Practiss - Welcome

ØRECLESS: Neonatal Resuscitation in a Rural Family Practice.

You’re walking through the local Farmers’ Market and contemplating what flavour to make your next homemade jam. You made strawberry last year (and the year before), so you should probably change things up. You’re also on-call for obstetrics in a rural 1A maternity site (no local cesarean section capabilities), and the nearest urban centre is 300 km away. You’ve decided on getting some apricots when you get a call from the hospital.

A 30 y/o woman presents to the ED at approximately 40 weeks gestation in stage two active labour. She had a normal prenatal course, was well throughout her pregnancy, is nulliparous, and is carrying a singleton pregnancy. She has no known allergies, her family history and medical history are insignificant, and her general physical exam is otherwise normal.

There were no complications throughout the delivery. The neonate was dried with a cloth. The Apgar score was nine at one minute, and the neonate was handed to the woman for skin-to-skin contact. It’s a busy day in the hospital, and the only people you have available for assistance are two nurses and the woman’s husband.

The learner will manage neonatal distress and cardiac arrest following delivery by practicing a clinical approach to neonatal resuscitation.

This simulation is part of ØRECLESS (Rural Emergencies and Complications in Labour Events Simulations Suite).

Goals and Learning Objectives

Technical/Equipment Recommendations

Supporting Roles and Scripts

Moulage and Scenario Set-Up

Printable Supporting Documents (Will also be accessible at relevant Scenario Stage)

Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.

Original Author: Tiana Bressan
Originally published on: January 3, 2024
Most Recent Modification:

Prebriefing

A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it^1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information^1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.

Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective^2-4, and establish and maintain the simulation as a safe space for learning^1,4,5.

Prebrief Guide (Sample Phrases in Italics)

Welcome and Introduction

Orient to Basic Logistics

Clarify Objectives

Review the Evaluation Structure for the Day

Clarify Expectations

This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.

Establish Confidentiality

Establish the Fiction Contract

Explain and Assign Roles

Go over Logistical Details

Orient to the Environment

Ask for questions!

References

1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.

2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004

3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.

4. INACSL Standards Committee (2016, December). INACSL standards of best practice: Simulation^SMFacilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.

5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.

Case Briefing

You’re walking through the local Farmers’ Market and contemplating what flavour to make your next homemade jam. You made strawberry last year (and the year before), so you should probably change things up. You’re also on-call for obstetrics in a rural 1A maternity site (no local cesarean section capabilities), and the nearest urban centre is 300 km away. You’ve decided on getting some apricots when you get a call from the hospital.

A 30 y/o woman presents to the ED at approximately 40 weeks gestation in stage two active labour. She had a normal prenatal course, was well throughout her pregnancy, is nulliparous, and is carrying a singleton pregnancy. She has no known allergies, her family and medical history are insignificant, and her general physical exam is otherwise normal.

There were no complications throughout the delivery. The neonate was dried with a cloth. The Apgar score was nine at one minute, and the neonate was handed to the woman for skin-to-skin contact. It’s a busy day in the hospital, and the only people you have available for assistance are two nurses and the woman’s husband.

Patient Chart
Name: Charlotte Campbell	Age: 30	Gender: F	Weight: 74.3 kg	Height: 158 cm
Temp: 37.1	HR: 85 bpm	BP: 115/79	RR: 20/min	O₂Sat: 100%	GCS: 15

1. Neonatal Resuscitation

The neonate has been delivered. Maternal vitals are normal. The neonate was dried with a cloth. The Apgar score was nine at one minute, and the neonate was handed to the woman for skin-to-skin contact. The cord has been clamped and cut. The only available assistance includes two nurses and the woman’s husband. Woman: “My baby isn’t moving anymore. I don’t think he’s breathing!”

