The Many NICU Shades of Gray: Understanding and Navigating Uncertainty in Clinical Care.

Urgent need for formal medical training in infectious diseases in India

A descriptive study of parents' experiences with neonatal home care following initial care in the neonatal intensive care unit. As survival rates improve among premature and critically ill infants with an increased risk of morbidity, parents' responsibilities for neonatal care grow in scope and degree under the banner of family-centred care. Concurrent with medical advances, new questions arise about the role of parents and the experience of being provided neonatal care at home. An interview study with a phenomenological hermeneutic approach. Parents from a Swedish neonatal (n=22) home care setting were extensively interviewed within oneyear of discharge. Data were collected during 2011-2012. The main theme of the findings is that parents experience neonatal home care as an inner emotional journey, from having a child to being a parent. This finding derives from three themes: the parents' experience of leaving the hospital milieu in favour of establishing independent parenthood, maturing as a parent and processing experiences during the period of neonatal intensive care. This study suggests that neonatal home care is experienced as a care structure adjusted to incorporate parents' needs following discharge from a neonatal intensive care unit. Neonatal home care appears to bridge the gap between hospital and home, supporting the family's adaptation to life in the home setting. Parents become empowered to be primary caregivers, having nurse consultants serving the needs of the whole family. Neonatal home care may therefore be understood as the implementation of family-centred care during the transition from NICU to home.

The newborn care facilities, policies, and patient load in the perinatal care centers (PNCCs) in Saudi Arabia were assessed in 1985 as a first step toward providing data that would be needed in for...

Introduction: Final year emergency medicine residents may be transitioning to practice with little to no training on how to effectively supervise and assess trainees. It remains unclear how comfortable final year residents and new-to-practice physicians are with these competencies. The goal of our study was to examine physician comfort with supervision and assessment, whether there was a perceived need for formal training in these areas, and what gaps, barriers and enablers would exist in implementing it. Methods: Qualitative data were collected in two phases during September 2016-November 2017 through interviews of PGY5 emergency residents and new-to-practice staff at the University of Toronto and McMaster University in Ontario, Canada. A semi-structured interview guide was developed and used during the first round of interviews at the University of Toronto during phase one. Results from phase one were used to refine the interview guide, to be used in phase two, to ensure that all potential areas of thematic generation were touched upon. Phase two occurred at the University of Toronto and McMaster University using the refined interview guide. All transcripts were coded, analyzed, and collapsed into themes. Data analysis was guided by a constructivist grounded theory based in a relativist paradigm. Results: Thematic analysis revealed five themes. Residents and staff alike described acquiring the skills of supervision and assessment passively, primarily through modeling the behaviours of others; the training that is available in these areas is variably used, creating a diversity of physician comfort levels within these two competencies; the many competing priorities in the emergency department represent significant barriers to improving supervision and assessment; providing negative feedback is universally difficult and often avoided, sometimes resulting in struggling trainees not being identified until late in residency; the move towards competency based education (CBE) will act as an impetus for more formal curriculum being required in these areas. Conclusion: As residency programs transition to a CBE model, there will be a greater need for formal training in supervision and assessment to achieve a standard level of comfort and competence among senior residents physicians in independent practice. These competencies will also need an emphasis on how to identify struggling trainees, and how to approach negative and constructive feedback.

Underuse Versus Overuse of Neonatal Intensive Care: What Is the Right Amount?

Problem: Neonatal Intensive Care Unit (NICU) clinicians must frequently relay difficult news to patient families, and the need for formal training for NICU trainees to develop this skill has been established. Although previous studies have shown improved trainee self-efficacy and comfort in handling difficult conversations after formal communication training, it remains unclear whether these interventions lead to improved objectively assessed short-term and long-term performance. Intervention: A simulation-based intervention emphasizing the SPIKES protocol for delivery of bad news was implemented for 15 fellows in the 3-year Baylor College of Medicine Neonatal-Perinatal Medicine fellowship program in the 2013–2014 academic year. Simulations involved video-recorded encounters between each fellow and a standardized parent (SP) involving communication of difficult news. Each fellow was evaluated before (preintervention), immediately after (postintervention), and 3–4 months after the intervention (follow-up) with an (a) evaluation of video-recorded sessions by two expert raters blinded to the timing of the encounter (blinded rater evaluation [BRE]), (b) Self-Assessment Questionnaire, (c) Content Test evaluating knowledge of taught concepts, and (d) SP evaluation (SPE). Context: The 1st- and 2nd/3rd-year fellows participated in the study at separate times in the academic year to accommodate their schedules. First-year fellows had had more prior communication training and less NICU clinical experience than the 2nd/3rd-year fellows at the time of their intervention. Outcome: Although all fellows displayed improved Self-Assessment and Content Test scores at postintervention with retention at the follow-up assessment, the BREs showed no statistically significant improvement in postintervention scores and showed a decline in follow-up scores. First-year fellows had higher BRE postintervention scores than the senior fellows. SPEs showed no difference in scores at all 3 assessment stages. Lessons Learned: As previously described in the literature, trainee self-efficacy and knowledge may improve in the short term and long term with a simulation-based curriculum in communication of difficult news. However, these results may be inconsistent with those of objective evaluations by expert raters and standardized parents. The impact of the curriculum may be heightened if it reinforces previously learned skills, but the effect may wane over time if not reinforced frequently with additional formal training or in the clinical setting. The results of this study highlight the importance of objective assessments in evaluating the utility of a simulation-based communication curriculum and the need for longitudinal curricula to promote retention of the concepts and skills being taught.

