Marc Berg, MD

Abstract

Globally, inadequate healthcare provider (HCP) proficiency with evidence-based guidelines contributes to millions of newborn, infant, and child deaths each year. HCP guideline proficiency would improve patient outcomes. Conventional (in person) HCP in-service education is limited in 4 ways: reach, scalability, adaptability, and the ability to contextualize. Adaptive e-learning environments (AEE), a subdomain of e-learning, incorporate artificial intelligence technology to create a unique cognitive model of each HCP to improve education effectiveness. AEEs that use existing internet access and personal mobile devices may overcome limits of conventional education. This paper provides an overview of the development of our AEE HCP in-service education, Pediatric Acute Care Education (PACE). PACE uses an innovative approach to address HCPs' proficiency in evidence-based guidelines for care of newborns, infants, and children. PACE is novel in 2 ways: 1) its patient-centric approach using clinical audit data or frontline provider input to determine content and 2) its ability to incorporate refresher learning over time to solidify knowledge gains. We describe PACE's integration into the Pediatric Association of Tanzania's (PAT) Clinical Learning Network (CLN), a multifaceted intervention to improve facility-based care along a single referral chain. Using principles of co-design, stakeholder meetings modified PACE's characteristics and optimized integration with CLN. We plan to use three-phase, mixed-methods, implementation process. Phase I will examine the feasibility of PACE and refine its components and protocol. Lessons gained from this initial phase will guide the design of Phase II proof of concept studies which will generate insights into the appropriate empirical framework for (Phase III) implementation at scale to examine effectiveness.

View details for DOI 10.1177/20552076231180471

View details for PubMedID 37529543

View details for PubMedCentralID PMC10387696

Abstract

Introduction: To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment (AEE). The objectives of this study were to 1) assess implementation success with use of in-person support and nudging strategy and 2) describe baseline provider knowledge and metacognition.Methods: 6-month observational study at 1 zonal hospital and 3 health centers in Mwanza, Tanzania. To assess implementation success, we used the RE-AIM framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity.Results: aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing, and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centers. Median clinical experience was 4 years [IQR 1,9] and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD17%). Providers averaged 78% (SD31%) completion of initial learning and 7%(SD11%) of refresher assignments. 130 (67%) providers had 1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% [IQR:38-63%], unconscious-incompetence 32% [IQR:23-42%], conscious-incompetence 7% [IQR:2-15%], and unconscious-competence 2% [IQR:0-3%]. Higher baseline conscious-competence (OR 31.6 [95%CI:5.8, 183.5) and being a nursing officer (aOR: 5.6 [95%CI:1.8, 18.1]), compared to medical officer) were associated with initial learning completion or persistent activity.Conclusion: aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning, and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalization is needed.Key questions: What is already known on this topic . Summarize the state of scientific knowledge on this subject before you did your study and why this study needed to be done . - In sub-Saharan Africa, gaps in care quality may contribute to its high neonatal mortality.- Provider knowledge is a main driver of care quality, but current conventional in-service education methods are inadequate in adaptivity, reach, effectiveness, and refresher assignments.- Hard copies of national guidelines have been disseminated to health facilities expectations are HCPs will learn and adhere to them.- Adaptive eLearning, a subdomain of e-learning, holds the potential to overcome limitations to in-service medical education, but the optimal implementation strategy is unknown. What this study adds . Summarize what we now know because of this study that we did not know before . - Baseline knowledge of essential and sick newborn care was low, mostly due to unconscious incompetence (providers thinking they were correct when they were incorrect).- Initial learning completion increased significantly with the use of an in-person program manager and an escalating nudging strategy, and technical issues were not identified as a significant limitation to participation. How this study might affect research, practice, or policy . Summarize the implications of this study . - Provider self-reporting may underestimate knowledge gaps as most gaps are not known by providers.- Adaptive e-learning may be a feasible and acceptable way to disseminate guideline and improve quality of care if an implementation strategy can be identified to increase refresher assignment completion.- Once the ideal implementation strategy is identified, effectiveness of adaptive e-learning at scale can be evaluated.