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

Expected Learner Actions
Stimulate neonate by rubbing the back 2-3 times Suction if meconium-stained liquor or mouth/nose is full of secretions Attempted stimulation ⇒ Nurse: "He's gasping!" Transfer neonate to the resuscitation area Slightly extend head/neck Choose mask size (Normal-weight: Size 1, Small <2.5 kg: Size 0) Start positive pressure ventilation with mask and self-inflating bag within one minute of birth (40-60 breaths/min, Duration: 30-60 seconds, 5-10 cm H2O to maximum 40 cm H2O) Ensure chest is moving adequately (caution: pneumothorax with excessive chest expansion) Consider endotracheal intubation (if required) Assess heart rate with a stethoscope Learner checks heart rate ⇒ Facilitator: "Neonate heart rate has dropped below 60 bpm." Begin chest compressions (3 compressions/1 breath q2sec) until HR >100bpm Supplemental oxygen (100%) during chest compressions Assess heart rate with a stethoscope (after 60 seconds) Learner checks heart rate ⇒ Facilitator: "Neonate heart rate remains below 60 bpm." Obtain venous access (insert an umbilical venous catheter) Administer IV epinephrine: 0.01-0.03 mg/kg (0.1 to 0.3 mL/kg of a 0.1 mg/mL solution) or 0.05-0.1mg/kg (0.5-1 mg/kg of a 0.1 mg/mL solution) Consider hypovolemia or pneumothorax Assess heart rate with a stethoscope
10 min. OR Actions Complete ⇒ 2. Case Complete

Expected Learner Actions

Stimulate neonate by rubbing the back 2-3 times
Suction if meconium-stained liquor or mouth/nose is full of secretions
Attempted stimulation ⇒ Nurse: "He's gasping!"

Transfer neonate to the resuscitation area
Slightly extend head/neck
Choose mask size (Normal-weight: Size 1, Small <2.5 kg: Size 0)
Start positive pressure ventilation with mask and self-inflating bag within one minute of birth (40-60 breaths/min, Duration: 30-60 seconds, 5-10 cm H2O to maximum 40 cm H2O)
Ensure chest is moving adequately (caution: pneumothorax with excessive chest expansion)
Consider endotracheal intubation (if required)
Assess heart rate with a stethoscope
Learner checks heart rate ⇒ Facilitator: "Neonate heart rate has dropped below 60 bpm."

Begin chest compressions (3 compressions/1 breath q2sec) until HR >100bpm
Supplemental oxygen (100%) during chest compressions
Assess heart rate with a stethoscope (after 60 seconds)
Learner checks heart rate ⇒ Facilitator: "Neonate heart rate remains below 60 bpm."

Obtain venous access (insert an umbilical venous catheter)
Administer IV epinephrine: 0.01-0.03 mg/kg (0.1 to 0.3 mL/kg of a 0.1 mg/mL solution) or 0.05-0.1mg/kg (0.5-1 mg/kg of a 0.1 mg/mL solution)
Consider hypovolemia or pneumothorax
Assess heart rate with a stethoscope

10 min. OR Actions Complete ⇒ 2. Case Complete

2. Case Complete

FHR has increased to 100 bpm and the status of the neonate has improved. Observation of the neonate continues, transport to the referral centre is considered, and the case is complete.

Go to Debrief

Apgar Score

Apgar Score Record score 1-5 mins after birth
Indicator		0 Points	1 Point	2 Points
A	Activity (Muscle Tone)	Absent	Some tone and flexion	Active motion with flexed muscle tone
P	Pulse	Absent	Less than 100bpm	100+ bpm
G	Grimace (Reflex irritability)	Floppy, No response to stimulation	Grimacing	Cries, coughs, or sneezes
A	Appearance (Skin Color)	Pale or blue	Pink but blue extremities	Entirely pink
R	Respiration	Absent	Slow, irregular, weak, or gasping	Crying vigorously
Total Score: 0-3: Low 4-6: Moderately Abnormal 7-10: Normal

Created using information from: Simon LV, Hashmi MF, Bragg BN. APGAR Score. StatPearls. 2022 Feb. https://www.ncbi.nlm.nih.gov/books/NBK470569/

Neonatal Resuscitation: Flow Charts and Target Oxygenation

bpm: beats per minute; PPV: positive pressure ventilation; CPAP: continuous positive airway pressure; HR: heart rate; ETT: endotracheal tube; GA: gestational age.

*If there is no labored breathing or persistent cyanosis, the neonate stays with the mother for ongoing evaluation. Refer to UpToDate's topics on initial management of newborn infants for additional details.