The terms palliative care, supportive care, and comfort care are used to describe individualized care that can provide a dying person the best quality of life until the end. The term “end-of-life care” is also used in a general sense to refer to all aspects of care of a patient with a potentially fatal condition. While the concept of palliative care is not new, it has only recently been applied to the neonatal population. To the best of our knowledge, none of the neonatal intensive care units (NICUs) in Saudi Arabia have adopted a neonatal program for palliative care. We believe the main reason is lack of knowledge of such programs and the fear of being accused of being heartless and cruel by providing comfort care for dying babies. Comfort care begins with the diagnosis of a life-threatening/terminal condition, and continues throughout the course of illness regardless of the outcome. In this perspective, our aim is to introduce these programs for caregivers in the NICUs in Saudi Arabia. For this purpose, we have reviewed the current recommendations in establishing neonatal palliative care programs and discussed some of the social and religious aspects pertaining to this issue.

The knowledge and implementation skills of the DNR order amongst physicians in training appear to be quite variable. Few studies had assessed residents' views on this complex topic. Our objective was to describe the medical residents’ practices and perceptions toward DNR order. A 26 question survey was distributed to medical residents during the academic day activity. Only 56 residents completed the questionnaire (75% response rate). 61.40% of the residents understood the definition of DNR order. 85.96% thought physicians shouldn’t order diagnostic tests for DNR patients and 92.98% thought physicians shouldn’t give blood products and antibiotics to DNR patients. 45.61% thought DNR order would lead to poor care. 36.84% thought physician alone should decide about the DNR decision. 45.61% answered that DNR order never discussed with patients. 64.91% answered that consultant discussed DNR order with patients. 42.11% of residents were involved in the discussion of DNR order. 66.67% answered that time to decide about the DNR order on day of admission. 42.11% answered there was variation between consultants regarding the care of DNR patient. 43.86% answered there was variation in the clinical care before and after DNR order was placed. 87.72% thought here was a need for formal training in DNR discussion. 68.42% didn’t know if KFSH and RC had clinical guidelines for DNR patients care. Conclusion: (1) Majority of the residents had misunderstanding regarding DNR patient care and comfortable care. There is a need for developing a structured residency program curriculum to address resident skills in end-oflife care. (2) Encouraged discussions DNR issues in the outpatient setting could prevent unwanted resuscitation in the acute setting. (3) Efforts are needed to increase patients and their families’ awareness about the meaning of DNR order. (4) There is a need to unify and improve quality of care provided to DNR patients by developing specific strategies within a framework of goals of care.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

IntroductionDespite the recent recognition of emergency medicine (EM) as a distinct specialty in Greece, emergency departments(ED) there continue to be staffed by physicians with training in other medical specialties, although some hold EM certifications. In this study we aimed to evaluate the perceived level of competency and preparedness of physicians who work in EDs in Greece. We also sought to identify gaps in clinical EM expertise, solicit opinions on the need for EM residency training in Greece, and determine the well-being and job satisfaction of physicians practicing in Greek EDs.MethodsThis was a mixed-methods, cross-sectional, electronic, nationally representative survey of physicians working in EDs across all health districts in Greece. The survey was administered in Greek and anonymously conducted online. We used the Pearson chi-squared test to determine whether there was an association between EM certification and comfort with seeing subsets of patients. The study received institutional review board approval, and all participants signed an online consent form.ResultsThe study surveyed 105 of 263 physicians working in 52 Greek EDs (39.9% response rate). We found that of the 105 physicians surveyed, 63 (60.0%) were not certified in EM. A Pearson chi-squared test revealed a significant association between comfort level in seeing pediatric, trauma, and critically ill patients, and EM certification (X2 = 13.37, P = .001). Qualitative analysis found that physicians had a desire to engage in training opportunities, with many citing cost, time, and age as barriers. Despite these challenges, 64.1% of physicians reported satisfaction with their decision to work in the ED.ConclusionMost frontline emergency physicians working in Greece are uncomfortable caring for the full breadth of ED patients. This survey represents the first assessment of the attitudes, clinical preparedness, and perceived need for EM residency training among emergency physicians in Greece. Critical next steps should include enhanced training on targeted aspects of emergency care for practicing emergency physicians in the nation and continued efforts to establish formal EM residency training in Greece.

