BACKGROUND:

Preterm infants are at risk for hypothermia in the delivery room (DR). Hypothermia and community hospital delivery are factors associated with increased morbidities and mortality in preterm infants. Community hospital providers have less experience with preterm deliveries and thermoregulation methods in the DR.

METHODS:

Community hospital DR providers in Indiana completed a cognitive test evaluating preterm infant DR management. A simulation-based team assessment was evaluated by using a scoring tool. After debriefing, the simulation performance was repeated and rescored. Afterward, providers completed a cognitive knowledge posttest. Eleven to eighteen months later, sites were revisited with cognitive knowledge and team simulated scenarios reassessed.

RESULTS:

Twenty-five community hospitals with >400 multidisciplinary providers participated in the initial study visit. Average pre- and posttest scores were 48.8% and 94.1% respectively (P value <.001). Participants performed an average of 22.8 of 36 scoring items during a simulated preterm delivery including 4.4 of 8 thermoregulation related actions. Performance immediately improved in a statistically significant manner during the repeat scenario. When sites were revisited, participants performed an average of 26.7 of 36 scoring items including 6.1 of 8 thermoregulation actions during a simulated preterm delivery a statistically significant (P <.001) improvement from the initial visit.

CONCLUSIONS:

Simulation education regarding preterm infant DR management improved community providers immediate knowledge and skills and also follow-up performance at ∼1 year. In simulation, providers performed thermoregulation maneuvers more often and efficiently, critical to resuscitation because delays in thermoregulation can significantly adversely affect outcomes.

What’s Known on This Subject:

Preterm infants are at increased risk of temperature aberrations after delivery, which can lead to increased morbidities and mortality. Preterm infants born at community hospitals are at higher risk of poor outcomes compared with infants delivered at tertiary care centers.

What This Study Adds:

Community hospital delivery room providers have a knowledge gap on preterm infant delivery room management, which led to flow disruptions from the Neonatal Resuscitation Program guidelines. Simulation education led to improved performance in the resuscitation of a simulated preterm infant.

Premature infants are at increased risk of hypothermia because of thin skin, minimal amounts of adipose tissue, large body surface area to mass, and limited metabolic compensation.1  Hypothermia leads to cardiopulmonary compromise and hypoglycemia. Inability to maintain delivery room (DR) euthermia is associated with increased rates of intraventricular hemorrhage, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, sepsis, and mortality.24  Thus, having knowledge and skills to promote DR euthermia in this population is paramount.

The Neonatal Resuscitation Program (NRP) advises multiple DR measures to minimize hypothermia in infants <32 weeks’ gestation. These include increasing ambient room temperatures to 74 to 77°F (23.3–25°C), by using radiant warmers and chemical warming mattresses and immediately placing infants in polyethylene bags, with a hat on the head.5,6  Placing temperature probes on infants is advised for ideal monitoring and thermoregulation.6  NRP simulation education is increasingly used in community hospitals for training.7,8  In studies, researchers have supported NRP simulation education as an effective educational tool.911 

Preterm infants born at community hospitals have increased morbidities and mortality compared with infants delivered at tertiary care centers.1215  We hypothesize that community hospital providers have knowledge gaps regarding preterm infant DR management that lead to deviations in NRP protocols and that simulation education in an experiential learning format can improve the DR management of these infants.1618 

This study was approved by the Indiana University Institutional Review Board. The term “community hospital” refers to hospitals providing level I or level II obstetric services. In Indiana Perinatal Hospital Standards, level I services are defined as providing care to women who are low risk and expected to have an uncomplicated birth and providing newborn care for stable infants ≥35 0/7 weeks' gestation. Level II services provide the aforementioned care and the ability to care for high risk newborns born at ≥32 0/7 weeks' gestation and ≥1500 g birth weight.19 

This study used a prepost design, modeling Kolb’s experiential learning theory with key components of concrete experience, reflective observation, abstract conceptualization, and active experimentation to apply the knowledge gained.20  Phone consent was obtained from sites before the study and from individual providers on the simulation day. Individuals from Indiana University Neonatal Outreach Simulation (IUNOS) team traveled to community hospitals to perform assessments and education in situ (in the actual clinical environment). The study simulation was facilitated by 1 of 3 core neonatologists for consistency. Community hospital DR providers included nursing staff, respiratory therapists, and physicians from the following specialties: pediatrics, family medicine, and obstetrics.

