Video recording of neonatal resuscitation: A feasibility study to inform widespread adoption

Table 1 Overview of video recording of actual neonatal resuscitation as a quality assurance activity program and contextual details

Overarching goal	Enhance the likelihood of caregivers’ delivering effective, safe and high quality NR care
Specific goal	Feasibility of introducing NRQAA program as a standard of care activity in a tertiary perinatal centre
Method of implementation Assessment of readiness	Quality assurance activity. Not introduced as a research study or a teaching activity Although NRP certification of all caregivers, in-situ unadvertised mock code (2008), high fidelity simulation using SimnewB (2010) were occurring in the unit, training in team behaviors, crisis resource management and error prevention had not happened
Training in team behaviors and exposure to VR	Interprofessional workshop in team behaviors, crisis resource management and error prevention (October 2011-January 2012), orientation of all new resuscitation team members and learners to team behaviors (January 2011 onwards), use of VD during mock resuscitations and training sessions (July 2011 onwards) were introduced. Pre resuscitation briefing of all anticipated high risk deliveries were introduced as a routine (September 2011). Team composition, configuration during resuscitation, member roles, anticipation of worst-case scenario and care planning were to be discussed by the neonatal fellow in briefing meetings. An expectation to complete the resuscitation and stabilization within 60 min of life was communicated to all members. T piece resuscitator for CPAP and PPV, Oxygen administration based on pulse oximetry reading and targeting saturation value appropriate for minute of life, and prophylactic CPAP for all < 33 wk s gestation infants were introduced as a part of larger QI initiative (January-July 2011)
Training instructors in debriefing	Only two out of 6 instructors had formal training in simulation and debriefing. These two instructors in-turn trained other instructors
Technology	Fixed IP video cameras with audio and video capturing capability and mounted on the roof/walls of the delivery rooms were used. They were wired to a web server placed in a room adjacent to NICU. VR was supposed to be turned on by the resuscitation team members (primarily by RTs) and stopped at the end of resuscitation. This video was automatically stored on the webserver and could be accessed or retrieved by instructors till its erasure
Securing resources	Funding for installation of video camera, web server and storage were obtained from the hospital KT grant. All personnel in QI subcommittee contributed their non clinical time for the program
Consent from family and staff	Obtained waiver of consent as the project was introduced as a Quality assurance standard of care practice and not as a research study. Consent was required for use of video for non quality assurance activity such as teaching providers and learners beyond the NICU team members and for research
	Information about NRQAA was to be provided for all care providers and parents
Medical record vs quality assurance record Data ownership, management and disclosure of error	Video was considered, as quality of care documents as videos would offer any health benefit to patient would not be used for care and treatment of individual patient and those other records of resuscitation apart from video would be preserved in medical records
	NRQAA committee was to oversee the NRQAA documents. No personal identifiers were collected. Any error was to be disclosed to the family as per the hospital policies
Video storage and security	Videos were directly stored on hospital web servers. They were accessible from a single computer located in a room adjacent to NICU. All VD was supposed to happen in the same room. The room was locked at all times and had swipe access. Access to VR was limited to instructors. All instructors had to sign a confidentiality and security statement after receiving training in accessing and reviewing videos. Any use of videos by instructors apart from quality assurance activity as well as sharing of access information and delegation was prohibited
	Following video review the videos were erased from the server manually
Medico legal concerns	NRQAA was not organized through QCIPA, as viewing of video by all team members or occasionally by parent would not have been possible. Thus an opportunity for collaborative learning and reflecting on one’s own performance would have been lost
	Care providers were to understand that a video was subpoenable and parents had to consult hospital legal counsel and NRQAA committee before the release of the video
Risk of spoliation or intentional destruction of evidence allegation. Video erasure policy	Video destruction policy was defined with a caveat that any patients for whom there has been a report to hospital heath care liability insurance provider, a request for records, or involvement of a coroner, a professional college or any notice of any legal proceeding whatsoever involving the patient, that those videos be maintained as until any proceeding is finalized. We opted to delete the videos when videos are reviewed and debriefed or within 14 d of recording, whichever come first. We also informed care givers and parents that the videos will not be made available for any other reasons apart from those described above
Privacy of patient and staff	The video cameras were focused on the on the infant and not on caregivers. Caregivers’ hands were captured inadvertently during the process. All audio including caregivers’ conversation was captured during the VR. As per the Personal Heath Information protection Act, 2004 (PHIPA) NRQAA was to institute measures to ensure personal information is not inadvertently disclosed or accessed by inappropriate person through out the program course.
	All learners while attending the VD activity were to sign a confidentiality agreement form. All NICU care providers were to abide with existing hospital confidential policy, which clearly prohibited the use of personal names or discussion performance issues outside the quality forums
Privacy office recommendations	Management of access and transfer if any to be done by a person approved by NRQAA. The program lead is responsible for oversight of the process
	Retention time to not exceed 14 d
	Transfer and destruction log along with the signature of individual conducting transaction should be noted
	Use encrypted USB key approved by hospital ICT team for any data transfer between NICU and hospital server
	Ensure erasure process meets security requirements
Refusal from staff/family	Risk of refusal was proactively addressed by communicating the rationale for VR and attempting to minimize misconceptions among caregivers. An adequate lead-time and multiple forums to discuss concerns arising out of VR were provided. Similarly supervisors were encouraged to address concerns related to their respective professions and to support their colleagues during NRQAA
	VR was supposed to be initiated by resuscitation team by turning on the switch as opposed to motion sensing/auto recording
	All video reviews and VDs were supposed to be done by physicians during the feasibility period
Institutional support	All stakeholders were informed and their support was obtained before launching the project, e.g., Quality of care and patient safety team, Information technology, Privacy, Obstetrics, Engineering, Infection control, Executives, legal council, risk management, REB and senior executives of the hospital
Support from professional bodies	Support was obtained from Canadian Medical Protection Agency, Nursing association, heads of professional practice of nurses and respiratory therapy, nursing unions
Project management	Project timelines, committee members roles, training and evaluation were all defined by the program lead
Resource limitations	In order to minimize cost of installation, instructors time and workload the following limitations were accepted apriori before the launch of the program
	Video cameras were installed in three out of possible 13 delivery rooms. These three rooms had contributed to 60%-70% of all high-risk deliveries in 2007-2009. Obstetric staffs were informed to preferentially triage all less than 33 wk gestation laboring mothers to above three rooms
	Video review was limited to first 10 min of life and scheduled VD to day deliveries on weekdays.
	Superimposition of heart rate, SpO2, pressure and flow from pulse oximter and ventilator onto VR s were not done
	Instructors did not have access to review the videos remotely
	Resources for all instructors to take certification courses in debriefing was limited

