- Human Factors Analysis
- Extracorporeal Membrane Oxygenation
- Human Performance Optimization
- Neonatal-Perinatal Medicine
- Prenatal Consultation
- High Frequency Ventilation
- Neonatal Resuscitation
- Cardiopulmonary Resuscitation
- Neonatal Intensive Care
Director, Center for Advanced Pediatric and Perinatal Education (CAPE), Packard Children's Hospital at Stanford (2002 - Present)
Associate Chief, Education, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University (2000 - Present)
Associate Program Director, Neonatal and Developmental Biology Program, Stanford University (1993 - Present)
Director, Fellowship Training Program in Neonatal-Perinatal Medicine, Department of Pediatrics, Stanford University (1993 - 2013)
National Steering Committee, Neonatal Resuscitation Program (NRP), American Academy of Pediatrics (AAP) (2001 - Present)
Executive Committee, Safety Across High Consequences Industries (SAHI), Department of Aviation Parks College of Engineering, Aviation and Technology, St. Louis University (2005 - Present)
Senior Fellow, Center for Aviation Safety Research (CASR), Department of Aviation, Parks College of Engineering, Aviation and Technology, St. Louis University (2010 - Present)
Adjunct Faculty, Department of Aviation, Parks College of Engineering, Aviation and Technology, St. Louis University (2010 - Present)
Board Certification: Pediatrics, American Board of Pediatrics (1989)
Residency:University of Nebraska Medical Center (1990) NE
Residency:University of Nebraska Medical Center (1989) NE
Fellowship:Stanford University School of Medicine (1993) CA
Board Certification: Neonatal-Perinatal Medicine, American Board of Pediatrics (1993)
Internship:University of Nebraska Medical Center (1987) NE
Medical Education:Creighton University (1986) NE
Current Research and Scholarly Interests
In 2002 I founded the Center for Advanced Pediatric and Perinatal Education (CAPE, http://www.cape.lpch.org), dedicated to fetal, neonatal, pediatric and obstetric simulation. Finding ways to use simulation-based learning methodologies to improve the performance of professionals and systems in healthcare and enhance patient safety is the primary focus of my work. Work currently being done at CAPE stands in service of the mission of the Lucile Salter Packard Children's Hospital at Stanford as well as the broader international pediatric and obstetric community. CAPE's achievements include but are not limited to the following:
1) CAPE has established itself as an international leader in healthcare simulation. Trainees and visitors from 45 states in the U.S. and more than 45 foreign countries have come to CAPE. The work being done within its walls has been formally presented and/or conducted on five of the worlds seven continents.
2) CAPEs Simulation Instructor Training Program is viewed as a national standard in pediatrics and obstetrics.
3) Clinically relevant research conducted at CAPE using simulation as a methodology continues to influence the practice of pediatrics and obstetrics on local, regional and national levels. Examples include areas such as code cart design, resuscitation techniques and high-risk communication strategies.
4) CAPE has a longstanding partnership with the American Academy of Pediatrics and its NeoSim program serves as the basis for the new simulation-based Neonatal Resuscitation Program (NRP), the national standard of care for newborns in the U.S. With the AAP, CAPE has also co-developed a number of novel training resources including a) the 2011 NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning, b) the 2011 NRP Instructor Manual, and c) a Key Behavioral Skills Wall Chart for display in delivery rooms across the U.S.
5) CAPE has worked with industry to develop and field test new technologies for use in simulation-based learning including an interface to control bedside monitor data streams (Patient Monitor Driver, Advanced Medical Simulation, Inc.), a fetal monitor simulator (FetalSim, Advanced Medical Simulation, Inc.) and a number of neonatal, infant, pediatric and obstetric patient simulators (Laerdal Medical, Inc.). It has also actively collaborated in the development and implementation of a novel high definition audiovisual system tailored to meet the needs of simulation centers (Apple, Inc. and VMI, Inc.)
6) CAPE is the originator of the Packard Circle of Safety, the process that defines how simulation is integrated into the daily activities of Lucile Packard Childrens Hospital to improve patient safety.
7) CAPE has worked closely with the Center for Nursing Excellence at Packard to facilitate the dissemination of simulation throughout the hospital. The model of unit-based simulation task forces developed at CAPE is a national example for building a successful large-scale simulation program.
8) Training programs developed at CAPE are attended by every nurse at Packard Childrens Hospital; every student in the Stanford University School of Medicine; every resident General Pediatrics, Gynecology and Obstetrics, Anesthesia, and Emergency Medicine; and every fellow in Neonatal-Perinatal Medicine, Maternal-Fetal Medicine and Pediatric Surgery.
9) CAPE is the academic home to faculty and postdoctoral fellows in the Stanford departments of Pediatrics, Gynecology and Obstetrics, Emergency Medicine, and Anesthesia. It also serves as a host laboratory for projects in the BioDesign and BioSimulation programs at Stanford.
10) CAPE has been a responsible steward of its founding gift and the endowment provided by an anonymous donor in our community and has successfully developed a diversified model of financial support while maintaining a solvent budget.
- Independent Studies (5)
Simulation as a methodology for assessing the performance of healthcare professionals working in the delivery room.
Seminars in fetal & neonatal medicine
2013; 18 (6): 369-372
Formal evaluation of healthcare professionals has been accomplished primarily through assessment of the ability to recall content knowledge despite the fact that cognitive, technical and behavioral skills are all important aspects of human performance in this domain. In addition human performance is also influenced by elements that are extrinsic to the human being including the systems and subsystems with which they must interact. Rigorous assessment of human and system performance in the actual healthcare environment is extremely challenging for a number of reasons. Simulation provides a methodology by which this performance can be objectively assessed, thereby facilitating the delivery of effective, safe and efficient patient care.
View details for DOI 10.1016/j.siny.2013.08.010
View details for PubMedID 24051303
Editorial: Bringing latent safety threats out into the open.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2013; 39 (6): 267-?
View details for PubMedID 23789164
Anterolateral congenital diaphragmatic hernia with omphalocele: A case report and literature review
AMERICAN JOURNAL OF MEDICAL GENETICS PART A
2013; 161A (3): 585-588
The combination of congenital diaphragmatic hernia (CDH) and omphalocele is quite rare but can be seen in several syndromes. We report on a female newborn with this combination that had not been diagnosed prenatally. The patient suffered respiratory failure that persisted despite intensive care support, suggesting severe secondary pulmonary hypoplasia. Autopsy revealed the combination of an anterolateral CDH and omphalocele in the absence of other anomalies. We believe this to be the first such case to be reported in the literature.
View details for DOI 10.1002/ajmg.a.35703
View details for Web of Science ID 000315341700025
View details for PubMedID 23401132
The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: implications for delivery of care, training and technology design.
2013; 84 (3): 369-372
Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than ± 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation.Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochran's Q and chi square test were used to compare HR detection by method and across scenarios.Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination.Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.
View details for DOI 10.1016/j.resuscitation.2012.07.035
View details for PubMedID 22925993
Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial
BMJ QUALITY & SAFETY
2013; 22 (2): 124-129
To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC).A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test.Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use.The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.
View details for DOI 10.1136/bmjqs-2012-001336
View details for Web of Science ID 000314211900005
View details for PubMedID 23112286
Simulation-based learning combined with debriefing: trainers satisfaction with a new approach to training the trainers to teach neonatal resuscitation.
BMC research notes
2013; 6: 251
Prompt initiation of appropriate neonatal resuscitation skills is critical for the neonate experiencing difficulty transitioning to extra-uterine life. The use of simulation training is considered to be an indispensable tool to address these challenges. Research has yet to examine the effectiveness of simulation and debriefing for preparation of trainers to train others on the use of simulation and debriefing for neonatal resuscitation. This study determines the degree to which experienced NRP instructors or instructor trainers perceived simulation in combination with debriefing to be effective in preparing them to teach simulation to other health care professionals.Participants' perceptions of knowledge, skills, and confidence gained following a neonatal resuscitation workshop (lectures; scenario development and enactment; video recording and playback; and debriefing) were determined using a pre-post test questionnaire design. Questionnaire scores were subjected to factor and reliability analyses as well as pre- and post-test comparisons.A total of 17 participants completed 2 questionnaires. Principal component extraction of 18 items on the pre-test questionnaire resulted in 5 factors: teamwork, ability to run a simulation, skills for simulation, recognizing cues for simulation and ability to debrief. Both questionnaire scores showed good reliability (?: 0.83 - 0.97) and factorial validity. Pre- and post-test comparisons showed significant improvements in participants' perceptions of their ability to: conduct (as an instructor) a simulation (p?.05, ?2 .47); participate in a simulation (p?.05, ?2 .45); recognize cues (p?.05, ?2 .35); and debrief (p?.05, ?2 .41).Simulation training increased participants' perceptions of their knowledge, skills, and confidence to train others in neonatal resuscitation.
View details for PubMedID 23827017
The Delivery Room of the Future The Fetal and Neonatal Resuscitation and Transition Suite
CLINICS IN PERINATOLOGY
2012; 39 (4): 931-939
Despite advances in the understanding of fetal and neonatal physiology and the technology to monitor and treat premature and full-term neonates, little has changed in resuscitation rooms. The authors' vision for the Fetal and Neonatal Resuscitation and Transition Suite of the future is marked by improvements in the amount of physical space, monitoring technologies, portable diagnostic and therapeutic technologies, communication systems, and capabilities and training of the resuscitation team. Human factors analysis will play an important role in the design and testing of the improvements for safe, effective, and efficient resuscitation of the newborn.
View details for DOI 10.1016/j.clp.2012.09.014
View details for Web of Science ID 000312623900015
View details for PubMedID 23164188
Nursing department orientation: are we missing the mark?
Journal for nurses in staff development : JNSD : official journal of the National Nursing Staff Development Organization
2012; 28 (1): 24-26
Hospitals routinely provide orientation for the new nurses they hire. The evolution of nursing practice is not reflected in the current teaching methods of nursing orientation. The authors examine the past 60 years of nursing department orientation and assert the need to move toward more effective and innovative teaching strategies.
View details for DOI 10.1097/NND.0b013e318240a6f3
View details for PubMedID 22261902
Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation
2011; 128 (4): E954-E958
Emergent umbilical venous catheter (UVC) placement for persistent bradycardia in the delivery room is a rare occurrence that requires significant skill and involves space constraints. Placement of an intraosseous needle (ION) in neonates has been well described. The ION is already used in the pediatric population and is placed at an anatomic location distant from where chest compressions are performed. In this study we compared time to placement, errors in placement, and perceived ease of use for UVCs and IONs in a simulated delivery room.Forty health care providers were recruited. Subjects were shown an instructional video of both techniques and allowed to practice placement. Subjects participated in 2 simulated neonatal resuscitations requiring intravenous epinephrine. In 1 scenario they were required to place a UVC and in the other an ION. Scenarios were recorded for later analysis of placement time and error rate. Subjects were surveyed regarding the perceived level of difficulty of each technique.The average time required for ION placement was 46 seconds faster than for UVC placement (P < .001). There was no significant difference in the number of errors between UVC and ION placement or in perceived ease of use.In a simulated delivery room setting, ION placement can be performed more quickly than UVC insertion without any difference in technical error rate or perceived ease of use. ION insertion should be considered when rapid intravenous access is required in the neonate at the time of birth, especially by health care professionals who do not routinely place UVCs.
View details for DOI 10.1542/peds.2011-0657
View details for Web of Science ID 000295406800022
View details for PubMedID 21930542
The Case for OBLS: A Simulation-based Obstetric Life Support Program
SEMINARS IN PERINATOLOGY
2011; 35 (2): 74-79
Errors by health care professionals result in significant patient morbidity and mortality, and the labor and delivery ward is one of the highest risk areas in the hospital. Parturients today are of higher acuity than anytime previously, and maternal mortality is increasing. Obstetrical staff must therefore be familiar with emergency protocols geared to the maternal-fetal dyad. However, the medical literature suggests that obstetrical providers are not optimally trained to render care during maternal cardiopulmonary arrest. We describe the evolution of immersive learning and simulation in the Neonatal Resuscitation Program, and suggest the development of a multidisciplinary team, simulation-enhanced obstetric crisis training program (OBLS) may likewise benefit obstetrical health care professionals. OBLS would emphasize high quality basic life support, uterine displacement, use of an automatic external defibrillator, and delivery of the fetus within 5 minutes of maternal arrest should resuscitative efforts prove ineffective.
View details for DOI 10.1053/j.semperi.2011.01.006
View details for Web of Science ID 000289600200006
View details for PubMedID 21440814
Using the Movie Apollo 13 as a Video Primer in Behavioral Skills for Simulation Trainees and Instructors
SIMULATION IN HEALTHCARE
2010; 5 (5): 303-310
Behavioral skills such as effective communication, teamwork, and leadership are critically important to successful outcomes in patient care, especially in resuscitation situations where correct decisions must be made rapidly. However, historically, these important skills have rarely been specifically addressed in learning programs directed at healthcare professionals. Not only have most healthcare professionals had little or no formal education and training in applying behavioral skills to their patient care activities but also many of those serving as instructors and content experts for training programs have few resources available that clearly illustrate what these skills are and how they may be used in the context of real clinical situations. This represents a serious shortcoming in the education and training of healthcare professionals and stands in distinct contrast to other industries.Aerospace, similar to other high-consequence industries, has a long history of the use of simulation to improve human performance and reduce risk: astronauts and the engineers in Mission Control spend hundreds of hours in simulated flight in preparation for every mission. The value of time spent in the simulator was clearly illustrated during the flight of Apollo 13, the third mission to land men on the moon. The Apollo 13 crew had to overcome a number of life-threatening technical and medical problems, and it was their simulation-based training that allowed them to display the teamwork, ingenuity, and determination needed to return to earth safely.The movie Apollo 13 depicts in a highly realistic manner the events that occurred during the flight, including the actions of the crew in space and those in Mission Control in Houston. Three scenes from this movie are described in this article; each serves as a useful example for healthcare professionals of the importance of simulation-based learning and the application of behavioral skills to successful resolution of crises. This article is meant to serve as a guide as to how this movie and other similar media may be used for facilitated group or independent learning, providing appropriate context and clear examples of key points to be discussed.
View details for DOI 10.1097/SIH.0b013e3181e5e329
View details for Web of Science ID 000282961900009
A National Survey of Pediatric Residents and Delivery Room Training Experience
JOURNAL OF PEDIATRICS
2010; 157 (1): 158-U211
To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.
View details for DOI 10.1016/j.jpeds.2010.01.029
View details for Web of Science ID 000278649200037
View details for PubMedID 20304418
- Simulation: The New "Triple Threat" PEDIATRIC RESEARCH 2010; 67 (2): 130-131
Delivery Room Management of the Newborn
PEDIATRIC CLINICS OF NORTH AMERICA
2009; 56 (3): 515-?
Neonatal resuscitation is an attempt to facilitate the dynamic transition from fetal to neonatal physiology. This article outlines the current practices in delivery room management of the neonate. Developments in cardiopulmonary resuscitation techniques for term and preterm infants and advances in the areas of cerebral resuscitation and thermoregulation are reviewed. Resuscitation in special circumstances (such as the presence of congenital anomalies) are also covered. The importance of communication with other members of the health care team and the family is discussed. Finally, future trends in neonatal resuscitation are explored.
