Ritu Chitkara

All Publications

• Pallister-Killian Syndrome. NeoReviews Chitkara, R., Chock, V., Barth, R., Dahmoush, H., Smith, C., Matalon, D. R., Herring, M., Hintz, S. 2024; 25 (11): e751-e756

  View details for DOI 10.1542/neo.25-11-e751

  View details for PubMedID 39482245

• Prenatal Diagnosis and Postnatal Management of a Fetal Pericardial Mass. NeoReviews Weigel, N., Hintz, S., Kaplinski, M., Barth, R., Balakrishnan, K., Panelli, D., Ma, M., Chitkara, R. 2023; 24 (10): e683-e689

  View details for DOI 10.1542/neo.24-10-e683

  View details for PubMedID 37777619

• In Situ Simulation and Clinical Outcomes in Infants Born Preterm. The Journal of pediatrics Chitkara, R., Bennett, M., Bohnert, J., Yamada, N., Fuerch, J., Halamek, L. P., Quinn, J., Padua, K., Gould, J., Profit, J., Xu, X., Lee, H. C. 2023: 113715

  Abstract

  To evaluate impact of a multi-hospital collaborative quality improvement project implementing in situ simulation training for neonatal resuscitation on clinical outcomes for infants born preterm.Twelve neonatal intensive care units (NICUs) were divided into 4 cohorts; each completed a 15-month long program in a stepped wedge manner. Data from California Perinatal Quality Care Collaborative were used to evaluate clinical outcomes. Very low birthweight (VLBW) infants born between 22 through 31 weeks gestation were included. Primary outcome was survival without chronic lung disease (CLD); secondary outcomes included intubation in the delivery room (DR), DR continuous positive airway pressure (CPAP), hypothermia (<36ºC) upon NICU admission, severe intraventricular hemorrhage, and mortality prior to hospital discharge. A mixed effects multivariable regression model was used to assess the intervention effect.Between March 2017 and December 2020, a total of 2,626 eligible VLBW births occurred at 12 collaborative participating sites. Rate of survival without CLD at participating sites was 74.1% in Mar-Aug2017 and 76.0% in Jul-Dec 2020 (RR 1.03 [0.94,1.12]; no significant improvement occurred during the study period for both participating and non-participating sites. The effect of in situ simulation on all secondary outcomes was stable.Implementation of a multi-hospital collaborative providing in situ training for neonatal resuscitation did not result in significant improvement in survival without CLD. Ongoing in situ simulations may have an impact on unit practice and unmeasured outcomes.

  View details for DOI 10.1016/j.jpeds.2023.113715

  View details for PubMedID 37659586

• Neonatal Healthcare Professionals' Experiences When Implementing a Simulation and Debriefing Program in Neonatal Intensive Care Settings: A Qualitative Analysis. Advances in neonatal care : official journal of the National Association of Neonatal Nurses Quinn, J., Quinn, M., Lieu, B., Bohnert, J., Halamek, L. P., Profit, J., Fuerch, J. H., Chitkara, R., Yamada, N. K., Gould, J., Lee, H. C. 2023

  Abstract

  BACKGROUND: Simulation-based training (SBT) and debriefing have increased in healthcare as a method to conduct interprofessional team training in a realistic environment.PURPOSE: This qualitative study aimed to describe the experiences of neonatal healthcare professionals when implementing a patient safety simulation and debriefing program in a neonatal intensive care unit (NICU).METHODS: Fourteen NICUs in California and Oregon participated in a 15-month quality improvement collaborative with the California Perinatal Quality Care Collaborative. Participating sites completed 3 months of preimplementation work, followed by 12 months of active implementation of the simulation and debriefing program. Focus group interviews were conducted with each site 2 times during the collaborative. Content analysis found emerging implementation themes.RESULTS: There were 234 participants in the 2 focus group interviews. Six implementation themes emerged: (1) receptive context; (2) leadership support; (3) culture change; (4) simulation scenarios; (5) debriefing methodology; and (6) sustainability. Primary barriers and facilitators with implementation of SBT centered around having a receptive context at the unit level (eg, availability of resources and time) and multidisciplinary leadership support.IMPLICATIONS FOR PRACTICE AND RESEARCH: NICUs have varying environmental (context) factors and consideration of unit-level context factors and support from leadership are integral aspects of enhancing the successful implementation of a simulation and debriefing program for neonatal resuscitation. Additional research regarding implementation methods for overcoming barriers for both leaders and participants, as well as determining the optimal frequency of SBT for clinicians, is needed. A knowledge gap remains regarding improvements in patient outcomes with SBT.