Participants were informed that they would be participating in DR resuscitations. To minimize performance bias, participants were unaware that it would be preterm infant resuscitation. The consented participants were given a pretest that included questions on general newborn resuscitation as well as preterm deliveries to keep providers blinded to the nature of the study. Providers were divided into groups of 3 to 5 individuals to participate in simulated scenarios, stratified on participant discipline to best replicate DR team configuration. Group assignment was made by the IUNOS coordinator, without knowledge of participant level of experience.

Scenarios were performed in labor and delivery rooms prepared per the hospital’s standard for newborn delivery. Before entering the room, a scripted prompt (Supplemental Information) orientated participants to the impending delivery of a 27 weeks’ gestational age infant.

Participants were instructed to obtain additional needed supplies not already present in the labor and delivery room. To standardize the simulation, 3 minutes and 45 seconds after the scripted prompt was read, the manikin, a Gaumard Premie Blue S108 Premature Newborn Simulator, was delivered by an embedded participant acting as an obstetrician. The obstetrician had scripted responses to team questions. The scenario ended after the team managed all aspects of thermoregulation and ventilation, if chest compressions were begun, or if 7 minutes of time elapsed since delivery.

During the scenario, the study facilitator used a scoring tool (Supplemental Fig 4) to evaluate team performance. The scoring tool was developed by using the NRP recommendations for preterm deliveries. Scenarios were videotaped and reviewed by 2 authors (L.M. and A.L.B.) to ensure the accuracy of study facilitator scoring. For discrepancies in scoring, the video was used as the final score. After the scenario, a structured debriefing focused on thermoregulation, ventilation, and team dynamics occurred. A cognitive aid, “Premature Delivery Checklist,” was provided to participants (Fig 1). This checklist was developed by directly transposing descriptive steps of thermoregulation and ventilation for preterm infants from the NRP textbook into an abbreviated format, serving as simple reminders of each step. The checklist had been piloted at the academic institution, with minor revisions made on the basis of feedback. After debriefing, study participants performed the scenario a second time, during which their performance was scored again by the study facilitator. The cognitive aid was available for use during the second scenario. After debriefing the second scenario, participants were given a posttest on preterm infant DR management.

FIGURE 1

Preterm delivery cognitive aid. ETT, endotracheal tube; MRSOPA, mask adjustment, reposition airway, suction mouth and nose, open mouth, pressure increase, alternative airway.

FIGURE 1

Preterm delivery cognitive aid. ETT, endotracheal tube; MRSOPA, mask adjustment, reposition airway, suction mouth and nose, open mouth, pressure increase, alternative airway.

Close modal

Eleven to eighteen months after the initial visit, the IUNOS team revisited sites for follow-up assessments and education. The follow-up time frame was based on hospital scheduling availability and availability of the IUNOS team, which aims to visit each hospital once per year. Participants were asked to report participation in the initial visit because initial and repeat visit participants were not always congruent. At the repeat visit, individuals completed a cognitive knowledge test on preterm infant DR management before performing simulations. The IUNOS coordinator, without knowledge of individuals’ previous participation or experience level, divided providers into groups of 3 to 5 individuals to participate in the simulated scenarios, again stratifying on the basis of participant discipline to best replicate the DR team configuration. Because not all participants were present for the initial visit, the group composition differed on the repeat visit. The scenario was again performed in labor and delivery rooms. Before entering the room, participants were given the same scripted prompt orienting them to the impending preterm infant delivery.

The study facilitator (1 of the same 3 neonatologists from the initial visit) again scored the team on their scenario performance, with scenario videotaping to ensure accuracy of scoring. Neither participant experience level nor knowledge of previous study participation was known by facilitators during scenario performance. After the scenario, a structured debriefing was conducted, focused on thermoregulation, ventilation, and team dynamics. After the debriefing, as during the initial study visit, the groups performed the scenario a second time with repeat scoring and debriefing.

