ObjectiveTo assess benefits of recording and reviewing neonatal resuscitation as experienced by neonatal care providers.DesignA qualitative study using semistructured interviews questioning neonatal care providers about their experiences with recording and reviewing neonatal resuscitation. Data were analysed using the qualitative data analysis software Atlas.ti V.7.0.SettingNeonatal care providers working at neonatal intensive care units (NICUs) of the Leiden University Medical Center, the Netherlands, and the University of Pennsylvania School of Medicine, USA, participated in this study.ResultsIn total, 48 NICU staff members were interviewed. Reported experiences and attitudes are broadly similar for both NICUs. All interviewed providers reported positive experiences and benefits, with special emphasis on educational benefits. Recording and reviewing neonatal resuscitation is used for various learning activities, such as plenary review meetings and as tool for objective feedback. Providers reported to learn from reviewing their own performance during resuscitation, as well as from reviewing performances of others. Improved time perception, reflection on guideline compliance and acting less invasively during resuscitations were often mentioned as learning outcomes. All providers would recommend other NICUs to implement recording and reviewing neonatal resuscitation, as it is a powerful tool for learning and improving. However, they emphasised preconditions for successful implementation, such as providing information, not being punitive and focusing on the benefits for learning and improving.ConclusionRecording and reviewing neonatal resuscitation is considered highly beneficial for learning and improving resuscitation skills and is recommended by providers participating in it.
With an increasingly complex healthcare environment, ethics is becoming a more critical part of medical education. We aimed to explore European paediatric trainees’ experiences of facing ethical dilemmas and their medical ethics education whilst assessing their perceptions of ethical dilemmas in current and future practice. The Young Sections of the European Academy of Paediatrics and European Society of Paediatric and Neonatal Intensive Care developed an explorative online survey covering demographics, ethical dilemmas faced and ethics training. The survey was made available in nine languages from November 2019 to January 2020 via newsletters and social media. Participants (n = 253) from 22 countries, predominantly female (82%) and residents (70%), with a median age of 29-years, completed the survey. The majority (58%) faced ethical dilemmas monthly or more frequently. Most ethics training was received by ethics lectures in medical school (81%) and on the job (60%). A disagreement between the healthcare team and patient/family was the most frequently faced moral dilemma (45%); the second was withholding/withdrawing life-prolonging measures (33%). The latter was considered the most challenging dilemma to resolve (50%). Respondents reported that ethical issues are not sufficiently addressed during their training and wished for more case-based teaching. Many have been personally affected by moral dilemmas, especially regarding withholding/withdrawing life-prolonging measures, and often felt inadequately supported.Conclusion: Paediatric trainees face many moral issues in daily practice and consider that training about managing current and future ethical dilemmas should be improved, such as by the provision of a core European paediatric ethics curriculum. What is Known:• Paediatric services are becoming more complex with an increase in ethical dilemmas asking for rigorous training in ethics.• Ethics training is often lacking or covered poorly in both pre- and postgraduate medical education curricula.• Existing ethics training for European paediatric trainees is haphazard and lacks standardisation. What is New:• The PaEdiatric Residents and Fellows Ethics (PERFEct) survey provides insight into the European paediatric trainees’ views regarding ethical dilemmas in their current and future practice.• European paediatric trainees report a lack of ethics training during paediatric residency and fellowship.• This study provides content suggestions for standardised medical ethics training for paediatric trainees in Europe.
Neonatal resuscitation is provided to approximately 3% of neonates. Adequate ventilation is often the key to successful resuscitation, but this can be difficult to provide. There is increasing evidence that inappropriate respiratory support can have severe consequences. Several neonatal intensive care units have recorded and reviewed neonatal resuscitation procedures for quality assessment, education and research; however, ethical dilemmas sometimes make it difficult to implement this review process. We reviewed the literature on the development of recording and reviewing neonatal resuscitation and have summarised the ethical concerns involved. Recording and reviewing vital physiological parameters and video imaging of neonatal resuscitation in the delivery room is a valuable tool for quality assurance, education and research. Furthermore, it can improve the quality of neonatal resuscitation provided. We observed that ethical dilemmas arise as the review process is operating in several domains of healthcare that all have their specific moral framework with requirements and conditions on issues such as consent, privacy and data storage. These moral requirements and conditions vary due to local circumstances. Further research on the ethical aspects of recording and reviewing is desirable before wider implementation of this technique can be recommended.
Less invasive surfactant administration (LISA) is an effective, minimally invasive technique of administering surfactant to infants with respiratory distress syndrome. While termed less invasive, LISA still requires airway instrumentation with direct laryngoscopy, thus may be considered painful. However, the issue of whether or not to routinely sedate infants for LISA remains contentious, with significant variation in practice between centres. Proponents for giving pharmacological analgesia and/or sedation predominantly focus on patient comfort during the procedure. However, those who favour non-pharmacological measures of pain management focus on the potential for procedural success without the risk of adverse events, such as respiratory depression and potentially the need for escalation to intubation, which may occur with pharmacological agents. The neonatal population who may benefit from LISA is varied. Due to this variety in presentation type, gestational age, and unit experience, there is a need to provide an individualized, tailored approach to sedation and analgesia for these infants. Using a blanket approach to sedation will lead to infants being exposed to sedative medications on the assumption of potential distress, rather than in response to signs of actual distress. This places the infant at risk of the adverse reactions, potentially without them ever having needed the beneficial effect of the medications. This seems an unnecessary risk. This article explores the ethical arguments pertaining to analgesia and sedation during the LISA technique, concluding that a standardized approach to the usage of pharmacological sedation is undesirable. Moreover, we maintain that procedural analgesia and sedation should be based on individualized, infant-centred assessment, rather than on a rigid, standardized approach.
Objective: Evaluate whether weekly audits of neonatal resuscitation using video and physiological parameter recordings improved guideline compliance and documentation in medical records. Study design: Neonatal care providers of the Neonatal Intensive Care Unit (NICU) of Leiden University Medical Center reviewed recordings of neonatal resuscitation during weekly plenary audits since 2014. In an observational pre-post cohort study, we studied a cohort of infants born before and after implementation of weekly audits. Video and physiological parameter recordings of infants needing resuscitation were analyzed. These recordings were compared with the prevailing resuscitation guideline and corresponding documentation in the medical record using a pre-set checklist. Results: A total of 212 infants were included, 42 before and 170 after implementation of weekly audits, with a median ( IQR ) gestational age of 30 (27–35) weeks vs. 30 (29–33) weeks ( p = 0.64) and birth weight of 1368 (998–1780) grams vs. 1420 (1097–1871) grams ( p = 0.67). After weekly audits were implemented, providers complied more often to the guideline (63 vs. 77%; p < 0.001). Applying the correct respiratory support based on heart rate and respiration, air conditions (dry vs. humidified air), fraction of inspired oxygen (FiO 2 ), timely start of interventions and evaluation of delivered care improved. Total number of correctly documented items in medical records increased from 39 to 65% ( p < 0.001). Greatest improvements were achieved in documentation of present providers, mode of respiratory support and details about transport to the NICU. Conclusion: Regular auditing using video and physiological parameter recordings of infants needing resuscitation at birth improved providers' compliance with resuscitation guideline and documentation in medical records.
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