UpToDate: Neonatal resuscitation in the delivery room.

Medications used in Neonatal Resuscitation

UpToDate: Neonatal resuscitation in the delivery room.

Debriefing

Choosing a Debrief Framework:

A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.


	Time	Facilitator Level	Prep Time	Scenario Type	Flexibility
PEARLS (Our Favourite)	Moderate	Novice	Moderate	Any	High
GAS	Short-Moderate	Novice	Low	Short w/ Clear Objectives	Low
Team Dynamics	Moderate	Novice	Moderate	Any, esp. Team-focused	Moderate
SHARP	Very Short	No experience	None	Any	Low
Diamond	Short	Novice	Low	Low number of non-technical skills	Low
Plus-Delta	Very Short	No experience	None	Any	Moderate
Debriefing w/ Good Judgement	Moderate-Long	Novice	Moderate	Any	Moderate

PEARLS Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Phase	Objective		Task		Sample Phrases
1. Setting the Scene	Create a safe context for learning		State the goal of debriefing; articulate the basic assumption		“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
2. Reactions	Explore feelings		Solicit initial reactions and emotions		“Any initial reactions?” “How are you feeling?”
3. Description	Clarify Facts		Develop a shared understanding of the case		“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
4. Analysis	Explore a variety of performance domains: Decision making Technical skills Communication Resource utilization Leadership Situational Awareness Teamwork		See bottom of guide for details on the analysis phase		For each item to be debriefed: 1. Preview Statement: (to introduce topic) “At this point, I’d like to spend some time talking about [insert topic] because [insert rationale]" 2. Pick Analysis method + Analyze: (see below for more info on each method) a. Learner Self-Assessment b. Focused Facilitation c. Provide information 3. Mini Summary: (to summarize discussion of topic) *“That was a great discussion. Are there any additional comments related to [insert here]”* Phase Wrap-up: "Any outstanding issues or concerns before we start to close?"
5. Application or Summary	Identify take-aways		Can be learner- or instructor-centered		Learner-centered: “What are some takeaways from this discussion for our clinical practice?” Instructor-centered: “The key learning points for the case were [insert learning points]”
Analysis Phase Details
Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage):
Approach		Objective		Sample Phrases
Learner Self-Assessment Time: Short/Moderate Performance Domain: Cognitive/Technical Rationale Evident: Yes/No Facilitator Experience: Low		Promote reflection by asking learners to assess their own performance		“What aspects were managed well and why?” “What aspects do you want to change and why?”
Focused Facilitation Time: Moderate/Long Performance Domain: Cognitive/Behavioural Rationale Evident: No Facilitator Experience: More experience required, can be difficult		Probe deeper on key aspects of performance, uncover mental frames guiding performance		Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” *"I noticed [observation]* I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?”**
Provide Information Time: Short Performance Domain: Cognitive/Technical Rationale Evident: Yes Facilitator Experience: Low		Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed		“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]”

PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.

GAS Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Phase	Goal	Actions	Possible Scripts
Gather (Listen) 25%	Actively listen to participants to understand what they think and how they feel Identify what occurred during scenario	Elicit emotional state	*How do you feel?*
		Request narrative(s)	*How do you think it went?* *Can you tell me what happened?*
		Request clarifying or supplemental information	*Can anyone add anything to that account?*
Analyze (Guide Reflection) 50%	Provide feedback on performance Facilitate participant’s reflection on and analysis of their actions and systems issues Investigate basis for performance gaps	Review accurate record of events	*I noticed…*
		Report observations (correct and incorrect steps) Ask questions to reveal participant thinking	*I noticed…. What was the thought process behind….* *When….happened, I saw….What do you think…..* *I saw…I think….How do you see it?*
		Stimulate reflection and provide redirection	*Tell me more about…* *How did you feel about….* *I understand, but tell me about X aspect of the scenario*
Summarize (Help gather Conclusions) 25%	Facilitate identification and review of lessons learned	Identify positive aspects of session (participants)	*What are two things that you thought were effective or went well?*
		Discuss behaviours that require change	*What do you think are some areas you/your team need to work on?*
		Summarize session	*In today’s session, we….* *Going forward, we should….*

References/Adapted From:

Phrampus P.E., O’Donnell J.M. (2013) Debriefing Using a Structured and Supported Approach. In: Levine A.I., DeMaria S., Schwartz A.D., Sim A.J. (eds) The Comprehensive Textbook of Healthcare Simulation. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5993-4_6
Baily K (2019) Gather – Analyze – Summarize: The Simple GAS Method for Healthcare Simulation Debriefing (w/ Quick Template). www.healthysimulation.com/18874/gas-debriefing/

Team Dynamics Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Instructions:

Use the table below to guide your debriefing (Example phrases provided in plain text)
Observe and record elements of team dynamics
Identify 2 or 3 elements of team dynamics to discuss per debriefing section

Actions

Gather

Analyze

Summarize

Closed-loop communication

Orders acknowledged and confirmed when given
Orders announced when executed

Clear Messages

Team members speak clearly
Orders are questioned when doubt exists

Clear Roles

All team members have appropriate roles
Roles are reallocated when appropriate

Knowing one’s limitations

Calls for assistance
Seeks advice when appropriate

Knowledge Sharing

Sharing information between team members
Asks for ideas and suggestions

Constructive Intervention

Identifies priorities
Questions colleagues who make mistakes

Reevaluation and Summarizing

Reevaluates patient
Summarizes patient condition and treatment plan

Mutual Respect

Speaks in a professional, friendly tone of voice
Provides positive feedback

Student Observations

Can you describe the events from your perspective?
How did you think your treatments went?
Can you review the events of the scenario?
What could you have improved?
What did the team do well?

Instructor Observations

I noticed that [insert action here]
I observed that [insert action here]
I saw that [insert action here]

Done Well

How were you able to [insert action here]?
Why do you think you were able to [insert action here]?
Tell me a little bit more about how you [insert action here]?

Needs Improvement

Why do you think [insert action here] occurred?
How do you think [insert action here] could have been improved?
What was your thinking while [insert action here]?
What prevented you from [insert action here]?

Student-led Summary

What are the main things you learned?
Can someone summarize the key points made?
What are the main take-home messages?

Instructor-led Summary

Let’s summarize what we learned….
Here is what I think we learned….
The main take-home messages are….

References/Adapted from:

Cheng, A MD, FRCPC; Rodgers, DL. EdD; van der Jagt, É MD, MPH; Eppich, W MD, MEd; O’Donnell, J CRNA, MSN, DrPH (2012) Evolution of the Pediatric Advanced Life Support course, Pediatric Critical Care Medicine. 13(5). 589-595 doi: 10.1097/PCC.0b013e3182417709
American Heart Association Team Dynamics Debriefing Tool. 2011. https://ahainstructornetwork.americanheart.org/idc/groups/ahaecc-public/@wcm/@ecc/documents/downloadable/ucm_488325.pdf

SHARP Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Before Case

Set learning objectives
What would you like to get out of this case?

After Case

How did it go?
What went well? Why?

Address Concerns
What did not go so well? Why?

Review learning points
Were your learning objectives met for this case?
What did you learn about your clinical/technical skills?
What did you learn about your teamwork skills?

Plan ahead
What actions can you take to improve your future practice?

Framework from:

Imperial College London (ND). The London Handbook for Debriefing: Enhancing Performance Debriefing in Clinical and Simulated Settings. www.imperial.ac.uk/media/imperial-college/medicine/surgery-cancer/pstrc/lw2222ic_debrief_book_a5.pdf

Diamond Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Diamond Debrief: Sample Phrases

Description

“So what happened?...and then what happened next?”

Continue asking until confident that the details of the scenario have been raised by the learners

“Let’s not judge our performance now, let’s just focus on what happened”

Transition

“This scenario was designed to show…”

“Let’s address technical and clinical questions. What is the protocol for…?”

“How do we normally deal with this clinical situation?”

“Everyone ok with that?”

Analysis

“How did that make you feel?” To participants, then group

“Why?” Then use silence

“How did you/they do that exactly?”

“Why did you respond in that way? “ or “Why did you take that action?”

“It feels like…was an issue. Did it feel like that to you?”

What I’m hearing from you is…is that correct?”

