Impact of standardized communication techniques on errors during simulated neonatal resuscitation Nicole K. Yamada, MD, FAAP Senior Fellow, Neonatal-Perinatal Medicine Division of Neonatal and Developmental Medicine October 10, 2014

2 In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

TRACON: Cactus 1529 turn left heading two-seven-zero. Pilot: This is Cactus 1539 – hit birds. We lost thrust in both engines. We’re turning back towards La Guardia. TRACON: Ok yeah, you need to return to La Guardia. Turn left heading of two-two-zero. Pilot: Two-two-zero. TRACON: Tower, stop your departures. We got an emergency returning. Tower: Who is it? TRACON: It’s He...uh…bird strike. He lost all engines. He lost the thrust in the engines. He is returning immediately. Tower: Cactus 1529 – which engines? TRACON: He lost thrust in both engines he said. Tower: Got it. TRACON: Cactus 1529 if we can get it for you, do you want to try to land runway one-three? Pilot: We’re unable; we may end up in the Hudson. TRACON: Alright Cactus 1529 – it’s going to be left traffic to runway three-one. Pilot: Unable. TRACON: Okay what do you need to land?

RN: Stim! Stim! Stim! MD places a floppy, cyanotic baby on the radiant warmer. MD and RN warm, dry, and stimulate. RN auscultates for HR while reaching for PPV mask. MD: [to father] Hello. Congratulations. RN: Hold on, I can’t hear [the HR while baby is being dried]. Stop stop. MD stops drying. RN: It’s slow. [RN begins PPV with pop-off valve alarming, inadequate filling volume of bag, and inappropriately fast RR.] Keep stim-ing. RN: [to baby] What’s going on? Huh? MD: [auscultates HR] I think we need to intubate. RN: Yeah, go ahead. Why don’t you get that bag while I get the [intubation] tray. MD: [MD takes over PPV, and continues improper technique] Can you call for an extra hand from the NICU please? MD: [to RN] I can’t get it, can you do it? RN: Yeah, ok. Neonatal Resuscitation RN takes over PPV, and MD steps away to get intubation supplies.

MD: Did you guys hear me? Can you guys call the NICU? Because we need an extra hand. OB RN: Call the team? What do you want? Who do you want? WHO DO YOU WANT? RN: WHO DO YOU WANT? MD: Um, anybody. Uh. One of the doctors. Get one of the doctors. OB anesthesiologist is at the bedside and listens to the baby’s heart rate, then puts down the stethoscope and walks around to other side of bed. OB RN: [on phone with NICU] Hi can we get one of the doctors in OR A please. [hangs up] RN alternates between providing inadequate PPV and rubbing the baby’s back. RN: Okay, come on. You feeling better? [baby begins cries weakly] There you go. OB RN: You want the tray? RN: Yeah, she’s getting it. [Continues inadequate PPV for 5 breaths, then stops to pick up the stethoscope.] We need to keep listening to her. RN: She’s got a great heart rate. She just doesn’t want to breathe. MD: She does have a good heart rate? OB anesthesiologist: Yeah. It was very good. Very strong. Neonatal Resuscitation

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12 “HR > 100 bpm”Implies no PPV (or stop PPV) “HR 60 bpm)PPV indicated “HR < 60 bpm”Implies start CC after 30 sec of effective PPV “HR zero” (or undetectable)Influences length of resuscitation

13 When breath sounds present: “Breath sounds present left” “Breath sounds present right” “Breath sounds present bilaterally” When breath sounds decreased: “Breath sounds decreased left” “Breath sounds decreased right” “Breath sounds decreased bilaterally” When breath sounds absent: “Breath sounds absent left” “Breath sounds absent right” “Breath sounds absent bilaterally”

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15 Non-Standard Communication Mean (SD) Resuscitation Lexicon Mean (SD) P-value Average error rate0.40 (0.07)0.37 (0.08)0.18 Errors of omission0.32 (0.06)0.28 (0.08)0.09 Errors of commission0.08 (0.04)0.09 (0.04)0.28

16 Non-Standard Communication Mean (SD) Resuscitation Lexicon Mean (SD) P-value Average number of communication techniques used 6.7 (2.5)15.5 (5.0)0.0015* Time to initiation of PPV32.4 sec (16.9 sec)30.7 sec (15.4 sec)0.58 Time to initiation of CC120.7 sec (66.8 sec)112.8 sec (70.8 sec)0.78

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Questions? Nicole Yamada, M.D.