Presentation
Delivery Room Intubation Decision Making for Neonates with Congenital Anomalies: A Video Reflexive Ethnography Study
SessionPoster Session 1
DescriptionBackground
The first minutes of life for a newborn with congenital anomalies are critical, as an interdisciplinary, well-coordinated team must provide the resuscitative steps the neonate needs for optimal patient outcomes. In some cases, the neonate may require respiratory assistance in the form of continuous airway pressure (CPAP), positive pressure ventilation (PPV), or intubation. The team lead and/or airway provider must constantly assess the neonate’s condition and make the decision on the level of respiratory support the newborn requires. Decisions surrounding level of respiratory support are complex and require the integration of multiple inputs. Thus, it is critical to understand how these decisions are made, and the parameters clinicians use to inform their decisions. Understanding how providers make these decisions could aid in information presentation during delivery and the development of cognitive aids.
This study took place in a Special Delivery Unit (SDU) dedicated to neonates with known congenital anomalies within a large urban tertiary care pediatric hospital with approximately 500 deliveries per year. Delivery room resuscitations take place in dedicated resuscitation rooms adjoining delivery rooms and all resuscitations are video recorded for quality assurance purposes. To understand decision making surrounding intubation, the study employed video-reflexive ethnography (VRE) with clinicians who led resuscitation in which the neonate underwent intubation. A VRE session consists of watching a video of the practitioner performing a task and then having a discussion to investigate the complex situation. As VREs take place after the task is completed, the clinician does not need to interrupt patient care, and research has shown that workload scores collected after VREs are similar to scores collected after the person completed the task, indicating that VREs are a reliable method to elicit practitioner reflection without interrupting patient care.
All resuscitations in the SDU are videorecorded. Eligibility criteria included a video recorded resuscitation where a neonate underwent intubation in the delivery room. Videos or resuscitation with immediate intubation based on prenatal diagnosis (i.e. moderate to severe congenital diaphragmatic hernia) were ineligible. Videos with a secondary specialized team due to congenital anomaly were also excluded. Prior to VRE sessions, an interprofessional team developed an interview script which included questions regarding the provider’s expectations for the resuscitation, if they anticipated intubation, decisions to intubate, task analysis, situational awareness, and workload. The VRE session consisted of a human factors engineer watching the video recording with the team leader (attending or fellow) during the resuscitation. T At the end of the interview, participants completed the Surgical Task Load Index (Surg-TLX) questionnaire, a validated tool for use in healthcare that measures mental, physical, and temporal demands, as well as the task complexity, situational stress, and distractions. The human factors engineer then performed a semi-structured interview following the developed interview script. The interviews were transcribed by a HIPAA compliant transcription service. Deidentified transcripts were analyzed by a team member with expertise in qualitative analysis. 10 participants completed the study (n=9 neonatology attendings, and n = 1 neonatology fellow) with an average experience in the SDU of 8 years (min = 8 months, max = 17 years). The mean Surg-TLX workload score was 35.4 (out of a 100 ), with situational stress being the highest contributor (mean 41.6) followed by temporal stress (40.2).
Qualitative analysis indicated participants used a combination of factors to influence intubation decisions. These included pre-birth information and the neonate’s clinical presentation. Pre-birth information included anomaly and gestational age probability of intubation, prenatal characteristics, cardiac function, notes in mom’s chart, experience with similar neonates, imaging, discussions with other specialists, and clinical status and diagnosis. Clinical presentation at birth was the predominant factor when making the decision to intubate, which included respiratory effort, oxygen requirements, and desaturation events. Cognitive burden increased the difficulty of making the decision to intubate.
Participants described the intubation decision as a continuous assessment of risk and benefits. They described factors that contributed to intubation delays including borderline respiratory status without obvious intubation indications and cognitive burden.
Participants reported ways to reduce cognitive burden in the resuscitation room, such as having open communication with team members and being able to get good visualization of the neonate. They also described the pre-resuscitation huddle as a valuable preparation tool to develop a shared team mental model, assign roles, and to ensure the team preparation in the event of intubation. Future work will include collecting additional data for resuscitations in which intubation was considered but not performed. This study is part of a larger body of human factors and systems analysis work done as part of an effort to improve the SDU and is the first step in understanding intubation decision making which may lead to efforts to decrease cognitive load, improvement in data presentation, and the development of cognitive aids.
Application
The information from the VRE sessions related to intubation decision making is part of ongoing quality improvement and human factors efforts in the SDU. Future work will investigate how decision making when intubation is avoided. Human factors opportunities will be identified, leading to interventions to support respiratory support decision making in the resuscitation room. These may include efforts to decrease cognitive load, improvement in data presentation, and the development of cognitive aids.
Overview of Presentation
The presentation will provide an overview of the study including, inclusion criteria or videos, video selection, how the VRE sessions were conducted, the qualitative analysis, results, and future directions. The data analyzed consists of qualitative data from the VRE interviews providing recurrent themes, facilitators, and barriers, as well as quantitative data related to workload analysis. The combination of qualitative and quantitative data will continue to inform Human Factors projects in the SDU.