View details for DOI 10.1016/j.pcl.2009.03.003
View details for Web of Science ID 000267523700006
View details for PubMedID 19501690
The simulated delivery-room environment as the future modality for acquiring and maintaining skills in fetal and neonatal resuscitation
SEMINARS IN FETAL & NEONATAL MEDICINE
2008; 13 (6): 448-453
The science underlying neonatal resuscitation is growing exponentially in quantity and quality. So, too, is the knowledge of effective methodologies that facilitate acquisition and maintenance of the cognitive, technical, and behavioral skills necessary to for successful resuscitation of the newborn. One of these methodologies, simulation-based training, offers many advantages over more traditional methodologies: By providing key visual, auditory, and tactile cues it creates a high level of physical, biological, and psychological fidelity to the real environment and thus is able to elicit realistic responses from trainees. Training scenarios coupled with debriefings (where discussion of what went well and what could be improved upon occur in a nonjudgmental fashion) provide rich learning experiences that rival or exceed those in the real clinical environment. Simulation-based training will likely become the standard for not only routine training but also high-stakes assessment such as licensure and board certification.
View details for DOI 10.1016/j.siny.2008.04.015
View details for Web of Science ID 000260971000013
View details for PubMedID 18524705
Teamwork during resuscitation
PEDIATRIC CLINICS OF NORTH AMERICA
2008; 55 (4): 1011-?
Effective resuscitation requires the integration of several cognitive, technical, and behavioral skills. Because resuscitation is performed by teams of health care professionals, these individuals must be able to work together in a coordinated and efficient manner, making teamwork a critical skill for care of patients in distress. Despite the importance of teamwork in health care, little consensus exists as to what it is, how it can most effectively be learned, and how it should be assessed. This article reviews current knowledge on the measurement, training, and importance of teamwork in pediatric resuscitation.
View details for DOI 10.1016/j.pcl.2008.04.001
View details for Web of Science ID 000259090300011
View details for PubMedID 18675031
Simulation-based medical error disclosure training for pediatric healthcare professionals.
Journal for healthcare quality : official publication of the National Association for Healthcare Quality
2007; 29 (4): 12-19
Ethical and regulatory guidelines recommend disclosure of medical errors to patients and families. Yet few studies examine how to effectively train healthcare professionals to deliver communications about adverse events to family members of affected pediatric patients. This pilot study uses a preintervention-postintervention study design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses (N=16). The results of a paired t test showed statistically significant increases in nurses' communication self-efficacy to carry out medical disclosure (t = 6.68, p < .001). Ratings of setting "realism" and simulation effectiveness were high (21 out of 25 composite score). Findings provide preliminary support for further research on simulation-based disclosure training for healthcare professionals.
View details for PubMedID 17849675
Implementation and case-study results of potentially better practices for collaboration between obstetrics and neonatology to achieve improved perinatal outcomes
2006; 118: S153-S158
The objective of this study was to make improvements in communication and collaboration between neonatal and obstetric specialties. Five NICUs from the Vermont Oxford Network's Evidence-Based Quality Improvement Collaborative in Neonatal and Perinatal Medicine tested potentially better practices that overlap obstetric and NICU care.One area of practice improvement was the management of the pregnancy at the margin of viability. Another included the use of team training and video simulation to improve team performance during high-risk deliveries using aviation-based communication techniques. Another focus of the collaborative was the creation of a multicenter database to measure combined perinatal and neonatal outcomes.The principle outcomes are increased patient satisfaction with teamwork between neonatology and obstetric services and improved team response times for emergent deliveries and the increased use of team communication skills during video simulations of high-risk deliveries.Implementing these potentially better practices can result in improved communication and collaboration related to perinatal and neonatal care.
View details for DOI 10.1542/peds.2006-0913M
View details for Web of Science ID 000243201000013
View details for PubMedID 17079618
Evaluation and development of potentially better practices for perinatal and neonatal communication and collaboration
2006; 118: S147-S152
The obstetric and neonatal exploratory focus group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative 2002 set out to improve collaboration, communication, and coordination between maternal and neonatal caregivers in 3 areas: the pregnancy at 22 to 26 weeks, measurement of maternal outcomes that are linked with neonatal outcomes, and team performance during high-risk delivery. Antepartum and intrapartum maternal attributes and interventions also were considered important measurements to identify practice variations and their relationship to neonatal outcomes for ongoing obstetric and neonatal collaboration.Potentially better practices were developed on the basis of evidence in the literature, expert opinion, and internal analysis at the participating perinatal centers. The potentially better practices include development of local guidelines at each center for the care and counseling of pregnant women who are at risk for delivering at the margin of viability; communication strategies for obstetric and neonatology providers relating to high-risk pregnancy treatment plans; team communication and performance at high-risk deliveries; design of organizational structures and processes that facilitate obstetric and neonatal collaboration; and development of perinatal data to evaluate effects of perinatal practices on maternal, fetal, and neonatal outcomes.As a result of the project, participating centers developed local guidelines for pregnancies between 22 and 26 weeks, created a cross-center maternal database that currently is being linked to neonatal outcomes, and completed a pilot study on video simulation of neonatal-perinatal team communication.Increased understanding of practice variation in the management of care for infants who are at the margins of viability, locally developed guidelines, and a focus on improved team communication during delivery can be accomplished with a multicenter collaborative approach.