  View details for DOI 10.1097/ANC.0000000000001085

  View details for PubMedID 37399571

• Heterogeneity of Treatment Effects of Hydrocortisone by Risk of Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants in the National Institute of Child Health and Human Development Neonatal Research Network Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA network open Gentle, S. J., Rysavy, M. A., Li, L., Laughon, M. M., Patel, R. M., Jensen, E. A., Hintz, S., Ambalavanan, N., Carlo, W. A., Watterberg, K. 2023; 6 (5): e2315315

  Abstract

  Extremely preterm infants who develop bronchopulmonary dysplasia (BPD) are at a higher risk for adverse pulmonary and neurodevelopmental outcomes. In the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) Hydrocortisone Trial, hydrocortisone neither reduced rates of BPD or death nor increased rates of neurodevelopmental impairment (NDI) or death.To determine whether estimated risk for grades 2 to 3 BPD or death is associated with the effect of hydrocortisone on the composite outcomes of (1) grades 2 to 3 BPD or death and (2) moderate or severe NDI or death.This secondary post hoc analysis used data from the NICHD NRN Hydrocortisone Trial, which was a double-masked, placebo-controlled, randomized clinical trial conducted in 19 US academic centers. The NICHD HRN Hydrocortisone Trial enrolled infants born at a gestational age of less than 30 weeks who received mechanical ventilation for at least 7 days, including at the time of enrollment, and who were aged 14 to 28 postnatal days. Infants were enrolled between August 22, 2011, and February 4, 2018, with follow-up between 22 and 26 months of corrected age completed on March 29, 2020. Data were analyzed from September 13, 2021, to March 25, 2023.Infants were randomized to 10 days of hydrocortisone or placebo treatment.Infants' baseline risk of grades 2 to 3 BPD or death was estimated using the NICHD Neonatal BPD Outcome Estimator. Differences in absolute and relative treatment effects by baseline risk were evaluated using interaction terms in models fitted to the efficacy outcome of grades 2 to 3 BPD or death and the safety outcome of moderate or severe NDI or death by follow-up.Among the 799 infants included in the analysis (421 boys [52.7%]), the mean (SD) gestational age was 24.9 (1.5) weeks, and the mean (SD) birth weight was 715 (167) g. The mean estimated baseline risk for grades 2 to 3 BPD or death was 54% (range, 18%-84%) in the study population. The interaction between treatment group and baseline risk was not statistically significant on a relative or absolute scale for grades 2 to 3 BPD or death; the size of the effect ranged from a relative risk of 1.13 (95% CI, 0.82-1.55) in quartile 1 to 0.94 (95% CI, 0.81-1.09) in quartile 4. Similarly, the interaction between treatment group and baseline risk was not significant on a relative or absolute scale for moderate or severe NDI or death; the size of the effect ranged from a relative risk of 1.04 (95% CI, 0.80-1.36) in quartile 1 to 0.99 (95% CI, 0.80-1.22) in quartile 4.In this secondary analysis of a randomized clinical trial, the effect of hydrocortisone vs placebo was not appreciably modified by baseline risk for grades 2 to 3 BPD or death.ClinicalTrials.gov Identifier: NCT01353313.