Education and training are very critical to development of high-quality neonatal palliative care. However, little investigation has been done into Taiwanese neonatal clinicians' educational needs regarding neonatal palliative care. The purposes of this study were to characterize and identify neonatal clinicians' educational needs regarding neonatal palliative care. A cross-sectional descriptive surveyed method via a self administered questionnaire was used in this research. Thirty neonatologists were recruited by a convenience sampling and 30 nurses were recruited by a randomized sampling. Out of sixty neonatal clinicians' survey, few had received the education in neonatal palliative care. Most reported minimal training in, experience with, and knowledge of neonatal palliative care. For neonatologists, two of twelve most strongly-felt educational needs were "discussing palliative care and ethical decision-making with parents" (70%) and "informing parents the poor progress in neonates" (63.3%). In contrast, neonatal nurses wanted more training regarding pain control (50%). Communication skills, including the discussing poor prognosis, bad news, and code status and talking with neonates about end-of-life care, were the educational need most commonly felt by both neonatologists and nurses. Survey data from neonatologists and neonatal nurses in Taiwan indicate a need for further training on a range of neonatal palliative care competencies.

To investigate, for preterm babies born between 27+0 and 31+6 weeks gestation in England, optimal place of birth and early care. Mixed methods. National Health Service neonatal care, England. To investigate whether birth and early care in neonatal intensive care units (tertiary units) compared to local neonatal units (non-tertiary units) influenced gestation-specific survival and other major outcomes, we analysed data from the National Neonatal Research Database, for 29,842 babies born between 27+0 and 31+6 weeks gestation and discharged from neonatal care between 1 January 2014 and 31 December 2018. We utilised an instrumental variable (maternal excess travel time between local neonatal units and neonatal intensive care units) to control for unmeasured differences. Sensitivity analyses excluded postnatal transfers within 72 hours of birth and multiple births. Outcome measures were death in neonatal care, infant mortality, necrotising enterocolitis, retinopathy of prematurity, severe brain injury, bronchopulmonary dysplasia, and receipt of breast milk at discharge. We also analysed outcomes by volume of neonatal intensive care activity. We undertook a health economic analysis using a cost-effectiveness evaluation from a National Health Service perspective and using additional lives saved as a measure of benefit, explored differences in quality of care in high compared with low-performing units and performed ethnographic qualitative research. The safe gestational age cut-off for babies to be born between 27+0 and 31+6 weeks and early care at either location was 28 weeks. We found no effect on mortality in neonatal care (mean difference -0.001; 99% confidence interval -0.011 to 0.010; p = 0.842) or in infancy (mean difference -0.002; 99% confidence interval -0.014 to 0.009; p = 0.579) (n = 18,847), including after sensitivity analyses. A significantly greater proportion of babies in local neonatal units had severe brain injury (mean difference -0.011; 99% confidence interval -0.022 to -0.001; p = 0.007) with the highest mean difference in babies born at 27 weeks (-0.040). Those transferred in the first 72 hours were more likely to have severe brain injury. For 27 weeks gestation, birth in centres with neonatal intensive care units reduced the risk of severe brain injury by 4.2% from 11.9% to 7.7%. The number needed to treat was 25 (99% confidence interval 10 to 59) indicating that 25 babies at 27 weeks would have to be delivered in a neonatal intensive care unit to prevent one severe brain injury. For babies born at 27 weeks gestation, birth in a high-volume unit (> 1600 intensive care days/year) reduced the risk of severe brain injury from 0.242 to 0.028 [99% confidence interval 0.035 to 0.542; p = 0.003; number needed to treat = 4 (99% confidence interval 2 to 29)]. Estimated annual total costs of neonatal care were £262 million. The mean (standard deviation) cost per baby varied from £75,594 (£34,874) at 27 weeks to £27,401 (£14,947) at 31 weeks. Costs were similar between neonatal intensive care units and local neonatal units for births at 27+0 to 29+6 weeks gestation, but higher for local neonatal units for those born at 30+0 to 31+6 weeks. No difference in additional lives saved were observed between the settings. These results suggested that neonatal intensive care units are likely to represent value for money for the National Health Service. However, careful interpretation of this results should be exercised due to the ethical and practical concerns around the reorganisation of neonatal care for very preterm babies from local neonatal units to neonatal intensive care units purely on the grounds of cost savings. We identified a mean reduction in length of stay (1 day; 95% confidence interval 1.029 to 1.081; p < 0.001) in higher-performing units, based on adherence to evidence- and consensus-based measures. Staff reported that decision-making to optimise capacity for babies was an important part of their work. Parents reported valuing their baby's development, homecoming, continuity of care, inclusion in decision-making, and support for their emotional and physical well-being. Birth and early care for babies ≥28 weeks is safe in both neonatal intensive care units and local neonatal units in England. For anticipated births at 27 weeks, antenatal transfer of mothers to centres colocated with neonatal intensive care units should be supported. When these inadvertently occur in centres with local neonatal units, clinicians should risk assess decisions for postnatal transfer, taking patient care requirements, staff skills and healthcare resources into consideration and counselling parents regarding the increased risk of severe brain injury associated with transfer. This study is registered as Current Controlled Trials NCT02994849 and ISRCTN74230187. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/70/104) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 12. See the NIHR Funding and Awards website for further award information.