View details for DOI 10.1542/peds.2006-0913L
View details for Web of Science ID 000243201000012
View details for PubMedID 17079617
Continuous positive airway pressure during neonatal resuscitation
CLINICS IN PERINATOLOGY
2006; 33 (1): 83-?
Despite the large body of information regarding the beneficial effects of continuous positive airway pressure (CPAP) in infants with respiratory distress syndrome (RDS) data are insufficient at this time to support or refute its use during neonatal resuscitation. An individualized approach to infants with respiratory distress is recommended.
View details for DOI 10.1016/j.clp.2005.11.010
View details for Web of Science ID 000236684700008
View details for PubMedID 16533635
Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part I: methodologic and technologic innovations.
Simulation in healthcare
2006; 1 (4): 220-227
Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim.A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program.Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training.Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.
View details for DOI 10.1097/01.SIH.0000243550.24391.ce
View details for PubMedID 19088593
- Simulation-based training: opportunities for the acquisition of unique skills. The virtual mentor : VM 2006; 8 (2): 84-87
Simulating extracorporeal membrane oxygenation emergencies to improve human performance. Part II: assessment of technical and behavioral skills.
Simulation in healthcare
2006; 1 (4): 228-232
Healthcare professionals are expected to make rapid, correct decisions in critical situations despite what may be a lack of real practical experience in a particular crisis situation. Successful resolution of a medical crisis depends upon demonstration not only of appropriate technical skills but also of key behavioral skills (eg, leadership, communication, and teamwork). We have developed a hands-on, high fidelity, simulation-based training program (ECMO Sim) to provide healthcare professionals with the opportunity to learn and practice the technical and behavioral skills necessary to manage ECMO emergencies.Nine ECMO nurse specialists participated in two sequential randomly assigned simulated ECMO emergencies. The simulated emergencies were captured on videotape and reviewed with the subjects during facilitated debriefings that occurred immediately following each scenario. All videotapes were scored for key technical and behavioral skills by reviewers blinded to the sequence of the scenarios. The ratings of the subjects' technical and behavioral skills in each scenario were compared.Subjects performed key technical skills correctly more often in the second simulated ECMO emergency. In addition, their response times for three out of five specific technical tasks improved from the first to the second simulated emergency by an average of 27 seconds. Subjects' behavioral skills were rated more highly by masked reviewers in the second simulated ECMO emergency. The improvement in comprehensive behavioral scores from the first to the second scenario reached statistical significance in eight of nine subjects.After exposure to high-fidelity simulated ECMO emergencies, subjects demonstrated significant improvements in their technical and behavioral skills. ECMO Sim creates a learning environment that readily supports the acquisition of the technical and behavioral skills that are important in solving clinically significant, potentially life-threatening problems that can occur when patients are on ECMO.
View details for DOI 10.1097/01.SIH.0000243551.01521.74
View details for PubMedID 19088594
Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: A randomized, controlled, crossover trial involving simulated resuscitation scenarios
2005; 116 (3): E326-E333
Access to resuscitation equipment is a critical component in delivering optimal care in pediatric arrest situations. Historically, children's hospitals and clinics have used a standard pediatric resuscitation cart ("standard cart") in which drawers are organized by intervention (eg, intubation module, intravenous module), requiring multiple drawers to be opened during a code. Many emergency departments, however, use a pediatric resuscitation cart based on the Broselow tape ("Broselow cart") in which each drawer is color coded and organized by patient length and weight ranges; each drawer contains all necessary equipment for resuscitation of a patient in that specific length/weight range. A literature review has revealed no studies examining the utility of either cart.To compare which resuscitation cart organization (standard versus Broselow) allows for faster access to equipment, more accurate selection of appropriately sized equipment, and better user satisfaction. Methodology. We performed a prospective, randomized, controlled, crossover trial in which 21 pediatric health care providers were assigned the role of obtaining the appropriate equipment during 2 standardized, simulated codes alternately using either a standard or Broselow cart. Time to and accuracy of the selection of appropriate medical equipment along with posttesting satisfaction were measured. All simulations were performed in the Center for Advanced Pediatric Education at Stanford University Medical Center (Stanford, CA), a training facility designed to replicate the real medical environment with the technology to allow for videotaping of scenarios.Of the 21 subjects, 62% found the Broselow cart "easy" or "very easy" to use versus 33% for the standard cart. Of the 21 subjects, 67% preferred the Broselow cart, 10% preferred the standard cart, and 23% indicated no preference. Intubation supplies and nasogastric tubes were found significantly faster when using the Broselow cart (mean time: 29.1 and 20 seconds, respectively) versus the standard cart (mean time: 38.7 and 38.2 seconds, respectively). Correct equipment was provided a statistically significant 99% of the time with the Broselow cart versus 83% of the time with the standard cart. Ten percent of the subjects had prior experience with the Broselow cart versus 62% having experience with the standard cart.Despite less prior experience with the Broselow cart, subjects in this study found it easier to use and preferred it over the standard cart. In addition, subjects located intubation equipment and nasogastric tubes significantly faster when using the Broselow cart, and correct equipment was provided significantly more often with the Broselow cart. These data suggest that sites caring for pediatric patients should consider modeling their resuscitation carts after the Broselow cart to enhance provider confidence and patient safety.