  View details for DOI 10.1001/jamanetworkopen.2023.15315

  View details for PubMedID 37256621

• Spinal Muscular Atrophy Type 1: Fetal Diagnosis, Prenatal Coordination, and Postnatal Management in the Era of Novel Therapies. NeoReviews Chitkara, R., Chock, V., Davis, A., Rocha, C. T., Day, J. W., Fluharty, B., Hintz, S. 2022; 23 (7): e520-e526

  View details for DOI 10.1542/neo.23-7-e520

  View details for PubMedID 35773512

• Hydrocortisone to Improve Survival without Bronchopulmonary Dysplasia. The New England journal of medicine Watterberg, K. L., Walsh, M. C., Li, L., Chawla, S., D'Angio, C. T., Goldberg, R. N., Hintz, S. R., Laughon, M. M., Yoder, B. A., Kennedy, K. A., McDavid, G. E., Backstrom-Lacy, C., Das, A., Crawford, M. M., Keszler, M., Sokol, G. M., Poindexter, B. B., Ambalavanan, N., Hibbs, A. M., Truog, W. E., Schmidt, B., Wyckoff, M. H., Khan, A. M., Garg, M., Chess, P. R., Reynolds, A. M., Moallem, M., Bell, E. F., Meyer, L. R., Patel, R. M., Van Meurs, K. P., Cotten, C. M., McGowan, E. C., Hines, A. C., Merhar, S., Peralta-Carcelen, M., Wilson-Costello, D. E., Kilbride, H. W., DeMauro, S. B., Heyne, R. J., Mosquera, R. A., Natarajan, G., Purdy, I. B., Lowe, J. R., Maitre, N. L., Harmon, H. M., Hogden, L. A., Adams-Chapman, I., Winter, S., Malcolm, W. F., Higgins, R. D., Eunice Kennedy Shriver NICHD Neonatal Research Network, Polin, R. A., Laptook, A. R., Vohr, B. R., Hensman, A. M., Vieira, E., Pierre, L. S., Burke, R. T., Alksninis, B., Caskey, M., Hoffman, L., Johnson, K., Keszler, M. L., Knoll, A., Leach, T. M., Little, E., Stephens, B. E., Watson, V. E., Payne, A. H., Newman, N. S., Siner, B. S., Bhola, M., Yalcinkaya, G., Pallotto, E. K., Gauldin, C., Holmes, A., Johnson, K., Scott, A., Schibler, K., Yolton, K., Beiersdorfer, T., Cahill, T. E., Dudley, J., Gratton, T. L., Grisby, C., Kirker, K., Thompson, J., Wuertz, S., Goldstein, R. F., Ashley, P. L., Mago-Shah, D., Warren, M., Finkle, J., Fisher, K. A., Gustafson, K. E., Bose, C. L., Bernhardt, J., Bose, G., Wereszczak, J., Warner, D., Talbert, J., Clark, C., Kicklighter, S. D., Bentley, A., Edwards, L., Rhodes-Ryan, G., White, D., Carlton, D. P., Stoll, B. J., Hale, E. C., Loggins, Y., Bottcher, D., Carter, S. L., Kendrick-Allwood, S., Mulligan LaRossa, M., Mackie, C., Smikle, G., Comerford, L. C., Laursen, J., Sanders, A., Bremer, A. A., Wilson Archer, S., Papile, L. A., Harmon, H., Lytle, C., Herron, D. E., Gunn, S., Smiley, L., Wilson, L. D., Tyson, J. E., Duncan, A. F., Alaniz, N., Allain, E., Arldt-McAlister, J., Boral, D. S., Burson, K., Dempsey, A. G., Eason, E., Evans, P. W., Garcia, C., Green, C., Hall, D. J., Jiminez, M., John, J., Jones, P. M., Lillie, M. L., Martin, K., Martin, S. C., Mason, C. M., McDavid, G. E., McKee, S. L., Poe, M., Rennie, K., Rodgers, S. L., Siddiki, S. K., Sperry, D., Stephens, E. K., Pierce