Telehealth Training During the COVID-19 Pandemic: A Feasibility Study of Large Group Multiplatform Telesimulation Training.

Background:Video telehealth is an important tool for health care delivery during the COVID-19 pandemic. Given physical distancing recommendations, access to traditional in-person telehealth training for providers has been limited. Telesimulation is an alternative to in-person telehealth training. Telesimulation training with both remote participants and facilitators using telehealth software has not been described.Objective:We investigated the feasibility of a large group telesimulation provider training of telehealth software for remote team leadership skills with common neonatal cases and procedures.Methods:We conducted a 90-min telesimulation session with a combination of InTouch™ provider access software and Zoom™ teleconferencing software. Zoom facilitators activated InTouch software and devices and shared their screen with remote participants. Participants rotated through skill stations and case scenarios through Zoom and directed bedside facilitators to perform simulated tasks using the shared screen and audio connection. Participants engaged in a debrief and a pre- and postsurvey assessing participants' comfort and readiness to use telemedicine. Data were analyzed using descriptive statistics and paired t tests.Results:Twenty (n = 20) participants, five Zoom and eight bedside facilitators participated. Twenty-one (21) pre- and 16 postsurveys were completed. Most participants were attending neonatologists who rarely used telemedicine software. Postsession, participants reported increased comfort with some advanced InTouch features, including taking and sharing pictures with the patient (p < 0.01) and drawing on the shared image (p < 0.05), but less comfort with troubleshooting technical issues, including audio and stethoscope (p < 0.01). Frequently stated concerns were troubleshooting technical issues during a call (75%, n = 16) and personal discomfort with telemedicine applications and technology (56%, n = 16).Conclusion:Large group telesimulation is a feasible way to offer telehealth training for physicians and can increase provider comfort with telehealth software.

Use and perceived safety of stylets for neonatal endotracheal intubation: a national survey.

OBJECTIVE: To examine the use and perceived safety of stylets for neonatal intubation in a cohort of providers in the United States. STUDY DESIGN: A cross-sectional survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. RESULT: A total of 640 responses were received. 57% reported using a stylet 'every time' or 'almost every time' they intubated. The preferred stylet bend was a smooth bend of <30 degrees. 71% of respondents believed that stylets were safe. Reported complications from stylet use included tube dislodgement during stylet removal (32%), airway injury with bleeding (9%), and tracheal perforation (2%). CONCLUSION: Stylet use was common. There was fair consistency on preference for stylet bend and position. Stylet use was believed to be safe, but complications were observed by many respondents. Additional studies are needed to examine the risks and benefits of stylet use during neonatal intubation.

Evaluating an Association between Ampicillin and Intraventricular Hemorrhage in Preterm Infants.

Intraventricular hemorrhage (IVH) is a common and potentially devastating adverse outcome affecting up to 30% of preterm infants. ß-Lactam antibiotics affect platelet activation through interaction with platelet surface receptors. The objective of this study was to evaluate an association between ampicillin use and the development of IVH in preterm infants. This was a single-center and a retrospective case-control study of preterm low-birth-weight infants diagnosed with IVH and matched controls without IVH. Conditional logistic regression was performed on 10 clinical features from the first week of life to evaluate the association with IVH. Data were obtained for 174 subjects with no significant differences between groups in demographic factors and level of illness indicators. Earlier administration of the first dose of ampicillin was associated with increased odds of developing IVH (odds ratio [OR]: 0.95, p = 0.028) when controlling for other common associations. Longer courses of ampicillin were not significantly associated with the development of IVH (OR: 1.13, p = 0.089). The odds of developing IVH in our population increased with earlier, but not longer initial courses of ampicillin. Further research into the associations with IVH should include the assessment of ampicillin dose, timing, and duration.

In search of perinatal quality outcome measures: 1 hospital's in-depth analysis of the Adverse Outcomes Index.

OBJECTIVE: The purpose of this study was to assess the Adverse Outcome Index perinatal quality indicator system that was derived from administrative data. STUDY DESIGN: Adverse events were identified for 10 component measures; the Adverse Outcome Index was calculated by the National Perinatal Information Center from 42 months of administrative data. After retrospective chart review, we estimated positive predictive value for 10 measures that were obtained by corrected calculations of Adverse Outcome Index. RESULTS: Positive predictive values were 86-100% in 7 indicators, with lower values in 3 indicators: neonatal death, 0/2 fetuses; inborn birth trauma, 22/33 infants (67%); and maternal return to the operating room, 16/33 women (48.5%). In term admission to the neonatal intensive care unit, 107 false negatives were identified, with a negative predictive value of 45%. CONCLUSION: Indicator positive predictive value was variable. Performance can be strengthened by methods to identify both false-positive and false-negative adverse events that would include chart review and some measure specification revisions to improve alignment with original indicator intent. Interhospital comparison application requires further study.

Effects of transfusions in extremely low birth weight infants: a retrospective study.