Between the initial and repeat visits, NRP released revised recommendations. The revisions, published in 2015, were not widely adopted until later in 2016. There were no changes to the recommendations for thermoregulation interventions; however, in keeping with the revisions, delayed umbilical cord clamping was discussed and recommended to groups while debriefing the repeat study visit.6 

Descriptive statistics including mean and SD for continuous variables were performed for cognitive tests and scenario performance scores. Count and frequency percentage for binary variables was performed separately. For the cognitive test, paired t tests were used to compare the percentages of cognitive scores between the pretest and posttest during the initial visit. Two sample t tests were used to compare pretest cognitive scores during the initial visit with cognitive test scores during the repeat visit.

To evaluate scenario performance, the total scenario performance score, thermoregulation performance scores, time to placement in plastic wrap, and time to hat placement were compared between the first scenario in the initial visit and the first scenario in the repeat visit, by using 2 sample t tests. They were compared between scenarios in each visit by using paired t tests. χ2 tests were used to compare the binary outcomes of groups placing the infant in plastic or placing a hat on the infant in the initial versus repeat visit; McNemar’s tests were used to compare between scenarios in each visit.

The P values <0.05 were considered statistically significant.

Four hundred and seventy-one providers at 25 level I and II community hospitals in Indiana participated in the initial study visit between March 2015 and August 2016. The majority of providers (320) were nurses, with 57 respiratory therapists, 79 physicians, 3 midwives, and 3 certified registered nurse anesthetists. Providers correctly answered an average of 48.8% (SD = 30.0%) on pretest questions specific to premature infant DR resuscitation. One hundred and eight groups of 3 to 5 providers subsequently participated in the simulation scenarios.

During the initial visit first scenario, groups performed an average 22.8 (SD = 4.2) of 36 total DR scoring items and average 4.4 (SD = 1.4) of a subset of 8 thermoregulation specific items. During the initial visit second scenario, groups performed an average 32.9 (SD = 2.6) of 36 total items, significantly higher than the first scenario (P < .001; Fig 2). With regards to thermoregulation specific steps, groups performed an average 7.6 (SD = 0.8) of 8 items, also significantly higher than the first scenario (P < .001; Fig 3). In Table 1, we outline postdelivery thermoregulation steps and plastic wrap and hat usage, with the average time to placement in the scenarios. There was a statistically significant improvement in the use and average time to placement of both interventions.

FIGURE 2

Scenario performance scores during initial and repeat visits.

FIGURE 2

Scenario performance scores during initial and repeat visits.

Close modal
FIGURE 3

Thermoregulation performance scores during initial and repeat visits.

FIGURE 3

Thermoregulation performance scores during initial and repeat visits.

Close modal
TABLE 1

Plastic Wrap and Hat Use From Initial and Repeat Study Visits

Scenario 1Scenario 2Comparison of Time to Perform, P
n Performed (Total Groups)Average Time to Placement, sRange, sn Performed (Total Groups)Average Time to Placement, sRange, s
Initial visit        
 Plastic wrap 70 (108) 44 1–510 108 (108) 11 0–232 <.001 
 Hat 20 (108) 78 2–451 106 (108) 26 5–240 .02 
Repeat visit        
 Plastic wrap 87 (101) 25 1–241 101 (101) 1–23 <.001 
 Hat 56 (101) 31 3–173 101 (101) 24 6–74 .03 
Scenario 1Scenario 2Comparison of Time to Perform, P
n Performed (Total Groups)Average Time to Placement, sRange, sn Performed (Total Groups)Average Time to Placement, sRange, s
Initial visit        
 Plastic wrap 70 (108) 44 1–510 108 (108) 11 0–232 <.001 
 Hat 20 (108) 78 2–451 106 (108) 26 5–240 .02 
Repeat visit        
 Plastic wrap 87 (101) 25 1–241 101 (101) 1–23 <.001 
 Hat 56 (101) 31 3–173 101 (101) 24 6–74 .03 

Providers’ cognitive scores averaged 94.1% (SD = 16.0%) on posttest questions, a statistically significant improvement from pretest cognitive scores (48.8% as above; P value <.001).

Four hundred and twenty-three providers at 23 community hospitals participated in repeat study visits between April 2016 and October 2017. Two of the original sites were unable to participate in the repeat study visit, 1 because of high census and lack of clinical space on the simulation day and the second because of time limitations. Of the 423 providers, 208 had participated and 205 had not participated in the initial study visit, and 10 were unsure if they had previously participated. Providers scored an average of 63.5% (SD = 37.7%) on the cognitive knowledge test. Providers that participated in the initial study visit scored an average of 75.9% (SD = 32.7%), whereas those that had not scored an average of 52.4% (SD = 38.6%).

At the repeat visit, 7 of 101 groups did not have any providers that participated in the initial visit. During the repeat visit first scenario, groups performed an average 26.7 (SD = 5.0) of 36 total DR scoring items and an average 6.1 (SD = 1.5) of a subset of 8 thermoregulation specific items. During the repeat visit second scenario, groups performed an average 34.1 (SD = 2.1) of 36 total items, significantly higher than the repeat visit first scenario (P < .001; Fig 2). With regard to thermoregulation specific steps, groups performed an average 7.7 (SD = 0.7) of 8 scoring items, also significantly higher than the first scenario measurement (P < .001; Fig 3). In Table 1, we outline the 2 postdelivery thermoregulation specific steps and plastic wrap and hat usage, with the average time to placement from both visits and both scenarios. Again, there was a statistically significant improvement in the use and average time to placement of both interventions.

Resuscitation group composition was evaluated after the initial visit to discern if the presence of physicians or respiratory therapists impacted group performance, with no statistically significant differences in group performance noted.

With this study, we are the first to demonstrate that annual simulation education at community hospitals provided by experienced teams from the academic health center significantly improved cognitive knowledge and performance scores with regard to simulated DR resuscitation of preterm infants. Individual providers’ baseline cognitive knowledge of preterm resuscitation was improved at the repeat visit if they had participated in the initial education. Perhaps more importantly, team performance scores in simulation were improved one year later, although only one-half of providers participated in the initial study visit. In studies, researchers have indicated that there is substantial skill loss with nonpractice or nonuse and that the effect size of the decay increases after >365 days of nonuse.21  Furthermore, physical tasks are less susceptible to skill loss than cognitive tasks. Consistent with this, in our study, both cognitive and scenario scores on the repeat visit decreased, compared with the final scores from the initial visit in this population of providers who rarely resuscitate premature infants; however, cognitive scores revealed more decay than scenario scores.

In Indiana, 10% to 15% of preterm deliveries occur in hospitals with lower levels of perinatal services than intended for the neonate because of the unexpected and rapid nature of some preterm births.22  Previous studies have revealed that preterm infants have higher rates of morbidities and mortality when delivered at community hospitals instead of hospitals with tertiary NICUs.1215  These outcome disparities remain even after transfer to tertiary care units for the remainder of their hospital course.13  In this study, knowledge and performance of community providers in simulated preterm infant resuscitation improved, a step toward decreasing outcome discrepancies for preterm infants born at community hospitals, especially morbidities related to thermoregulation. Translating these results into clinical outcomes was outside the scope of this study; however, there is a growing body of evidence that simulation training is an effective tool in our arsenal to improve patient outcomes.2325 

Likely related to the infrequency of preterm deliveries at community hospitals, providers had knowledge gaps regarding DR management, evidenced by pretest cognitive scores. These gaps translated into deviations from NRP guidelines when performing DR resuscitation of simulated 27-week premature infants. For providers who previously participated in the study simulation education, baseline cognitive knowledge of preterm resuscitation was improved one year later. Providers who had not previously participated scored similarly on cognitive knowledge tests to the initial cohort. Despite almost one-half of providers in repeat visits not having participated in initial visits, study sites revealed improved simulation team performance. In multiple studies, researchers have demonstrated improvements in teamwork, communication, and patient outcomes, using in situ simulation education, including community hospital settings, although, before this study, none were specific to preterm deliveries.2631  Also unique to our study, although cognitive knowledge was not disseminated among individual team members, having any team members with previous participation in this simulation education intervention led to team improvement in simulated resuscitation skills. This is particularly encouraging because high turnover rates in health care and scheduling conflicts make it onerous to capture all providers for educational interventions.32 

Perhaps related to years of experience or time from previous educational training as discussed above, individual cognitive knowledge varied greatly, as demonstrated by wide SD among scores. Despite this variation, it is reassuring that teams performed above levels suggested by individual cognitive test scores.

Scoring and debriefing were performed on multiple aspects of resuscitation, including ventilation and thermoregulation. More emphasis was given to thermoregulation in this study because community providers reviewed ventilation skills in multiple other scenarios during their simulation outreach session. After simulation, providers used more thermoregulation measures and with improved efficiency, decreasing the average time to plastic wrap and hat placement, which is notable because heat loss begins immediately after birth and delays in addressing thermoregulation increase the risk of hypothermia.

In a Cochrane review of hypothermia prevention interventions in preterm and/or low birth weight infants, researchers considered DR thermoregulation maneuvers completed in <10 minutes.33  Our scenario ended by 7 minutes after birth, rather than 10 minutes, for several reasons. First, without thermal protection, a newborn’s core temperature decreases at a rate of 0.2°C to 1.0°C per minute.34  Second, for every 1.0°C decrease in admission temperature, the odds of in‐hospital mortality increase by 28%, and the odds of late‐onset sepsis increase by 11%.35  Third, the majority of thermoregulation maneuvers can be identified and prepared before birth, with the performance of remaining thermoregulation maneuvers within a few minutes after birth. Finally, in pilot testing, all teams turned their focus from thermoregulation to ventilation maneuvers within 2 to 3 minutes after the infant’s birth. Therefore, the preparation time of 3 minutes and 45 seconds and total scenario time of 10 minutes and 45 seconds was deemed adequate to complete the thermoregulation maneuvers, the primary focus of this study.

A significant strength of the study is the number (>400 each year) and multidisciplinary nature of the participants. Additionally, teams performed in their clinical environment, with access to their own equipment and personnel. In community hospitals, nurses are often the primary first responders. In this study, the majority of participants were nurses, although some teams included physicians and respiratory therapists. No significant difference in team scoring on the basis of the presence of physicians or respiratory therapists was noted.

There were limitations to the study. Many study hospitals participated in IUNOS education annually before participating in the study, including simulated preterm deliveries, although scenarios were not generally repeated after debriefing. The effect of previous simulation education is unclear. Over the 2 year study period, specific application of Kolb’s experiential learning with repeat scenarios after the initial debriefing resulted in improved performance, with decreased flow disruptions from NRP guidelines. Previous experiences with the IUNOS team may have increased the comfort level of community providers, making recruitment at multiple sites possible.

Other study limitations are that hospitals may have provided additional educational interventions between study visits, although static cognitive knowledge scores for first time participants suggest that additional interventions were minimal. A cognitive aid, distributed during the initial visit, was not fully evaluated with regard to team performance on the repeat visit. After our initial study visit, several sites reported using this aid to create supply bundles for preterm delivery. It is unclear how this affected team performance during our repeat visit, although it was encouraging that the aid enabled sites to make ongoing improvements.

Finally, although the education was performed in situ, facilitators were neonatologists from an academic center with simulation and debriefing training and experience. It is uncertain if significant improvements would have been demonstrated had simulations been facilitated by community hospital educators with less preterm infant DR and simulation experience.

Preterm infants have an increased risk of morbidities and mortality if euthermia is not maintained and if born at a community hospital.1214  Simulation education regarding preterm infant DR management improved community providers’ immediate knowledge and skills and follow-up performance at ∼1 year. Providers performed thermoregulation maneuvers in simulation more often and efficiently, which is critical to resuscitation because delays in thermoregulation can significantly affect outcomes. Simulation education is a valuable tool for improving knowledge and skills and can be used as a step toward decreasing outcome disparities in preterm infants unexpectedly delivered in the community. Further studies are needed to evaluate the effect of this training on preterm infant outcomes in the community hospital setting.

Dr Barbato conceptualized and designed the study, designed the data collection instruments and cognitive aid, coordinated and supervised data collection, and drafted the initial manuscript; Drs Wetzel and Byrne conceptualized and designed the study and revised the data collection instruments and cognitive aid; Ms Li and Ms Bo conducted the data analysis; Ms Mayer coordinated and supervised data collection; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded in part by the March of Dimes Indiana Chapter and by a grant through the Association of Pediatric Program Directors.

DR

delivery room

NRP

Neonatal Resuscitation Program

IUNOS

Indiana University Neonatal Outreach Simulation

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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