Improving Neonatal Outcomes Through Simulation

Simulating Real-Life Emergencies in a Level IV NICU

You’ve just walked into the Level IV NICU at shift change when the bedside nurse asks you to examine an infant. The baby is 41 weeks’ gestation, 3 hours old, and appears to be having seizures while undergoing therapeutic hypothermia for hypoxic ischemic encephalopathy.

The baby’s heart rate is 130 beats per minute; temperature 33.5 degrees Celsius; blood pressure 82/44, mean 60; and O2 saturation is 87-90%.

In addition, mom has just walked into the NICU and sees the baby seizing. She is frightened for her child, crying and upset. The team awaits your direction.

What critical actions would you take to stabilize the baby, and save his life? Would you recognize the seizure activity? Acknowledge and care for the mother? Call for pediatric neurology support?

These are just a few of the many questions you might face. Would you be prepared? Fortunately, this is a multidisciplinary simulation and an opportunity to practice what you’d do in just such a case.

Multidisciplinary Simulation: Preparing for the Unexpected

From deliveries in the cardiac catheterization lab to how to put a baby who has decompensated on ECMO, the Multidisciplinary Simulation Program at the Children’s Mercy Kansas City Level IV NICU develops and practices scenarios such as these routinely. The Children’s Mercy Simulation Program supports the Neonatology Simulation team by providing high-fidelity mannequins in a learning lab that allows participants to film and de-brief each scenario. The program also has mobile mannequins and technology to provide on-site simulations in the NICU, and at facilities throughout the Kansas City area, as well as outreach hospitals.

Led by Jessica Brunkhorst, MD, Division of Neonatology Simulation Director, and Danielle Reed, MD, Associate Program Director, the Children’s Mercy program is more than a decade old and is one of the most comprehensive in the nation.

The Level IV NICU, Fetal Health Center and ECMO teams receive real-life training using high-fidelity simulators and a variety of complex scenarios several times a month. The NICU teams practice a different scenario each time, on-site, on demand, 24/7.

Simulations for the ECMO nursing specialists and physicians take place during 16 four-hour sessions each year (two full days quarterly) and are performed in collaboration with the NICU and PICU, focusing on low-volume, high-acuity cases. Prior to COVID-19, these sessions occurred in the simulation lab and were recorded for review and learning. They are now being conducted virtually. Participation is critical to credentialing for physicians and ECMO nursing specialists, and expands the team’s knowledge in preparation for real-life events.

The simulation program also conducts a skills lab for fellows six times a year, and performs a two-hour neonatal resuscitation refresher monthly for new residents at Truman Medical Center.

Each simulation includes a debriefing, and is followed by an evaluation used to further refine scenarios and teaching methods. Feedback often focuses on the need for better communication among team members in high-stress situations, and developing critical thinking skills.

Tapping the Children’s Mercy Expertise in Simulation

One of the many features that makes the Children’s Mercy program unique is the broad range of simulations the team has created. From delivery scenarios to mock codes, each case helps team members practice and refine different skill sets.

So, when the Organization of Neonatal-Perinatal Medicine Training Program Directors (ONTPD), a section of the American Academy of Pediatrics, decided to create a library of simulation cases available to programs nationally, they sought the expertise of the Children’s Mercy team.

Dr. Brunkhorst, Dr. Reed and their colleague, Jotishna Sharma, MD, MEd, DCH, Neonatologist, all contributed to the endeavor by serving on the editorial team for this national resource. Cases are available for review or download to individuals with an AAP account at aap.org.

The simulation program also participated in a multisite study for fellows in collaboration with Rainbow Babies & Children’s Hospital. This study utilized a modified training curriculum employing former NICU parents instead of standardized patients for each scenario, providing the fellows with hands-on experience handling delicate situations with families who actually had children in the NICU.¹

Bringing High-Fidelity Simulation to Community Hospitals

With a 150-county service area, Children’s Mercy receives referrals of the most critically ill and complex newborns from hospitals throughout the region.

Under Dr. Brunkhorst’s leadership, the Children’s Mercy Simulation Program is now working with some of these regional and community hospitals interested in high-fidelity simulation. Training is tailored to each hospital’s individual needs, focusing on improving the care of neonates in the community.

To date, the program has conducted simulations at 12 hospitals in the region. Plans are to continue to grow the program, making it available to even more hospitals in the near future.

Learn More About Multidisciplinary Simulation at Children’s Mercy

Jessica Brunkhorst, MD, Neonatal Division Simulation Director

jbrunkhorst@cmh.edu

(816) 302-8113

Danielle Reed, MD, Associate Program Director, Pediatric Residency Program

djreed@cmh.edu

(816) 460-1086

transformpeds.childrensmercy.org

For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466 3729.

References

1. Families as Educators: A Family-centered Approach to Teaching Communication Skills to Neonatology Fellows. Parham D, Reed D, Olicker A, Parrill F, Sharma J, Brunkhorst J, Noel-MacDonnell J, Voos K. Journal of Perinatology (2019) 39:1392–1398. https://doi.org/10.1038/s41372-019-0441-7.