Impact of standardized communication
techniques on errors during simulated
neonatal resuscitation
Nicole K. Yamada, MD, FAAP
Senior Fellow, Neonatal-Perinatal Medicine
Division of Neonatal and Developmental Medicine
October 10, 2014
In the past 12 months, I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider(s) of
commercial services discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use of a
commercial product/device in my presentation.
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TRACON: Cactus 1529 turn left heading two-seven-zero.
Pilot: This is Cactus 1539 – hit birds. We lost thrust in both engines.
We’re turning back towards La Guardia.
TRACON: Ok yeah, you need to return to La Guardia. Turn left
heading of two-two-zero.
Pilot: Two-two-zero.
TRACON: Tower, stop your departures. We got an emergency
returning.
Tower: Who is it?
TRACON: It’s 1529. He...uh…bird strike. He lost all engines. He
lost the thrust in the engines. He is returning immediately.
Tower: Cactus 1529 – which engines?
TRACON: He lost thrust in both engines he said.
Tower: Got it.
TRACON: Cactus 1529 if we can get it for you, do you want to try
to land runway one-three?
Pilot: We’re unable; we may end up in the Hudson.
TRACON: Alright Cactus 1529 – it’s going to be left traffic to runway three-one.
Pilot: Unable.
TRACON: Okay what do you need to land?
RN: Stim! Stim! Stim!
MD places a floppy, cyanotic baby on the radiant warmer. MD and
RN warm, dry, and stimulate.
RN auscultates for HR while reaching for PPV mask.
MD: [to father] Hello. Congratulations.
RN: Hold on, I can’t hear [the HR while baby is
being dried]. Stop stop.
MD stops drying.
RN: It’s slow. [RN begins PPV with pop-off valve alarming,
inadequate filling volume of bag, and inappropriately fast RR.]
Keep stim-ing.
RN: [to baby] What’s going on? Huh?
MD: [auscultates HR] I think we need to intubate.
RN: Yeah, go ahead. Why don’t you get that bag while I get the
[intubation] tray.
MD: [MD takes over PPV, and continues improper technique] Can
you call for an extra hand from the NICU please?
MD: [to RN] I can’t get it, can you do it?
RN: Yeah, ok.
RN takes over PPV, and MD steps away to get intubation supplies.
Neonatal
Resuscitation
MD: Did you guys hear me? Can you guys call the NICU?
Because we need an extra hand.
OB RN: Call the team? What do you want? Who do you want?
WHO DO YOU WANT?
RN: WHO DO YOU WANT?
MD: Um, anybody. Uh. One of the doctors. Get one of the doctors.
OB anesthesiologist is at the bedside and listens to the baby’s
heart rate, then puts down the stethoscope and walks around to
other side of bed.
OB RN: [on phone with NICU] Hi can we get one of the doctors
in OR A please. [hangs up]
RN alternates between providing inadequate PPV and rubbing
the baby’s back.
RN: Okay, come on. You feeling better? [baby begins cries
weakly] There you go.
OB RN: You want the tray?
RN: Yeah, she’s getting it. [Continues inadequate PPV for 5 breaths, then stops to pick up the
stethoscope.] We need to keep listening to her.
RN: She’s got a great heart rate. She just doesn’t want to breathe.
MD: She does have a good heart rate?
OB anesthesiologist: Yeah. It was very good. Very strong.
Neonatal
Resuscitation
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“HR > 100 bpm”
Implies no PPV (or stop PPV)
“HR < 100 bpm” (and > 60 bpm)
PPV indicated
“HR < 60 bpm”
Implies start CC after 30 sec of effective PPV
“HR zero” (or undetectable)
Influences length of resuscitation
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When breath sounds present:
“Breath sounds present left”
“Breath sounds present right”
“Breath sounds present bilaterally”
When breath sounds decreased:
“Breath sounds decreased left”
“Breath sounds decreased right”
“Breath sounds decreased bilaterally”
When breath sounds absent:
“Breath sounds absent left”
“Breath sounds absent right”
“Breath sounds absent bilaterally”
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Non-Standard
Communication
Mean (SD)
Resuscitation
Lexicon
Mean (SD)
P-value
Average error rate
0.40 (0.07)
0.37 (0.08)
0.18
Errors of omission
0.32 (0.06)
0.28 (0.08)
0.09
Errors of commission
0.08 (0.04)
0.09 (0.04)
0.28
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Non-Standard
Communication
Mean (SD)
Resuscitation Lexicon
Mean (SD)
P-value
6.7 (2.5)
15.5 (5.0)
0.0015*
Time to initiation of PPV
32.4 sec (16.9 sec)
30.7 sec (15.4 sec)
0.58
Time to initiation of CC
120.7 sec (66.8 sec)
112.8 sec (70.8 sec)
0.78
Average number of
communication
techniques used
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Questions?
Nicole Yamada, M.D.
nkyamada@stanford.edu