NRQAA: Neonatal resuscitation as a quality assurance activity; VR: Video recording; NR: Neonatal resuscitation; VD: Video debriefing.

Table 2 Detailed matrix of outcomes and data collection

	Video review	Video debrief feedback evaluation	End of pilot period caregiver survey	End of pilot period instructor survey	End of pilot period focus group
Limited efficacy testing Caregivers’ perception on learning and enhancing patient safety Impact on desired organizational outcome Create learning environment Enhance patient safety		X	X	X	X
Acceptability and demand1 Management2 Caregivers Parents Instructors		X	X	X	X
Usability analysis to assess team behaviors, debrief and identify system issues VR and video review software technology2 Instruments	X	X		X	X
Resource needs3 Initial Maintenance					X
Unintended adverse or beneficial effects3 Sustainability Feasibility criteria Adaptations before widespread adoption	X	X	X	X	X
				X	X

¹Assessed by participation rates;

²Assessed in phases II and III;

³Assessed by observations from instructors logbook, team meeting minutes and comments in surveys. VR: Video recording.

Table 3 Policy, caregiver roles and latent safety threat issues noted during: Pre-resuscitation briefing

Issues	Solution
When do I call an attending for help during resuscitation?	Whenever chest compression is initiated
Can I transfer the first twin from resuscitaire to a basinet and then receive the next twin on the same resuscitaire?	No! Two separate resuscitaire should be kept ready
Why should I know the indication for a laboring mother receiving meropenam and opioids?	To decide on appropriateness of using Naloxone, neonatal isolation and performing a septic work up
Where is the main surgical OR where a C-section is happening on a mother with placenta increta?	To ensure resuscitation team members reach the OR in time
What special preparation is necessary?	Higher room temperature, familiarization with the new environment and all necessary equipment should be ensured
What are the indications for admitting a newborn with fetal arrhythmia to NICU?	Arrhythmia noted on connecting to a multi-channel monitor in stabilization room
How do I create beds for four less than 28 wk, anticipated high-risk deliveries?	Efficient problem solving and triaging
What worst case scenario should I anticipate while attending a delivery in a mother with Spinal Muscular Atrophy, unexplained IUGR and non-reassuring fetal heat rate	Hypoplastic lung with difficulty in resuscitation
What is the role of learners (clerks, residents, others) during resuscitation?	Team leader should assign roles on a case by case basis during the team huddle
Who is responsible for gathering all information on an anticipated high-risk delivery and case specific preparation?	The expectation is that the neonatal fellow covering the Labor and Delivery unit is responsible for gathering information and case specific care planning. The dedicated resuscitation nurse is responsible for calling a team huddle before attending a high risk delivery
How should the family’s preference for resuscitating a 23 or 24-wk infant be documented in antenatal consults and handed over?	Family’s preference for resuscitation should be documented in written and handed over at every shift. If family’s preferences change, the revised plans should be documented in written

Table 4 Policy, caregiver roles and latent safety threat issues noted during: Issues noted during video reviewing

	Potential problems/negative impact
Communication
Not-verbalizing the reasons for initiating an intervention. e.g., intubation, chest compression, etc.	Lack of understanding the reasons behind an intervention, limits team members' ability to provide suggestions
Chest compression and PPV rhythm not verbalized “one and two and three and breathe”	Lack of synchronization delays neonate’s response to resuscitation
Heart rate is not verbalized after auscultating	Delay in making a decision on initiation/non initiation of chest compression
Excessive reliance on non-verbal communication, e.g., asking for a suction catheter by “stretching hands” after inserting the laryngoscope orally, as opposed to a “verbal request”	Delay in receiving suction catheter causes frustration in the intubator and delays the resuscitation efforts
Silencing alarms and not communicating the alarm to the team leader	Lack of awareness impedes accurate decision making and timely initiation of interventions
Team members not communicating assertively, e.g., Considering a higher peak inspiratory pressure in a non-responding infant	Delay in trouble shooting leading to ineffective resuscitation
Not sharing of relevant obstetric information with NR team during resuscitation of a depressed infant, e.g., MSL, abruption, Morphine	Delay in considering appropriate interventions, e.g., ET suction, fluid bolus and Naloxone respectively
Leadership
Leader was totally passive	Leads to momentary assumption of role by another member. Often results in delayed decision making, team losing focus, excessive indulgence in unnecessary interventions, e.g., suctioning, and lack of assessment of response to interventions
Fixation error, e.g., Making decisions of intubation and chest compression in a nonresponsive infant without ensuring good seal during mask ventilation	Unnecessary invasive interventions with a potential for adverse events
Lack of evaluation of plans during resuscitation	Prevents team members ability to provide suggestions
Team members positioning/configuration
Hands free team leader standing at the head end and RRTs who are on one side of the infant	Leader impedes effective delivery of mask ventilation
Initiating chest compression with the side walls up	Impedes effective performance of chest compression
Technical
Ineffective seal around the mask during mask ventilation	Delay in responding to resuscitation
Attempting nasal intubation while resuscitating an unresponsive infant with severe bradycardia	Potential delay in intubation
Not venting stomach after a prolonged mask PPV	Secondary deterioration in SpO2 and heart rate
Not vigilant about FiO2 during resuscitation. Started 100% FiO2 only after 90 s of chest compression	Delay in response to resuscitation
Extubation while securing the ET tube as ET tube is not held firmly against the hard palate during taping	Potential for secondary deterioration or delay in resuscitation

NR: Neonatal resuscitation.

Table 5 Policy, caregiver roles and latent safety threat issues noted during: System issues noted during video debriefing

	Suggestions/solutions
No response from NICU front desk when called for additional help by resuscitation team in infant stabilization room	Avoid unmanned NICU front desk all the time
Preterm infant on CPAP transferred directly to NICU as opposed to stabilization in infant stabilization room and then to NICU	Transfer through stabilization room ensures that a ventilator and incubator is always ready for stabilization
Person attending resuscitation is different from the one who participated in team huddle	Case specific preparation and management plans discussed during team huddle becomes redundant
Difficulty in paging the resuscitation team members as the composition of resuscitation team changed during a shift	Dedicated resuscitation pagers to be carried by resuscitation team members as opposed to individual personal pagers
Infant stabilization room stocking was exhausted when 3 deliveries happened during a shift. Health care aides were replenishing stocks once a shift	Health care aides will be called to replenish stocks when necessary
Delay in sending the blood samples from infant stabilization room to lab	Tube system restored
Needle stick injury to a resuscitation team member while setting up the resuscitaire	Educate all caregivers to remove sharps after the procedures
Fall and injury to foot while running to attend a pink code in labor and delivery unit	Educate caregivers on taking precautions to avoid injury
Undue delay in starting a PIV in infant stabilization room due to non-availability of personnel	Educate RN team members about creating a backup support to establish PIV in time
Who is the first responder (MD/NP) to attend labor and delivery calls during handover? (8-9 am and 5-6 pm)	The day resuscitation team (MD/NP) members
Pending high-risk deliveries and family’s preference for resuscitation was not passed on to day team. Thus the day team was unclear about their roles when called to attend delivery	Should be an essential part of handover

Table 6 Policy, caregiver roles and latent safety threat issues noted during: Skills related questions posed by care givers during video debriefing

How do I communicate assertively?

How do I develop leadership skills?

What do I do when a RRT/TT member/Resident asks for intubation when the fellow is almost about to intubate?

How do I provide constructive feedback to team members during resuscitation?

When should I be “hands-on” and “hands-off” during resuscitation?

How can I ensure that I get others input during a difficult resuscitation?

It is very difficult to maintain a global perspective during resuscitation. How do I maintain it?

How do I deal with a member passing sarcastic comments/gestures during resuscitation? “Wish you all the best”

Table 7 Resource needs for facilitating video-debriefing activity and ongoing maintenance of the program

	Time
Facilitation of team activities1
Facilitating a pre-resuscitation briefing	15 min
Reviewing a resuscitation video	30-60 min
Facilitating a VD	60-90 min
Documentation of team activities-good practice1
Completing pre-resuscitation briefing template	5 min
Completing a video review template	5 min
Completing a video debrief template	5 min
Completing a weekly reporting template	5 min
Informing parents about VD activity	15 min
Ongoing maintenance
Training instructors-once	2 h
Training instructors to ensure reliable review and debriefing-once	2 h
Scheduling instructors and booking rooms	1-2 h/mo
Trouble shooting equipment, deleting videos and ensuring confidentiality of patients and caregivers	1-2 h/mo
Reporting system issues to quality councils and ensuring appropriate training for candidates lacking skills	1-2 h/mo
Addressing system issues and implementing solutions	Variable

¹Usual time taken for facilitating a single video-debriefing activity, unless otherwise stated. VD: Video debriefing.

Table 8 Issues affecting sustainability and suggested adaptations

Themes	Issue affecting sustainability	Suggested adaptations
Resources	Same day video-debriefing is resource intensive Transfer of ownership from project lead to unit leadership helps in buy-in	Conduct video-debriefing once every 2 wk on selected resuscitation recordings. Make the debriefing sessions open to all caregivers
		Provide resources for scheduling instructors, maintaining technology, and compensate for instructors time and effort Consider VR all deliveries and team members to seek video-debriefing on selected cases by attending on service/call
Low rate of VR	Hesitation to voluntarily record and participate in VR	Change from caregiver activated recording to motion sensor activated VR Link to certification/competence assessment (caregivers/learners)
System to remedy identified latent safety threats in real time	Identified but unaddressed issues result in caregiver disengagement	Set timelines for action
		Support caregivers to take ownership on addressing issues
		Communicate actions arising out of identified issues
		Establish connections with Quality and Education committees for systematic training on frequently identified issues
Inability to assess impact of team actions during resuscitation	Lack of vitals (heart rate, SpO2) data on VR	Consider superimposing vitals data on video-recording
Inconsistency in demonstrating team behaviors by caregivers	Lack of focused training in team behaviors and error prevention	Sustain video-debriefing activity for creating learning and self evaluation
	Team behavior evaluation not mandatory for maintenance of professional accreditation or trainee certification	Integrate demonstration of team behaviors during resuscitation into professional accreditation and certification requirements

VR: Video recording.

Table 9 Challenges identified during video recording and debriefing program

Challenges
Reminding care providers about team huddle, debriefing or turn-on the VR
Conflict with my other work (e.g., NICU service, etc.)
Reviewing videos in time
Engaging care providers during debriefing
Reviewing videos recorded in night
Providing feedback to caregivers who could not attend debriefing
Completing team huddle, video review and debrief templates in time
Completing the weekly report template
Interpreting the audio to assess team communication
Identifying debrief issues arising from videos for debriefing
Time for VD (60 min)
Informing parents about VD in a timely manner, once the VR has happened
Delay in implementing project on time
Reinforcing expectations, providing opportunities for learning especially with rapid turnover of caregivers and trainees in a tertiary centre

VR: Video recording; VD: Video debriefing.