AimsMany clinicians find themselves self-interpreting the radiological images of their patients, especially in the acute management setting whilst on-call. The aim of this study was to assess the competence and...

BackgroundAcross community settings, such as healthcare, interpreters play an important role in facilitating communication when service users and providers do not share a common language sufficiently. Because most countries lack legal standards in the field of Community Interpreting, Community Interpreters (CIPs) are often not adequately trained for this activity, and the need for formal training is increasingly emphasized. This study aims to evaluate a generic training for CIPs in Germany.MethodsThe training was developed for interpreters working in health and social care, education, and authorities in Germany. It consists of 500 units and a final examination. A mixed-methods design was applied to evaluate the training. Training participants’ (TPs) satisfaction, knowledge, competence, and professional self-efficacy expectations were measured by self-developed questionnaires. A pre-post multiple-choice knowledge test was developed to objectively assess the trainings’ impact on knowledge. Qualitative pre- and post-interviews were conducted for an in-depth evaluation of TPs’ motives for participating in the training, their experiences, improvements in knowledge and skills as well as their attitude changes. Trainers’ qualifications and satisfaction were assessed using self-developed questionnaires. Quantitative data were analyzed descriptively, and qualitative data were analyzed using a content analysis approach.ResultsIn total, n = 21 TPs and n = 18 trainers were included. Quantitative analysis revealed that trainers and TPs were overall satisfied with the training. TPs showed increased subjective and objective knowledge, competence, and professional self-efficacy expectations. Qualitative findings revealed changes in TPs’ knowledge about their role and ethical principles; they reported increased skills and confidence on both professional and personal levels. Due to the training, their interpreting performance changed from being relatively intuitive and “natural” to being informed and skills-based. They recognized the complexity of interpreting, thereby acknowledging their professional status. Obtaining a certificate after completing the examination increased their feeling of professionalism. However, TPs expressed the need for further in-depth training, as the training was rather generic and broad.ConclusionThe study demonstrates that generic training can enhance CIPs’ knowledge, skills, competence, professional and personal confidence, and perceived professionalism. It highlights the critical need for formalized training, certification, and overall qualification programs to ensure not only the quality of interpreting services but also to shape the profession of CIPs.

Emergency medicine residents may be transitioning to practice with minimal training on how to supervise and assess trainees. Our study sought to examine: 1) physician comfort with supervision and assessment, 2) what the current training gaps are within these competencies, and 3) what barriers or enablers might exist in implementing curricular improvements. Qualitative data were collected in two phases through individual interviews from September 2016 to November 2017, at the University of Toronto and McMaster University after receiving ethics approval from both sites. Eligible participants were final year emergency medicine residents, residents pursuing an enhanced skills program in emergency medicine, and attendings within their first 3 years of practice. A semi-structured interview guide was developed and refined after phase one, to reflect content identified in the first set of interviews. All interviews were recorded, transcribed, coded, and collapsed into themes. Data analysis was guided by constructivist grounded theory. A thematic analysis revealed five themes: 1) Supervision and assessment skills were acquired passively through modelling, 2) the training available in these areas is variably used, creating a diversity of comfort levels, 3) competing priorities in the emergency department represent significant barriers to improving supervision and assessment; 4) providing negative feedback is difficult and often avoided; and 5) competence by design will act as an impetus for formal curriculum development in these areas. As programs transition to competence by design, there will be a need for formal training in supervision and assessment, with a focus on negative feedback, to achieve a standardized level of competence among emergency physicians.