The first minutes of life for a newborn with congenital anomalies are critical, as an interdisciplinary, well-coordinated team must provide the resuscitative steps the neonate needs for optimal patient outcomes. In some cases, the neonate may require respiratory assistance in the form of continuous airway pressure (CPAP), positive pressure ventilation (PPV), or intubation. The team lead and/or airway provider must constantly assess the neonate’s condition and make the decision on the level of respiratory support the newborn requires. Decisions surrounding level of respiratory support are complex and require the integration of multiple inputs. Thus, it is critical to understand how these decisions are made, and the parameters clinicians use to inform their decisions. Understanding how providers make these decisions could aid in information presentation during delivery and the development of cognitive aids.
This study took place in a Special Delivery Unit (SDU) dedicated to neonates with known congenital anomalies within a large urban tertiary care pediatric hospital with approximately 500 deliveries per year. Delivery room resuscitations take place in dedicated resuscitation rooms adjoining delivery rooms and all resuscitations are video recorded for quality assurance purposes. To understand decision making surrounding intubation, the study employed video-reflexive ethnography (VRE) with clinicians who led resuscitation in which the neonate underwent intubation. A VRE session consists of watching a video of the practitioner performing a task and then having a discussion to investigate the complex situation. As VREs take place after the task is completed, the clinician does not need to interrupt patient care, and research has shown that workload scores collected after VREs are similar to scores collected after the person completed the task, indicating that VREs are a reliable method to elicit practitioner reflection without interrupting patient care.
All resuscitations in the SDU are videorecorded. Eligibility criteria included a video recorded resuscitation where a neonate underwent intubation in the delivery room. Videos or resuscitation with immediate intubation based on prenatal diagnosis (i.e. moderate to severe congenital diaphragmatic hernia) were ineligible. Videos with a secondary specialized team due to congenital anomaly were also excluded. Prior to VRE sessions, an interprofessional team developed an interview script which included questions regarding the provider’s expectations for the resuscitation, if they anticipated intubation, decisions to intubate, task analysis, situational awareness, and workload. The VRE session consisted of a human factors engineer watching the video recording with the team leader (attending or fellow) during the resuscitation. T At the end of the interview, participants completed the Surgical Task Load Index (Surg-TLX) questionnaire, a validated tool for use in healthcare that measures mental, physical, and temporal demands, as well as the task complexity, situational stress, and distractions. The human factors engineer then performed a semi-structured interview following the developed interview script. The interviews were transcribed by a HIPAA compliant transcription service. Deidentified transcripts were analyzed by a team member with expertise in qualitative analysis. 10 participants completed the study (n=9 neonatology attendings, and n = 1 neonatology fellow) with an average experience in the SDU of 8 years (min = 8 months, max = 17 years). The mean Surg-TLX workload score was 35.4 (out of a 100 ), with situational stress being the highest contributor (mean 41.6) followed by temporal stress (40.2).
Qualitative analysis indicated participants used a combination of factors to influence intubation decisions. These included pre-birth information and the neonate’s clinical presentation. Pre-birth information included anomaly and gestational age probability of intubation, prenatal characteristics, cardiac function, notes in mom’s chart, experience with similar neonates, imaging, discussions with other specialists, and clinical status and diagnosis. Clinical presentation at birth was the predominant factor when making the decision to intubate, which included respiratory effort, oxygen requirements, and desaturation events. Cognitive burden increased the difficulty of making the decision to intubate.
Participants described the intubation decision as a continuous assessment of risk and benefits. They described factors that contributed to intubation delays including borderline respiratory status without obvious intubation indications and cognitive burden.
Participants reported ways to reduce cognitive burden in the resuscitation room, such as having open communication with team members and being able to get good visualization of the neonate. They also described the pre-resuscitation huddle as a valuable preparation tool to develop a shared team mental model, assign roles, and to ensure the team preparation in the event of intubation. Future work will include collecting additional data for resuscitations in which intubation was considered but not performed. This study is part of a larger body of human factors and systems analysis work done as part of an effort to improve the SDU and is the first step in understanding intubation decision making which may lead to efforts to decrease cognitive load, improvement in data presentation, and the development of cognitive aids.
Application
The information from the VRE sessions related to intubation decision making is part of ongoing quality improvement and human factors efforts in the SDU. Future work will investigate how decision making when intubation is avoided. Human factors opportunities will be identified, leading to interventions to support respiratory support decision making in the resuscitation room. These may include efforts to decrease cognitive load, improvement in data presentation, and the development of cognitive aids.
Overview of Presentation
The presentation will provide an overview of the study including, inclusion criteria or videos, video selection, how the VRE sessions were conducted, the qualitative analysis, results, and future directions. The data analyzed consists of qualitative data from the VRE interviews providing recurrent themes, facilitators, and barriers, as well as quantitative data related to workload analysis. The combination of qualitative and quantitative data will continue to inform Human Factors projects in the SDU.
Event Type
Poster Presentation
TimeMonday, March 234:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments