Developing the NeoReadyTM: a systems approach to supporting teams during neonatal resuscitation

Abstract

The purpose of this program of research was to improve teamwork during neonatal resuscitation. As in other areas of healthcare, Crisis Resource Management (CRM)mthe aviation-derived teamwork modelmhas been incorporated into neonatal resuscitation training programs. Although there is evidence that CRM training improves teamwork during neonatal resuscitation, there are weak and inconsistent correlations between the CRM principles and teamwork behaviour. In this thesis, I argue that teamwork interventions need to be developed in context of the broader work system, and I also argue that interventions in the form of functional or cognitive aids should incorporate the science of design. Employing a user-centred design approach, I developed an intervention that is specific to the requirements of neonatal resuscitation teamsmwhich comprises a 4- part cognitive system aid (the NeoReadyTM).In the first phase of this program of research, I reviewed the effectiveness of neonatal resuscitation teamwork training interventions to date. An analysis of the differences between aviation crews and neonatal resuscitation teams provided insight into why CRM needs to be adapted to fit the needs of the team and their environment. One example of where CRM has been adapted to suit the requirements of the domain can be seen in anaesthesia. The CRM model used in anaesthesia and other domains advocates the use of cognitive aids. I investigated the evidence supporting the use of cognitive aids, and examined how they are used in neonatal resuscitation. Although there is evidence that cognitive aids can support individuals and teams, poor design of cognitive aids can lead to unintended and adverse consequences. Moreover, cognitive aids often only support individual cognition, whereas they can be used to support the broader cognitive system, including the environment. The first phase of research concluded with an evaluation of the neonatal resuscitation decision algorithm according to human factors design principles.In the second phase of this program of research, I conducted a team task analysis based on the main steps of resuscitation as outlined in the neonatal resuscitation algorithm. The task analysis revealed some of the areas that are most vulnerable to breakdown in team coordination. I presented general classes of potential solutions. Using an existing database of video recordings of neonatal resuscitations, I illustrated that team coordination can affect patient outcomesmspecifically that the transition between ceasing ventilation and commencing intubation could be improved by better team coordination. Another key contribution of this study was that it provided compelling evidence that the iii measure for intubation expertise should not be psychomotor performance, but rather how the intubation attempt affects the patient. These findings provide tangible evidence for the need to improve team coordination so to improve patient outcomes.In the third and final phase of this program of research, I describe the process of developing the NeoReadyTM intervention, which is designed to support team co-ordination during neonatal resuscitation. The NeoReadyTM is a 4-part cognitive system aid that includes (1) a resuscitation recording form that supports teamwork functions (e.g., role allocation); (2) a shelf attachment for the resuscitation trolley that provides much-needed space to prepare sterile procedures; (3) a turntable for the resuscitation trolley that standardises equipment layout in the order of the main steps of a resuscitation; and (4) an A3 display for the resuscitation trolley that makes the neonatal resuscitation algorithm and relevant reference tables clearly visible to the team. The NeoReadyTM was developed according to an interaction design approach, meaning that end-users were involved at every stage of the design process. Neonatal resuscitation teams that had not previously been involved in the design process, and that had no prior exposure to the prototypes, provided evaluation during field-based simulations. The NeoReadyTM system yielded moderate to high levels of usability, with an average score of 79.17 out of a possible score of 100 on the system usability scale (SUS).Teamwork training interventions in neonatal resuscitation have traditionally been designed from a top-down perspective, without considering the teamwork challenges and requirements specific to the domain. In contrast, this program of research has systematically evaluated the specific needs of neonatal teams through a mixed-methods approach that included observations of training and clinical practice, and interviews with team members. Moreover, teams provided feedback at every stage of the design process, so were effectively co-designers of the intervention. The rapid-prototyping technique with user feedback at every stage resulted in a novel solution to a range of team challenges. The intervention is specific to the context of a single-site study; however, the process can be applied to any other domain where there is an opportunity to improve team performance through design. In addition to presenting a solution specific to neonatal resuscitation teams, this program of research provides a template for rapid, low-cost quality improvement for other healthcare teams.