose significantly in all professionals from baseline to post-NLSAT, with the greatest change detected for midwives (+11.82 (SD 7.64, p<0.001)) compared with nurses (+8.86 (SD 12.1, p<0.001)) and doctors (+7.96 (SD 2.9.69, p<0.001)). Experience had no impact on stress levels. Conclusions: Anxiety levels induced by the NLSAT are significant and should be considered when instructing and developing the NLS course.

Amnioinfusion in preterm premature rupture of membranes (AMIPROM): a randomised controlled trial of amnioinfusion versus expectant management in very early preterm premature rupture of membranes--a pilot study.

BACKGROUND: Fetal survival is severely compromised when the amniotic membrane ruptures between 16 and 24 weeks of pregnancy. Reduced amniotic fluid levels are associated with poor lung development, whereas adequate levels lead to better perinatal outcomes. Restoring amniotic fluid by means of ultrasound-guided amnioinfusion (AI) may be of benefit in improving perinatal and long-term outcomes in children of pregnancies with this condition. OBJECTIVE: The AI in preterm premature rupture of membranes (AMIPROM) pilot study was conducted to assess the feasibility of recruitment, the methods for conduct and the retention through to long-term follow-up of participants with very early rupture of amniotic membranes (between 16 and 24 weeks of pregnancy). It was also performed to assess outcomes and collect data to inform a larger, more definitive, clinical trial. DESIGN: A prospective, non-blinded randomised controlled trial. A computer-generated random sequence using a 1 : 1 ratio was used. Randomisation was stratified for pregnancies in which the amniotic membrane ruptured between 16(+0) and 19(+6) weeks' gestation and 20(+0) and 24(+0) weeks' gestation. The randomisation sequence was generated in blocks of four. Telephone randomisation and intention-to-treat analysis were used. SETTING: Four UK hospital-based fetal medicine units - Liverpool Women's NHS Trust, St. Mary's Hospital, Manchester, Birmingham Women's NHS Foundation Trust and Wirral University Hospitals Trust. PARTICIPANTS: Women with confirmed preterm prelabour rupture of membranes between 16(+0) and 24(+0) weeks' gestation. Women with multiple pregnancies, resultant fetal abnormalities or obstetric indication for immediate delivery were excluded. INTERVENTIONS: Participants were randomly allocated to either serial weekly transabdominal AI or expectant management (Exp) until 37 weeks of pregnancy, if the deepest pool of amniotic fluid was < 2 cm. MAIN OUTCOME MEASURE: Short-term maternal, pregnancy and neonatal outcomes and long-term outcomes for the child were studied. Long-term respiratory morbidity was assessed using validated respiratory questionnaires at 6, 12 and 18 months of age and infant lung function was assessed at approximately 12 months of age. Neurodevelopment was assessed using Bayley's Scale of Infant Development II at a corrected age of 2 years. RESULTS: Fifty-eight women were randomised and two were excluded from the analysis owing to termination of pregnancy for lethal anomaly, leaving 56 participants (28 serial AI, 28 Exp) recruited between 2002 and 2009, with annual recruitment rates varying between 2 and 14. Recruitment to the study improved significantly from 2007 with National Institute for Health Research (NIHR) funding. There was no significant difference in perinatal mortality [19/28 vs. 19/28; relative risk (RR) 1.0; 95% confidence interval (CI) 0.70 to 1.43], maternal morbidity or neonatal morbidity. The overall chance of surviving without long-term respiratory or neurodevelopmental disability is 4/56 (7.1%): 4/28 (14.3%) in the AI arm and 0/28 in the expectant arm (0%) (RR 9.0; 95% CI 0.51 to 159.70). CONCLUSIONS: This pilot study found no major differences in maternal, perinatal or pregnancy outcomes. The study was not designed to show a difference between the arms and the number of survivors was too small to draw any conclusions about long-term outcomes. It does signal, however, that a larger, definitive, study to evaluate AI for improvement in healthy survival is indicated. The results suggest that, with appropriate funding, such a study is feasible. A larger, definitive, study with full health economic analysis and patient perspective assessment is required to show whether AI can improve the healthy survivor rate.

A longitudinal cohort study to investigate the retention of knowledge and skills following attendance on the Newborn Life support course.

AIM: To investigate whether airway management and non-invasive ventilatory skills are retained after the Neonatal Life support (NLS) course. METHODS: Candidates who attended and passed the NLS course were retested by two registered instructors using the NLS 'airway testing sheet' unannounced at 3-5 and 12-14 months after their NLS course. Prior to the test, they were also asked to complete a proforma, indicating their own assessment of their competence in being able to effectively carry out all the items used in the NLS airway test. RESULTS: Sixty-seven candidates were tested at 3-5 months, 26 (39%) passed first time, 34 (51%) on retest and 7 (10%) failed. At 12-14 months, 43 were tested, 19 (44%) passed on first attempt, 22 (51%) on retest and 2 (5%) failed. At 12-14 months, more candidates exposed to more than five resuscitations per month passed first time compared to those who were exposed to less than one resuscitation per month (p=0.029). More candidates who were offered resuscitation training at 6 monthly intervals compared to at yearly intervals passed the test on their first attempt at 3-5 months (p=0.022). Self-assessment of competence was not different between candidates who passed and those who failed. CONCLUSIONS: This study suggests that skills when tested in a simulated scenario are highly likely to have deteriorated within a few months of attending the NLS course. There is a need for research to determine whether deteriorations in skills after the NLS, as assessed by simulation, correlate with deterioration of skills in clinical practice.