“This is part of…” (identify the non-technical skill/human factor)

“We refer to that as a human factor or non-technical skill, which means…”

Transition

“So, what we’ve talked about in this scenario is…”

“What have we agreed we could do?”

Application

“What other kinds of situations might you face that might be similar? How are they similar?”

“How might these skills we discussed play out in those situations?”

“What are you going to do differently in your practice going forward?”

Underlying Principles

Description

Reinforce a safe learning environment.

Situate the debrief in the shared and meaningful activity that occurred.

Keep the focus dispassionate—discuss what happened but avoid focus on emotions.

Listen for emotional responses but resist the temptation to discuss emotions.

Make sure everyone shares the same understanding of what happened.

Transition

Transition into analysis by clarifying any technical and clinical issues

Analysis

Spend most of your time in Analysis.

Deconstruct behaviours into specific actions, and explore what happened in detail.

Ask about affective responses and validate them.

Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario).

Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”.

Reflect responses back, allowing participants to amend or augment.

Transition

Transition into Application by reinforcing learning.

Application

Focus on moving from the specifics of the scenario to the more general world of practice.

Break behaviours down into specific actions.

Explore the other kinds of situations that these might apply to.

Ask what participants will do differently in their practice.

Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300

Plus-Delta Debrief Framework

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Pluses:

Things that are working first
Items that the individual or team wants to build on
Ex: What went well?

Deltas:

Opportunities for improvement things that can be changed so that the individual team might become more effective
Should be specific, within the realm of possibility
To be reviewed and acted upon
Ex: What would you do differently next time?

Plus (+)	Delta (∆)

References:

Klair MB (2000). The Mediated Debrief of Problem Flights. in Facilitation and Debriefing in Aviation Training and Operations (1st ed). Routledge. www.taylorfrancis.com/chapters/mono/10.4324/9781315255576-12/mediated-debrief-problem-flights-key-dismukes-guy-smith
ACPS Quality Tools: Plus/Delta (ND). fhop.ucsf.edu/sites/fhop.ucsf.edu/files/custom_download/ACPS_Plus_Delta_Template.pdf

Neonatal Resuscitation:
Teaching Points for Newborn Resuscitation (15 min): https://youtu.be/0480Zbkgt5M

Phase	Purpose	Process	Sample Phrases
Reactions	Allow learners to express emotional reactions to simulation Provide facts underlying simulation	Ask for emotional reactions	*How are you feeling?* *What are some initial reactions to what just happened?* *So, in that scenario…*
Analysis	Uncover the ideas, thought processes, and other factors that lead to a learner behaviour (uncovering “frames”) Help learners find ways to improve	1. Observe an event or result. Comment on the observation. 2. Advocate for your position	*I saw that… I think…* *I noticed that…To me…* *I saw…I’m concerned that…*
		3. Investigate basis for learner’s thinking that led to the observed event or result	*What do you think?* *Why do you think that happened?* *How do you see it?* *What was the thought process behind….?*
		4. Close the gap through discussion and didactics	*I hear…. What would it take for you to do this next time?* *How could we do this differently next time?* *I think a few good ideas that came up were…* *I’d like to say a little bit about…from my experience/literature*
Summary	Distill lessons learned from debriefing Invite reflection on the experiences as a whole	Ask learners to summarize their takeaways, what went well/what could be done differently Summarize session and learning	*What are some takeaways from today?* *What went well today? What would you do differently next time?* *In today’s session, we….* *Going forward, we should…*

ØRECLESS: Neonatal Resuscitation in a Rural Family Practice.

Scenario Overview

Scenario Info:

Prebriefing:

Scenario Stages: (Toggle) Educational

Debriefing:

Clinical Pearls:

ØRECLESS: Neonatal Resuscitation in a Rural Family Practice.

Prebriefing

Case Briefing

1. Neonatal Resuscitation

2. Case Complete

Apgar Score

Neonatal Resuscitation: Flow Charts and Target Oxygenation

Medications used in Neonatal Resuscitation

Debriefing

PEARLS Debrief Framework

GAS Debrief Framework

Team Dynamics Debrief Framework

SHARP Debrief Framework

Diamond Debrief Framework

Plus-Delta Debrief Framework

Debriefing with Good Judgment Framework