Tate, P. L., Wright, S. L., Sanchez, P. J., Nelin, L. D., Jadcherla, S. R., Slaughter, J. L., Luzader, P., Burkhardt, S., Carey, H., Chao, M., Clark, E., Fearns, E., Fortney, C. A., Fowler, A., Grothause, J., Gutentag, J., Hague, C., McCool, J., Nelin, M. A., Park, C., Pietruszewski, L., Purnell, J., Shadd, J., Small, K., Stein, M., Sullivan, M., Sullivan, R. A., Timan, C. J., Yeates, K. O., Yoseff-Salameh, L., Keim, S. A., Newton, J., Levengood, K., Batterson, N., Rice, C., Wallace, D., Bann, C. M., Gantz, M. G., O'Donnell Auman, J., Gabrio, J., Leblond, D., Newman, J. E., Petrie Huitema, C. M., vonLehmden, A., Zaterka-Baxter, K. M., Stevenson, D. K., Chock, V. Y., Ball, M. B., Bentley, B., Chitkara, R., Davis, A. S., DeAnda, M. E., DeBattista, A. M., Earhart, B., Huffman, L. C., Krueger, C. E., Lucash, R. E., Proud, M. S., Hitchner Reichert, E. N., Sivakumar, D., Taylor, H., Weiss, H. E., Carlo, W. A., Collins, M. V., Cosby, S. S., Biasini, F. J., Domnanovich, K. A., McNair, T. E., Phillips, V. A., Whitley, S., York Chapman, S., Devaskar, U., Chanlaw, T., Geller, R., Colaizy, T. T., Widness, J. A., Brumbaugh, J. E., Harmon, H. M., Johnson, K. J., Walker, J. R., Goeke, C. A., Schmelzel, M. L., Eastman, D. L., Baack, M. L., Hogden, L. A., Meyer, L., Henning, M. M., Elenkiwich, C., Broadbent, M., Van Muyden, S., Ellsbury, D. L., Campbell, D. B., Tud, T. L., Fuller, J., Hartenberger, C., Kuan, E., Sundquist Beauman, S., Kirpalani, H., Eichenwald, E. C., Abbasi, S., Mancini, T., Chaudhary, A. S., Cucinotta, D. M., Bernbaum, J. C., Freeman Duncan, A., Dysart, K., Gerdes, M., Hurt, H., Jensen, E. A., Snyder, J., Ziolkowski, K., Guillet, R., Myers, G. J., Binion, K., Fallone, C., Farooq, O., Jensen, R. L., Kent, A., Maffett, D., Merzbach, J., Orme, C., Sacilowski, M. G., Sabaratnam, P., Scorsone, A. M., Wadkins, H. I., Wynn, K., Yost, K., Lakshminrusimha, S., Chandrasekharan, P., Guilford, S., Hartley-McAndrews, M. E., Williams, A., Zorn, W., Li, E., Donato, J., McKee, K. G., Coleman, K. R., Bean, S. A., Cole, C. A., Horihan, C. A., Brion, L. P., Vasil, D. M., Adams, S. S., Boss, L., Chen, L., De Leon, M. M., Eubanks, F., Guzman, A., Heyne, E., Lee, L. E., Lira, H., Madden, L. A., McDougald, E. R., Mozaffari, A., Pavageau, L., Sepulveda, P., Twell Boatman, C., Tolentino-Plata, K., Vera, A., Waterbury, J., Wright, R., Ohls, R. K., Baserga, M., Minton, S. D., Sheffield, M. J., Rau, C. A., Burnett, J., Christensen, S., Cole Bledsoe, L., Cunningham, S., Davis, B., Elmont, J. O., Hall, B., Loertscher, M. C., Marchant, T., Maxson, E., McGrath, K. M., Mickelsen, H. G., Morshedzadeh, G., Parry, D. M., Reich, B. A., Schaefer, S. T., Stout, K., Stuart, A. L., Weaver-Lewis, K., Woodbury, K. D., Shankaran, S., Sood, B. G., Bara, R., Agarwal, P., Bajaj, M., Childs, K., February, M., Goldston, L., Johnson, M. E., Panaitescu, B., Hinz Woldt, E., Barks, J., Carlson, M., Christensen, M. K., White, D. F., Wiggins, S. A., Gleason, C. A., Allen, M. C., Boyle, R. J., Clemons, T., D'Alton, M. E., Das, A., O'Shea, T. M., Steinhorn, R., Weiner, S. J., Willinger, M. 2022; 386 (12): 1121-1131