View details for DOI 10.1542/peds.2005-0320
View details for Web of Science ID 000231576600001
View details for PubMedID 16061568
High-fidelity simulation-based training in neonatal nursing.
Advances in neonatal care : official journal of the National Association of Neonatal Nurses
2004; 4 (6): 326-331
Simulation-based training is a novel approach that facilitates the use of higher order thinking skills. Simulation-based training challenges medical professionals to develop cognitive, technical, and behavioral skills through the use of mannequins, working medical equipment, and human colleagues. During scenarios, trainees must make use of their knowledge base, analyze and synthesize factors contributing to the crises, and evaluate the effects of their actions. Feedback indicates that simulation-based training programs are more pertinent to and better accepted by adult learners than traditional programs. The instructional methodologies used in simulation-based training programs are more in line with the tenets of adult learning.
View details for PubMedID 15609254
Training and competency assessment in electronic fetal monitoring: A national survey
OBSTETRICS AND GYNECOLOGY
2003; 101 (6): 1243-1248
To investigate current patterns of training and competency assessment in electronic fetal monitoring (EFM) for obstetrics and gynecology residents and maternal-fetal medicine fellows.A questionnaire was mailed to the directors of all 254 accredited US residencies in obstetrics and gynecology and 61 accredited US fellowships in maternal-fetal medicine. Questions focused on the methods used for teaching and assessing competency in EFM.Two hundred thirty-nine programs (76%) responded to the survey. Clinical experience is used by 219 programs (92%) to teach EFM, both initially and on an ongoing basis. Significantly more residencies than fellowships use written materials and lectures to teach EFM. More than half of all programs require trainees to participate in some type of EFM training at least every 6 months; 23 programs (10%) have no requirement at all. Subjective evaluation is used by 174 programs (73%) to assess competency in EFM. Written or oral examinations, skills checklists, and logbooks are used exclusively by residencies as means of competency assessment. Two thirds of all programs assess EFM skills at least every 6 months; 40 programs (17%), the majority of which are fellowships, have no formal requirement.Most US training programs use supervised clinical experience as both their primary source of teaching EFM and their principal competency assessment tool. Residencies are more likely to have formal instruction and assessment than are fellowships. Few programs are using novel strategies (eg, computers or simulators) in their curriculum.
View details for DOI 10.1016/S0029-7844(03)00351-0
View details for Web of Science ID 000183293300018
View details for PubMedID 12798531
Evaluation of a novel electronic fetal monitor simulator
MEDICINE MEETS VIRTUAL REALITY 11
2003; 94: 240-244
The purpose of this study was to evaluate the content validity and construct validity of a novel electronic fetal monitor (EFM) simulator. Fourteen residents in Gynecology and Obstetrics (OB/GYN) and 7 medical students in their OB/GYN clerkship interpreted 10 fetal heart rate (FHR) tracings and 4 clinical scenarios generated by the EFM simulator. Their responses were scored by experts in maternal-fetal medicine. Construct validity was determined by comparing subjects' scores to their level of experience. Subjects assessed content validity of the EFM simulator by rating the realism of its various elements on a 4-point Likert scale. Residents achieved statistically significant higher mean scores in the description of FHR tracings generated by the simulator than medical students and statistically significant higher mean scores in the correct interpretation of and interventions in 2 of 4 clinical scenarios. Two-thirds of the residents rated the simulator-generated FHR tracings and clinical scenarios as "real" or "very real." The EFM simulator exhibited both content and construct validity, supporting its use in an educational setting.
View details for Web of Science ID 000189484800048
View details for PubMedID 15455900
The advantages of prenatal consultation by a neonatologist.
Journal of perinatology
2001; 21 (2): 116-120
The neonatologist can be a valuable source of information for the pregnant woman and her partner faced with making difficult decisions. In specific clinical situations, a focused, thorough consultation by a neonatologist provides benefits for the parents, their child, the physicians, and the health care delivery system as a whole. Members of the perinatal team should act to facilitate early neonatal consultation in order to ease the transition from the obstetric to the neonatal team after delivery.
View details for PubMedID 11324357
Time for a new paradigm in pediatric medical education: Teaching neonatal resuscitation in a simulated delivery room environment
2000; 106 (4)
Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program.Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion.The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate.Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.
View details for Web of Science ID 000089623100002
View details for PubMedID 11015540
Secondary infection presenting as recurrent pulmonary hypertension.