Randomised controlled trial of the use of an educational board game in neonatology.

BACKGROUND: Games have been used in healthcare education to encourage active learning. AIM: To investigate whether an educational board game which had been developed in the speciality of neonatology could influence the learning experience of medical students during their neonatal attachment. METHOD: A randomised controlled trial of using the game was conducted amongst 67 student participants. RESULTS: The average final assessment score was 4.15 points higher in the group of students that played the game compared to the control group (95% CI-0.88-9.17; p = 0.09). The game was well received by the students. CONCLUSION: Although we cannot conclude firmly that the game produces an effect on learning, this study suggests that educational games should be investigated further in the delivery of undergraduate learning in specialities where exposure is brief.

Subspecialty neonatal trainees views on being prepared for the consultant role.

Higher specialist training offers an opportunity to focus on non-clinical skills as well as clinical issues. The authors wished to determine whether doctors who complete neonatal higher specialist training in the UK feel prepared for the consultant role with respect to management, research and teaching, as well as clinical activities. A questionnaire related to the preparedness of the consultant to carry out a range of activities was sent to all doctors who were appointed to the UK higher specialist training programme in neonatology from 2002 to 2008 who were currently working as consultants. Seventy-one of the 83 eligible participants completed the questionnaire. Roles that consultants felt extremely well prepared for related to clinical care, communication, team-working, prioritising tasks, teaching and audit. Trainees reported that roles that they had been not at all well prepared for were related to roles in management and service delivery, medicolegal issues and complaints, job planning and personal development, supporting doctors in difficulty and chairing meetings. Four key themes emerged from the analysis of free-text responses regarding specialty training: the influence of shift patterns/service provision, the lack of non-clinical preparation, learning on the job as a consultant later on and problems with grid training itself. This study showed that for neonatal paediatrics in the UK, new consultants feel confident about managing ill babies but are unprepared for other aspects of the consultant's role. Neonatal higher specialist training needs to allow opportunities for non-clinical training.

Left pulmonary artery sling presenting as unilateral echogenic lung on 20-week detailed antenatal ultrasound examination.

BACKGROUND: We report the first case of left pulmonary artery sling (LPAS) presenting as unilateral echogenic lung at a routine 20-week antenatal US examination. The infant had minimal symptoms at delivery, but developed an oxygen requirement and respiratory distress from day 10 of postnatal life. Antenatal US and antenatal MRI indicated an intrathoracic anomaly, so permitting definitive investigations in the neonatal period using CT, MRI and helical-CT-acquired virtual bronchoscopy. The infant successfully underwent corrective surgery. REASON TO REPORT: Antenatal ultrasound detected an anomaly permitting definitive diagnostic investigations to be performed shortly after birth. Investigations were completed before significant signs and symptoms developed. WHAT WAS UNIQUE: This is the first report of antenatally detected unilateral echogenic lung leading to the diagnosis of pulmonary artery sling. RAMIFICATIONS OF THIS REPORT: This report provides further evidence that improvements in antenatal ultrasound and MRI permit earlier diagnosis and improve patient management.

Assessing oxygen requirement after discharge in chronic lung disease: a survey of current practice.

UNLABELLED: In order to survey current management of oxygen in children with chronic lung disease (CLD) of prematurity in the United Kingdom and Ireland, 260 questionnaires asking about criteria that were considered important when removing supplemental oxygen from a child with CLD were sent to consultant paediatricians identified as being likely to be involved in the follow-up of children with CLD. A total of 120 questionnaires were returned from 114 centres. The factors that were considered important when removal of the patient's supplemental oxygen was being considered were: the oxygen saturation level in 100% responders; the respiratory rate in 62%; the heart rate in 37%; the length of time that the child had been in oxygen in 25%; changes on the chest radiograph in 22%; capillary blood gases in 18%, and arterial blood gases in 7%. The specific oxygen saturation level above which it was felt that the patient could stop oxygen therapy ranged from 85% to 98% (mean 93%). The situations which would prevent discontinuation of oxygen were: desaturation while feeding/ sleeping or exercising in 95% responders; failure to gain weight in 78%; presence of pulmonary hypertension in 62%, the parents' opinion or perception of their child's needs for supplemental oxygen in 58%; recent withdrawal of steroid therapy in 52%; a recent infection of the respiratory tract in 42%; history of cyanotic spells in 28%; and the advent of winter in 23%. CONCLUSION: there is an enormous variety of practice with regard to the management of supplemental oxygen for children with chronic lung disease suggesting an urgent need for research and evidence-based guidelines.