  Abstract

  BACKGROUND: Bronchopulmonary dysplasia is a prevalent complication after extremely preterm birth. Inflammation with mechanical ventilation may contribute to its development. Whether hydrocortisone treatment after the second postnatal week can improve survival without bronchopulmonary dysplasia and without adverse neurodevelopmental effects is unknown.METHODS: We conducted a trial involving infants who had a gestational age of less than 30 weeks and who had been intubated for at least 7 days at 14 to 28 days. Infants were randomly assigned to receive either hydrocortisone (4 mg per kilogram of body weight per day tapered over a period of 10 days) or placebo. Mandatory extubation thresholds were specified. The primary efficacy outcome was survival without moderate or severe bronchopulmonary dysplasia at 36 weeks of postmenstrual age, and the primary safety outcome was survival without moderate or severe neurodevelopmental impairment at 22 to 26 months of corrected age.RESULTS: We enrolled 800 infants (mean [±SD] birth weight, 715±167 g; mean gestational age, 24.9±1.5 weeks). Survival without moderate or severe bronchopulmonary dysplasia at 36 weeks occurred in 66 of 398 infants (16.6%) in the hydrocortisone group and in 53 of 402 (13.2%) in the placebo group (adjusted rate ratio, 1.27; 95% confidence interval [CI], 0.93 to 1.74). Two-year outcomes were known for 91.0% of the infants. Survival without moderate or severe neurodevelopmental impairment occurred in 132 of 358 infants (36.9%) in the hydrocortisone group and in 134 of 359 (37.3%) in the placebo group (adjusted rate ratio, 0.98; 95% CI, 0.81 to 1.18). Hypertension that was treated with medication occurred more frequently with hydrocortisone than with placebo (4.3% vs. 1.0%). Other adverse events were similar in the two groups.CONCLUSIONS: In this trial involving preterm infants, hydrocortisone treatment starting on postnatal day 14 to 28 did not result in substantially higher survival without moderate or severe bronchopulmonary dysplasia than placebo. Survival without moderate or severe neurodevelopmental impairment did not differ substantially between the two groups. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01353313.).

  View details for DOI 10.1056/NEJMoa2114897

  View details for PubMedID 35320643

• Lessons Learned from a Collaborative to Develop a Sustainable Simulation-Based Training Program in Neonatal Resuscitation: Simulating Success. Children (Basel, Switzerland) Arul, N. n., Ahmad, I. n., Hamilton, J. n., Sey, R. n., Tillson, P. n., Hutson, S. n., Narang, R. n., Norgaard, J. n., Lee, H. C., Bergin, J. n., Quinn, J. n., Halamek, L. P., Yamada, N. K., Fuerch, J. n., Chitkara, R. n. 2021; 8 (1)

  Abstract

  Newborn resuscitation requires a multidisciplinary team effort to deliver safe, effective and efficient care. California Perinatal Quality Care Collaborative's Simulating Success program was designed to help hospitals implement on-site simulation-based neonatal resuscitation training programs. Partnering with the Center for Advanced Pediatric and Perinatal Education at Stanford, Simulating Success engaged hospitals over a 15 month period, including three months of preparatory training and 12 months of implementation. The experience of the first cohort (Children's Hospital of Orange County (CHOC), Sharp Mary Birch Hospital for Women and Newborns (SMB) and Valley Children's Hospital (VCH)), with their site-specific needs and aims, showed that a multidisciplinary approach with a sound understanding of simulation methodology can lead to a dynamic simulation program. All sites increased staff participation. CHOC reduced latent safety threats measured during team exercises from 4.5 to two per simulation while improving debriefing skills. SMB achieved 100% staff participation by identifying unit-specific hurdles within in situ simulation. VCH improved staff confidence level in responding to neonatal codes and proved feasibility of expanding simulation across their hospital system. A multidisciplinary approach to quality improvement in neonatal resuscitation fosters engagement, enables focus on patient safety rather than individual performance, and leads to identification of system issues.

