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1.  Evaluation of Heart Rate Assessment Timing, Communication, Accuracy, and Clinical Decision-Making during High Fidelity Simulation of Neonatal Resuscitation 
Objective. Accurate heart rate (HR) determination during neonatal resuscitation (NR) informs subsequent NR actions. This study's objective was to evaluate HR determination timeliness, communication, and accuracy during high fidelity NR simulations that house officers completed during neonatal intensive care unit (NICU) rotations. Methods. In 2010, house officers in NICU rotations completed high fidelity NR simulation. We reviewed 80 house officers' videotaped performance on their initial high fidelity simulation session, prior to training and performance debriefing. We calculated the proportion of cases congruent with NR guidelines, using chi square analysis to evaluate performance across HR ranges relevant to NR decision-making: <60, 60–99, and ≥100 beats per minute (bpm). Results. 87% used umbilical cord palpation, 57% initiated HR assessment within 30 seconds, 70% were accurate, and 74% were communicated appropriately. HR determination accuracy varied significantly across HR ranges, with 87%, 57%, and 68% for HR <60, 60–99, and ≥100 bpm, respectively (P < 0.001). Conclusions. Timeliness, communication, and accuracy of house officers' HR determination are suboptimal, particularly for HR 60–100 bpm, which might lead to inappropriate decision-making and NR care. Training implications include emphasizing more accurate HR determination methods, better communication, and improved HR interpretation during NR.
doi:10.1155/2014/927430
PMCID: PMC4021850  PMID: 24883063
2.  Neonatal Candidiasis: Epidemiology, Risk Factors, and Clinical Judgment 
Pediatrics  2010;126(4):e865-e873.
OBJECTIVE
Invasive candidiasis is a leading cause of infection-related morbidity and mortality in extremely low-birth-weight (<1000 g) infants. We quantify risk factors predicting infection in high-risk premature infants and compare clinical judgment with a prediction model of invasive candidiasis.
METHODS
The study involved a prospective observational cohort of infants <1000 g birth weight at 19 centers of the NICHD Neonatal Research Network. At each sepsis evaluation, clinical information was recorded, cultures obtained, and clinicians prospectively recorded their estimate of the probability of invasive candidiasis. Two models were generated with invasive candidiasis as their outcome: 1) potentially modifiable risk factors and 2) a clinical model at time of blood culture to predict candidiasis.
RESULTS
Invasive candidiasis occurred in 137/1515 (9.0%) infants and was documented by positive culture from ≥ 1 of these sources: blood (n=96), cerebrospinal fluid (n=9), urine obtained by catheterization (n=52), or other sterile body fluid (n=10). Mortality was not different from infants who had positive blood culture compared to those with isolated positive urine culture. Incidence varied from 2–28% at the 13 centers enrolling ≥ 50 infants. Potentially modifiable risk factors (model 1) included central catheter, broad-spectrum antibiotics (e.g., third-generation cephalosporins), intravenous lipid emulsion, endotracheal tube, and antenatal antibiotics. The clinical prediction model (model 2) had an area under the receiver operating characteristic curve of 0.79, and was superior to clinician judgment (0.70) in predicting subsequent invasive candidiasis. Performance of clinical judgment did not vary significantly with level of training.
CONCLUSION
Prior antibiotics, presence of a central catheter, endotracheal tube, and center were strongly associated with invasive candidiasis. Modeling was more accurate in predicting invasive candidiasis than clinical judgment.
doi:10.1542/peds.2009-3412
PMCID: PMC3045840  PMID: 20876174
Candidiasis; premature infant; risk factors

Results 1-2 (2)