OBJECTIVES: To determine the risks and benefits associated with the transfusion of packed red blood cells (PRBCs) in extremely low birth weight (ELBW) infants. We hypothesized that when ELBW infants underwent transfusion with the University of Washington Neonatal Intensive Care Unit (NICU) 2006 guidelines, no clinical benefit would be discernible. STUDY DESIGN: We conducted a retrospective chart review of all ELBW infants admitted to the NICU in 2006. Information on weight gain, apnea, heart rate, and respiratory support was collected for 2 days preceding, the day of, and 3 days after PRBC transfusion. The incidence, timing, and severity of complications of prematurity were documented. RESULTS: Of the 60 ELBW infants admitted to the NICU in 2006, 78% received PRBC transfusions. Transfusions were not associated with improved weight gain, apnea, or ventilatory/oxygen needs. However, they were associated with increased risk of bronchopulmonary dysplasia, necrotizing enterocolitis, and diuretic use (P < .05). Transfusions correlated with phlebotomy losses, gestational age, and birth weight. No association was found between transfusions and sepsis, retinopathy of prematurity, or erythropoietin use. CONCLUSIONS: When our 2006 PRBC transfusion guidelines were used, no identifiable clinical benefits were identified, but increased complications of prematurity were noted. New, more restrictive guidelines were developed as a result of this study.

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

OBJECTIVE: To compare reports of medical errors in hospitalized children submitted using an electronic, anonymous reporting system with those submitted via traditional incident reports. STUDY DESIGN: During the 3-month study period in 2003, reports of medical errors from 2 units at a large children's hospital were made using an electronic, anonymous system. Three reviewers independently evaluated each report and determined whether the events described constituted a medical error. An identical procedure was used to categorize medical error data collected via incident reports from the 2 study units from 1999 to 2002. RESULTS: A total of 146 reports were made using the anonymous system, 131 of which documented medical errors. The rate of reporting medical errors with the anonymous system was 2.41/100 patient-days. The rate of reporting medical errors via incident reports in 1999-2002 was 2.40/100 patient-days. However, 33.8% of all incident reports dealt with mislabeled laboratory specimens; after excluding these reports, the rate of medical errors documented via incident reports was 1.56/100 patient-days. The rate of reporting was significantly higher with the anonymous system (rate ratio 1.54, 95% confidence interval 1.26, 1.90). With the anonymous system, 25.2% of reported medical errors were near-misses compared with 12.6% of the errors reported with the incident report system (P = .001). CONCLUSIONS: Implementation of the anonymous reporting system with training was associated with a statistically significant increase in the rate of reported medical errors. The reporting of near-miss events was significantly increased, suggesting this may be a useful format for gathering data on this type of medical error.

Use of incident reports by physicians and nurses to document medical errors in pediatric patients.

OBJECTIVES: To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports. METHODS: A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large children's hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with chi(2) tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors. RESULTS: A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported <20% of their perceived medical errors in the previous 12 months, and 32.6% had reported <40% of perceived errors committed by colleagues. After controlling for potentially confounding variables, nurses were significantly more likely to report >or=80% of their own medical errors than physicians (odds ratio: 2.8; 95% confidence interval: 1.3-6.0). Commonly listed reasons for underreporting included lack of certainty about what is considered an error (indicated by 40.7% of respondents) and concerns about implicating others (37%). Potential interventions that would lead to increased reporting included education about which errors should be reported (listed by 65.4% of respondents), feedback on a regular basis about the errors reported (63.8%) and about individual events (51.2%), evidence of system changes because of reports of errors (55.4%), and an electronic format for reports (44.9%). Although virtually all respondents would likely report a 10-fold overdose of morphine leading to respiratory depression in a child, only 31.7% would report an event in which a supply of breast milk is inadvertently connected to a venous catheter but is discovered before any breast milk goes into the catheter. CONCLUSIONS: Medical errors in pediatric patients are significantly underreported in incident report systems, particularly by physicians. Some types of errors are less likely to be reported than others. Information in incident reports is not a representative sample of errors committed in a children's hospital. Specific changes in the incident report system could lead to more reporting by physicians and nurses who care for pediatric patients.

Zinc protoporphyrin/heme as an indicator of iron status in NICU patients.

OBJECTIVE: Zinc protoporphyrin/heme ratio (ZnPP/H) has been well established as an indicator of functional iron deficiency in subjects 6 months of age to adult. The primary objective of this study was to establish normative values for ZnPP/H in NICU patients and secondarily to explore the utility of this test as an indicator of iron deficiency in neonates. Study design ZnPP/H and complete blood counts were obtained weekly on consecutive NICU patients. Gestational age, growth variables, iron supplementation, erythropoietin treatment, and blood transfusions were documented. Results are reported as mean +/- SD. A value of P <.05 was considered significant. RESULTS: ZnPP/H ratios (n = 639) were evaluated from 143 infants. During the first week of life, ZnPP/H was inversely correlated with gestational age (n = 78, P <.001, r = -0.72). Maternal diabetes, growth retardation, and exposure to chorioamnionitis were independent risk factors for high ZnPP/H. Both iron supplementation and blood transfusion decreased ZnPP/H (P <.001). Erythropoietin treatment was associated with an increase in reticulocyte count and ZnPP/H (P <.001). CONCLUSIONS: ZnPP/H is inversely correlated with gestational age, and the range in all newborn infants is higher than in adults. ZnPP/H is elevated in certain infant subpopulations, which suggests that they may require additional iron supplementation.