  View details for DOI 10.3390/children8010039

  View details for PubMedID 33445638

• A Neonatal Intensive Care Unit's Experience with Implementing an In-Situ Simulation and Debriefing Patient Safety Program in the Setting of a Quality Improvement Collaborative. Children (Basel, Switzerland) Eckels, M. n., Zeilinger, T. n., Lee, H. C., Bergin, J. n., Halamek, L. P., Yamada, N. n., Fuerch, J. n., Chitkara, R. n., Quinn, J. n. 2020; 7 (11)

  Abstract

  Extensive neonatal resuscitation is a high acuity, low-frequency event accounting for approximately 1% of births. Neonatal resuscitation requires an interprofessional healthcare team to communicate and carry out tasks efficiently and effectively in a high adrenaline state. Implementing a neonatal patient safety simulation and debriefing program can help teams improve the behavioral, cognitive, and technical skills necessary to reduce morbidity and mortality. In Simulating Success, a 15-month quality improvement (QI) project, the Center for Advanced Pediatric and Perinatal Education (CAPE) and California Perinatal Quality Care Collaborative (CPQCC) provided outreach and training on neonatal simulation and debriefing fundamentals to individual teams, including community hospital settings, and assisted in implementing a sustainable program at each site. The primary Aim was to conduct two simulations a month, with a goal of 80% neonatal intensive care unit (NICU) staff participation in two simulations during the implementation phase. While the primary Aim was not achieved, in-situ simulations led to the identification of latent safety threats and improvement in system processes. This paper describes one unit's QI collaborative experience implementing an in-situ neonatal simulation and debriefing program.

  View details for DOI 10.3390/children7110202

  View details for PubMedID 33137897

• Liver Failure and Rash in a 6-week-old Girl PEDIATRICS IN REVIEW Mediratta, R., Schwenk, H., Rao, A., Chitkara, R. 2018; 39 (6): 315–U22

  View details for PubMedID 29858298

• Prediction of neonatal respiratory distress in pregnancies complicated by fetal lung masses. Prenatal diagnosis Girsen, A. I., Hintz, S. R., Sammour, R., Naqvi, A., El-Sayed, Y. Y., Sherwin, K., Davis, A. S., Chock, V. Y., Barth, R. A., Rubesova, E., Sylvester, K. G., Chitkara, R., Blumenfeld, Y. J. 2017

  Abstract

  The objective of this article is to evaluate the utility of fetal lung mass imaging for predicting neonatal respiratory distress.Pregnancies with fetal lung masses between 2009 and 2014 at a single center were analyzed. Neonatal respiratory distress was defined as intubation and mechanical ventilation at birth, surgery before discharge, or extracorporeal membrane oxygenation (ECMO). The predictive utility of the initial as well as maximal lung mass volume and congenital pulmonary airway malformation volume ratio by ultrasound (US) and magnetic resonance imaging (MRI) was analyzed.Forty-seven fetal lung mass cases were included; of those, eight (17%) had respiratory distress. The initial US was performed at similar gestational ages in pregnancies with and without respiratory distress (26.4 ± 5.6 vs 22.3 ± 3 weeks, p = 0.09); however, those with respiratory distress had higher congenital volume ratio at that time (1.0 vs 0.3, p = 0.01). The strongest predictors of respiratory distress were maximal volume >24.0 cm(3) by MRI (100% sensitivity, 91% specificity, 60% positive predictive value, and 100% negative predictive value) and maximal volume >34.0 cm(3) by US (100% sensitivity, 85% specificity, 54% positive predictive value, and 100% negative predictive value).Ultrasound and MRI parameters can predict neonatal respiratory distress, even when obtained before 24 weeks. Third trimester parameters demonstrated the best positive predictive value. © 2017 John Wiley & Sons, Ltd.

