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.