Intubation is a technically challenging but important skill for neonatal trainees to master. Trainees’ opportunities to perform neonatal intubation have decreased over time, due to less use of invasive ventilation, limited duty hours and changes in practice for infants born through meconium-stained fluid. Contemporary studies report suboptimal neonatal intubation success rates, ranging from 20% to 70% for paediatric residents and neonatology fellows.1
Videolaryngoscopy is a novel tool for performing, teaching and supervising intubation. Videolaryngoscopes include a camera on the laryngoscope blade which provides a wider, magnified view of the patient’s airway on a video screen. Most videolaryngoscopes, and the ones we are referring to here, can be used for either direct laryngoscopy by the intubator or indirect laryngoscopy (where the intubator uses images from the screen to perform the intubation). Both techniques allow for a supervisor to view the screen and coach the intubator during the procedure. In addition, several devices can also record videos of intubation attempts, which facilitate postintubation review and teaching.
Robinson et al 2 and O’Shea et al 3 explore the use of videolaryngoscopy to define success rates and determine reasons for failure in neonatal intubations.
In a randomised trial, O’Shea et al studied elective, premedicated intubations performed by …
Developmental disabilities and neuromotor delay adversely affect long-term neuromuscular function and quality of life. Current evidence suggests that early therapeutic intervention reduces the severity of motor delay by harnessing neuroplastic potential during infancy. To date, most early therapeutic intervention trials are of limited duration and do not begin soon after birth and thus do not take full advantage of early neuroplasticity. The Corbett Ryan-Northwestern-Shirley Ryan AbilityLab-Lurie Children's Infant Early Detection, Intervention and Prevention Project (Project Corbett Ryan) is a multi-site longitudinal randomized controlled trial to evaluate the efficacy of an evidence-based physical therapy intervention initiated in the neonatal intensive care unit (NICU) and continuing to 12 months of age (corrected when applicable). The study integrates five key principles: active learning, environmental enrichment, caregiver engagement, a strengths-based approach, and high dosage (ClinicalTrials.gov identifier NCT05568264).We will recruit 192 infants at risk for neuromotor delay who were admitted to the NICU. Infants will be randomized to either a standard-of-care group or an intervention group; infants in both groups will have access to standard-of-care services. The intervention is initiated in the NICU and continues in the infant's home until 12 months of age. Participants will receive twice-weekly physical therapy sessions and caregiver-guided daily activities, assigned by the therapist, targeting collaboratively identified goals. We will use various standardized clinical assessments (General Movement Assessment; Bayley Scales of Infant and Toddler Development, 4th Edition (Bayley-4); Test of Infant Motor Performance; Pediatric Quality of Life Inventory Family Impact Module; Alberta Infant Motor Scale; Neurological, Sensory, Motor, Developmental Assessment; Hammersmith Infant Neurological Examination) as well as novel technology-based tools (wearable sensors, video-based pose estimation) to evaluate neuromotor status and development throughout the course of the study. The primary outcome is the Bayley-4 motor score at 12 months; we will compare scores in infants receiving the intervention vs. standard-of-care therapy.
Background: The transition from the neonatal intensive care unit (NICU) to home is a challenging time for caregivers of medically complex infants. Discharging patients in a safe and efficient manner can also present many challenges for health care providers. Telemedicine can improve the complex infant’s transition to home for caregivers and health care providers alike. Objectives: 1) To identify issues encountered by caregivers’ post discharge. 2) To evaluate the efficacy of video communication during …
The neonatal/infant intensive care unit (N/IICU) at the Children's Hospital of Philadelphia is a 98-bed, level IV unit through which second-year pediatric residents rotate monthly. We developed a quality improvement project to improve the resident educational experience using goal setting. Primary objectives were to increase resident educational goal identification to 65% and goal achievement to 85% by June 2017. Secondary objectives were to (1) increase in-person feedback from fellows and/or attendings to 90% by June 2017 and (2) sustain improvements through June 2018.The quality improvement team developed a driver diagram and administered a baseline survey to 48 residents who had rotated through the N/IICU in the 18 months before the project. Plan-Do-Study-Act cycles targeted project awareness and trialing of 3 different methods to elicit goals and track feedback, from July 2016 through June 2018.The baseline survey response rate was 52% (n = 25). Among 60 rotating residents, the median resident-reported rate of goal achievement increased from 37.5% to 50%, and residents receiving in-person feedback increased from 25% to 50%. Of the 63% (n = 38) of residents who participated in data collection, goal identification and achievement increased from 38% to 100% between academic year 2016 and academic year 2017, and in-person feedback increased from 24% to 82%.Instituting a goal-setting framework for residents during their N/IICU rotation increased goal achievement and in-person feedback. Consistent resident participation in postrotation data collection made measuring project outcomes challenging. These data support goal-oriented learning as an approach to enhance learner engagement and improve goal achievement.
Numerous conditions and circumstances place infants at risk for poor neuromotor health, yet many are unable to receive treatment until a definitive diagnosis is made, sometimes several years later. In this integrative perspective, we describe an extensive team science effort to develop a transdiagnostic approach to neuromotor health interventions designed to leverage the heightened neuroplasticity of the first year of life. We undertook the following processes: (1) conducted a review of the literature to extract common principles and strategies underlying effective neuromotor health interventions; (2) hosted a series of expert scientific exchange panels to discuss common principles, as well as practical considerations and/or lessons learned from application in the field; and (3) gathered feedback and input from diverse stakeholders including infant caregivers and healthcare providers. The resultant framework was a pragmatic, evidence-based, transdiagnostic approach to optimize neuromotor health for high-risk infants based on four principles: (a) active learning, (b) environmental enrichment, (c) caregiver engagement, and (d) strength-based approaches. In this perspective paper, we delineate these principles and their potential applications. Innovations include: engagement of multiple caregivers as critical drivers of the intervention; promoting neuromotor health in the vulnerability phase, rather than waiting to treat neuromotor disease; integrating best practices from adjacent fields; and employing a strengths-based approach. This framework holds promise for implementation as it is scalable, pragmatic, and holistically addresses both the needs of the infant and their family.
Neonatal tracheal intubation (TI) is a high-risk procedure associated with adverse safety events. In our newborn and infant ICU, we measure adverse tracheal intubation-associated events (TIAEs) as part of our participation in National Emergency Airway Registry for Neonates, a neonatal airway registry. We aimed to decrease overall TIAEs by 10% in 12 months.A quality improvement team developed an individualized approach to intubation using an Airway Bundle (AB) for patients at risk for TI. Plan-do-study-act cycles included AB creation, simulation, unit roll out, interprofessional education, team competitions, and adjusting AB location. Outcome measure was monthly rate of TIAEs (overall and severe). Process measures were AB initiation, AB use at intubation, video laryngoscope (VL) use, and paralytic use. Balancing measure was inadvertent administration of TI premedication. We used statistical process control charts.Data collection from November 2016 to August 2020 included 1182 intubations. Monthly intubations ranged from 12 to 41. Initial overall TIAE rate was 0.093 per intubation encounter, increased to 0.172, and then decreased to 0.089. System stability improved over time. Severe TIAE rate decreased from 0.047 to 0.016 in June 2019. AB initiation improved from 70% to 90%, and AB use at intubation improved from 18% to 55%. VL use improved from 86% to 97%. Paralytic use was 83% and did not change. The balancing measure of inadvertent TI medication administration occurred once.We demonstrated a significant decrease in the rate of severe TIAEs through the implementation of an AB. Next steps include increasing use of AB at intubation.
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