Journal of perinatology
2000; 20 (4): 262-264
Primary infection in the neonate, especially group B streptococcal infection, has long been recognized as a cause of persistent pulmonary hypertension of the newborn (PPHN), sometimes requiring treatment with inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO). However, secondary nosocomial infections in the neonatal period have not been widely reported as a cause of severe recurrent pulmonary hypertension (PHTN). We now present two cases of secondary infection in the neonate leading to significant PHTN. In both cases, the infants presented with PPHN soon after birth, requiring transfer to a level 3 neonatal intensive care unit and treatment with high-frequency oscillatory ventilation and iNO. After successful resolution of the initial PPHN, including extubation to nasal cannula, both infants developed signs of severe recurrent PHTN, leading to reintubation, high-frequency oscillatory ventilation and iNO therapy, and consideration of ECMO. In both cases, blood cultures taken at the time of recurrence of PHTN returned positive, one for Staphylococcus epidermidis, the other for methicillin-resistant Staphylococcus aureus. These unusual cases present the possibility of severe recurrent PHTN requiring iNO or ECMO in the setting of secondary infection. We speculate that these infants, although extubated after their first episodes of PHTN, were at risk for recurrence of PHTN due to continued pulmonary vascular reactivity.
View details for PubMedID 10879342
Congenital diaphragmatic hernia: the perinatalogist's perspective.
Pediatrics in review
1999; 20 (10): e67-70
View details for PubMedID 10512894
Neonatal hypoglycemia, part II: Pathophysiology and therapy
1998; 37 (1): 11-16
Contemporary research is elucidating both the molecular mechanisms of hypoglycemia-induced neuronal injury and its corresponding clinical manifestations. Recognizing and screening those neonates at highest risk of hypoglycemia-induced injury is an important skill for all physicians responsible for the care of newborns. Appropriate therapy, consisting of either oral or intravenous glucose, should never be delayed while one is awaiting laboratory confirmation of a "low" glucose level.
View details for Web of Science ID 000071577400002
View details for PubMedID 9475694
The value of neurophysiologic approaches in the anticipation and evaluation of neonatal hypoglycemia.
Acta paediatrica Japonica; Overseas edition
1997; 39: S33-43
The association of low blood glucose with central nervous system (CNS) injury was first described in 1937 by Hartmann and Jaudon. In the early 60 years since publication of these observations the effects of hypoglycemia upon the brain remain poorly understood. Technology capable of accurately determining plasma glucose concentrations has been developed. Investigators have sought to establish critical values below which glucose levels should not be allowed to fall. Despite these efforts the definitive level of glucose capable of producing brain injury in any particular patient remains unknown. Glucose homeostasis within the neonatal CNS represents a dynamic process consisting of many interrelated variables including gestational and chronologic age, genotype, relative health, blood flow, metabolic rate and availability of other suitable substrates. New technique for assessing the glucose delivery: consumption ratio and directly monitoring the cellular consequences of glucose deprivation within discrete regions of the brain will help to answer the question 'How long is too low and how long is too long?'
View details for PubMedID 9200877
ALTERED RHOMBOMERE-SPECIFIC GENE-EXPRESSION AND HYOID BONE DIFFERENTIATION IN THE MOUSE SEGMENTATION MUTANT, KREISLER (KR)
1993; 117 (3): 925-936
Rhombomeres appear transiently in the vertebrate hindbrain shortly after neurulation and are thought to represent embryologic compartments in which the expression of different combinations of genes leads to segment-specific differentiation of the developing hindbrain, the cranial ganglia, and the branchial arches. To determine the extent to which gene expression is related to the formation of visible rhombomere boundaries, we have examined, by in situ hybridization, the expression of five rhombomere-specific genes in mouse embryos homozygous for the kreisler (kr) mutation, in which rhombomeres 4-7 are replaced by a smooth morphologically unsegmented neural tube. Using molecular probes specific for Hoxb-1 (Hox-2.9), Hoxb-3 (Hox-2.7), Hoxb-4 (Hox-2.6), Krox-20, or Fgf-3 (Int-2), we found that the kr mutation affects the expression of all the genes we examined, but, surprisingly, the altered patterns of expression are not restricted to that portion of the mutant hindbrain which is morphologically abnormal. Rostral expression boundaries of Hoxb-3 and Hoxb-4 are displaced from their normal positions at r4/5 and r6/7 to the approximate positions of r3/4 and r4/5, respectively. The expression domains of Krox-20 and Fgf-3 are also displaced in a rostral direction and the intensity of Fgf-3 hybridization is greatly reduced. The expression domain of Hoxb-1 is affected differently from the other genes in kr/kr embryos; its rostral boundary at r3/4 is intact but the caudal boundary is displaced from its normal location at r4/5 to the approximate position of r5/6. Because boundaries of gene expression for Hoxb-1 and Hoxb-4 are found in a region of the kr/kr hindbrain that lacks visible rhombomeres, establishment of regional identity, as reflected by differential gene expression, does not require overt segmentation. To investigate whether the altered patterns of gene expression we observed in the kr/kr embryonic hindbrain are associated with morphologic changes in the adult, we examined neural crest-derived tissues of the second and third branchial arches, which normally arise from rhombomeres 4 and 6, respectively. We found that the hyoid bone in kr/kr animals exhibited an accessory process on the greater horn (a third arch structure) most easily explained by ectopic development of a second arch structure (the hyoid lesser horn) in an area normally derived from the third arch.