  View details for DOI 10.1002/pd.5002

  View details for PubMedID 28061000

• Using simulation to study difficult clinical issues: prenatal counseling at the threshold of viability across american and dutch cultures. Simulation in healthcare Geurtzen, R., Hogeveen, M., Rajani, A. K., Chitkara, R., Antonius, T., Van Heijst, A., Draaisma, J., Halamek, L. P. 2014; 9 (3): 167-173

  Abstract

  Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists.We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation.American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues.Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.

  View details for DOI 10.1097/SIH.0000000000000011

  View details for PubMedID 24401918

• 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. Resuscitation Chitkara, R., Rajani, A. K., Oehlert, J. W., Lee, H. C., Epi, M. S., Halamek, L. P. 2013; 84 (3): 369-372

  Abstract

  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 Chitkara, R., Rajani, A. K., Lee, H. C., Hansen, S. F., Halamek, L. P. 2013; 22 (2): 124-129

  Abstract

  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 PubMedID 23112286

• Newborn with prenatally diagnosed choroidal fissure cyst and panhypopituitarism and review of the literature. AJP reports Chitkara, R., Rajani, A., Bernstein, J., Shah, S., Hahn, J. S., Barnes, P., Hintz, S. R. 2011; 1 (2): 111-114

  Abstract

  Little has been reported on fetal diagnosis of choroidal fissure cysts and prediction of the clinical complications that can result. We describe the case of a near-term male infant with prenatally diagnosed choroidal fissure cyst and bilateral clubfeet. His prolonged course in the neonatal intensive care nursery was marked by severe panhypopituitarism, late-onset diabetes insipidus, placement of a cystoperitoneal shunt, and episodes of sepsis. Postnatal genetic evaluation also revealed an interstitial deletion involving most of band 10q26.12 and the proximal half of band 10q26.13. The patient had multiple readmissions for medical and surgical indications and died at 6 months of age. This case represents the severe end of the spectrum of medical complications for children with choroidal fissure cysts. It highlights not only the importance of comprehensive evaluation and multidisciplinary management and counseling in such cases, but also the need for heightened vigilance in these patients.

  View details for DOI 10.1055/s-0031-1293512

  View details for PubMedID 23705098

• Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation PEDIATRICS Rajani, A. K., Chitkara, R., Oehlert, J., Halamek, L. P. 2011; 128 (4): E954-E958

  Abstract

  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 PubMedID 21930542

• A National Survey of Pediatric Residents and Delivery Room Training Experience JOURNAL OF PEDIATRICS Lee, H. C., Chitkara, R., Halamek, L. P., Hintz, S. R. 2010; 157 (1): 158-U211

  Abstract

  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

  View details for PubMedCentralID PMC2886184

• A National Survey of Pediatric Residents and Delivery Room Training Experience Journal of Pediatrics Lee, H., Chitkara R, Halamek LP, Hintz SR 2010; 157 (1): 158-161
• Delivery Room Management of the Newborn PEDIATRIC CLINICS OF NORTH AMERICA Rajani, A. K., Chitkara, R., Halamek, L. P. 2009; 56 (3): 515-?

  Abstract

  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 PubMedID 19501690

• Pediatric Resident Attendance at Deliveries Journal of Investigative Medicine Chitkara R, Lee HC, Hintz SR 2009; 57 (1): 504
• Visual Diagnosis: Prenatally Diagnosed Abdominal Cystic Mass Neoreviews 2007 8: e554 Chitkara R, Lee HC 2007; 8: e554