View details for Web of Science ID A1993KY54800010
View details for PubMedID 8100767
Ultrasound in congenital hip disease. Part II--Prospective study.
The Nebraska medical journal
1990; 75 (6): 142-143
View details for PubMedID 2195365
Ultrasound in congenital hip disease. Part 1--Review of technique.
The Nebraska medical journal
1990; 75 (6): 134-141
View details for PubMedID 2195364
CHILDHOOD-CANCER SURVIVORS KNOWLEDGE OF THEIR DIAGNOSIS AND TREATMENT
ANNALS OF INTERNAL MEDICINE
1989; 110 (5): 400-403
To determine what factors correlated with the failure of the survivors of childhood cancer to acknowledge their diagnosis.A follow-up interview with 1928 adults who survived childhood cancer to evaluate the late effects of cancer and its treatment. Cancer was diagnosed in these survivors between 1945 and 1974 before they reached age 20: subjects had to have survived for at least 5 years and to have reached age 21.Fourteen percent of the survivors of malignancies at sites other than the central nervous system said that they had not had cancer. This proportion differed according to the survivors' race, the type of tumor and its treatment, the level of their father's education, the year of diagnosis, and the center where the tumor was diagnosed. Among survivors who knew that they had cancer previously, however, most (81%) correctly identified the type of treatment they had received.Physicians should be aware that a substantial proportion of long-term survivors of childhood cancer may not reveal their past history of cancer and its treatment, and possible clues to the cause of the presenting condition may thus be missed.
View details for Web of Science ID A1989T552700011
View details for PubMedID 2916808
Who's teaching neonatal resuscitation to housestaff?: Results of a national survey
AMER ACAD PEDIATRICS. 2001: 249-255
This study was designed to investigate current patterns of training in neonatal resuscitation in US residency programs in general pediatrics.A questionnaire was mailed to the chief residents and directors of all US residency programs in general pediatrics to determine who provides supervision and teaching of neonatal resuscitation in the delivery room and neonatal intensive care unit. This questionnaire also inquired as to the use within these residency programs of standardized resuscitation training courses such as Pediatric Advanced Life Support and Neonatal Resuscitation Program.Residents in their third and second years of training are most often cited as responsible for supervision and teaching of neonatal resuscitation in the delivery room, whereas attending neonatologists are cited most frequently as being responsible for these tasks in the neonatal intensive care unit. Pediatric Advanced Life Support is required by virtually all US residency programs, followed in frequency by Neonatal Resuscitation Program and Advanced Cardiac Life Support.Because those in training collectively provide much of the supervision and teaching of neonatal resuscitation, vigilance is required so that appropriate resuscitation skills are developed and maintained. Objective performance markers may be useful in assessing competency in caring for sick newborns.neonatal resuscitation, delivery room, Neonatal Resuscitation Program, Pediatric Advanced Life Support, Advanced Cardiac Life Support.
View details for Web of Science ID 000166714000020
View details for PubMedID 11158454
Neonatal hypoglycemia .1. Background and definition
SAGE PUBLICATIONS INC. 1997: 675-680
Hypoglycemia in the neonate remains a common problem. The association of low blood glucose concentrations and abnormal development has prompted extensive research into the anticipation, evaluation, and treatment of neonatal hypoglycemia. Glucose homeostasis in the fetus and neonate is a developmentally regulated dynamic process involving a number of intricate physiologic mechanisms. In addition, the determination of glucose concentrations is dependent upon both the type of tissue analyzed and the limitations of the specific method employed. The complexity of glucose metabolism makes it difficult to precisely define "normal" and "abnormal" glucose levels in preterm and term neonates.
View details for Web of Science ID A1997YK31400001
View details for PubMedID 9415833
The value of neurophysiologic approaches in the anticipation and evaluation of neonatal hypoglycemia
BLACKWELL SCIENCE. 1997: 33-43
View details for Web of Science ID A1997XG14300007
The OOPS procedure (operation on placental support): In utero airway management of the fetus with prenatally diagnosed tracheal obstruction
W B SAUNDERS CO. 1996: 826-828
Tracheal obstruction of the newborn caused by cervical masses such as teratomas and cystic hygromas can result in a profound hypoxic insult and even death, owing to an inability to establish an adequate airway after birth. Prenatal sonographic diagnosis of these congenital anomalies permits (1) anticipation of an airway problem at the time of delivery and (2) formulation of an algorithm for airway management while oxygen delivery to the baby is maintained through the placental circulation. This is the report of a fetus in whom a large anterior cervical cystic hygroma was detected by prenatal ultrasonography. A multidisciplinary management team was assembled, and an algorithm for airway management was developed. Elective cesarean delivery of the fetal head and thorax, under conditions of uterine tocolysis, permitted a controlled evaluation of the airway and endotracheal intubation while oxygen supply to the infant was maintained through the placenta. The baby remained intubated, and 2 days later underwent subtotal excision of the cervical cystic hygroma. Pharmacological maintenance of the feto-placental circulation after hysterotomy is an invaluable adjunct to airway management of the neonate with prenatally diagnosed tracheal obstruction.
View details for Web of Science ID A1996UQ51500024
View details for PubMedID 8783114