View details for DOI 10.1101/2023.07.11.23292406

View details for PubMedID 37502852

Abstract

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality.METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored.RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores.CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

View details for DOI 10.1542/peds.2022-060790

View details for PubMedID 37416979

Abstract

Diuretics are a mainstay therapy for congestive heart failure (CHF); however, over one-third of patients develop diuretic resistance. Second-generation artificial intelligence (AI) systems introduce variability into treatment regimens to overcome the compensatory mechanisms underlying the loss of effectiveness of diuretics. This open-labeled, proof-of-concept clinical trial sought to investigate the ability to improve diuretic resistance by implementing algorithm-controlled therapeutic regimens.Ten CHF patients with diuretic resistance were enrolled in an open-labeled trial where the Altus Care app managed diuretics' dosage and administration times. The app provides a personalized therapeutic regimen creating variability in dosages and administration times within pre-defined ranges. Response to therapy was measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) score, 6-minute walk test (SMW), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and renal function.The second-generation, AI-based, personalized regimen alleviated diuretic resistance. All evaluable patients demonstrated clinical improvement within ten weeks of intervention. A dose reduction (based on a three-week average before and last three weeks of intervention) was achieved in 7/10 patients (70 %, p=0.042). The KCCQ score improved in 9/10 (90 %, p=0.002), the SMW improved in 9/9 (100 %, p=0.006), NT-proBNP was decreased in 7/10 (70 %, p=0.02), and serum creatinine was decreased in 6/10 (60 %, p=0.05). The intervention was associated with reduced number of emergency room visits and the number of CHF-associated hospitalizations.The results support that the randomization of diuretic regimens guided by a second-generation personalized AI algorithm improves the response to diuretic therapy. Prospective controlled studies are needed to confirm these findings.

View details for DOI 10.1016/j.biopha.2023.114334

View details for PubMedID 36905809

View details for Web of Science ID 000921450901160

View details for Web of Science ID 000921450900037

Abstract

The plateau effect in training is a significant obstacle for professional athletes and average subjects. It evolves from both the muscle-nerve-axis-associated performance and various cardiorespiratory parameters. Compensatory adaptation mechanisms contribute to a lack of continuous improvement with most exercise regimens. Attempts to overcome this plateau in exercise have been only partially successful, and it remains a significant unmet need in both healthy subjects and those suffering from chronic neuromuscular, cardiopulmonary, and metabolic diseases. Variability patterns characterize many biological processes, from cellular to organ levels. The present review discusses the significant obstacles in overcoming the plateau in training and establishes a platform to implement subject-tailored variability patterns to prevent and overcome this plateau in muscle and cardiorespiratory performance.

View details for DOI 10.3390/ijerph19031722

View details for PubMedID 35162745

Abstract

Coronavirus disease 2019 (COVID-19), which is a respiratory illness associated with high mortality, has been classified as a pandemic. The major obstacles for the clinicians to contain the disease are limited information availability, difficulty in disease diagnosis, predicting disease prognosis, and lack of disease monitoring tools. Additionally, the lack of valid therapies has further contributed to the difficulties in containing the pandemic. Recent studies have reported that the dysregulation of the immune system leads to an ineffective antiviral response and promotes pathological immune response, which manifests as ARDS, myocarditis, and hepatitis. In this study, a novel platform has been described for disseminating information to physicians for the diagnosis and monitoring of patients with COVID-19. An adjuvant approach using compounds that can potentiate antiviral immune response and mitigate COVID-19-induced immune-mediated target organ damage has been presented. A prolonged beneficial effect is achieved by implementing algorithm-based individualized variability measures in the treatment regimen.

View details for DOI 10.1016/j.biopha.2021.112228

View details for PubMedID 34649354

Abstract

ABSTRACT: Respiratory failure and cardiopulmonary arrest in patients with SARS-CoV-2 infection require life-saving procedures that aerosolize virus and increase risk of transmission. To educate faculty, trainees, and staff on safe practices, a video with embedded questions was created demonstrating intubation and cardiopulmonary resuscitation in pediatric SARS-CoV-2+ patients. Just-in-time in situ simulations of these scenarios were also carried out while adhering to isolation and social distancing protocols. We demonstrated that use of simulation to train physicians and staff during the COVID-19 pandemic is possible and effective in improving confidence in performance of the procedures.

View details for DOI 10.1097/SIH.0000000000000607

View details for PubMedID 34381006

View details for DOI 10.1097/PCC.0000000000002465

View details for PubMedID 33136992

Abstract

OBJECTIVE: To describe the impact of a national interventional collaborative on pediatric readiness within General Emergency Departments.STUDY DESIGN: A prospective, multicenter, interventional study measured pediatric readiness in general emergency departments before and after participation in a pediatric readiness improvement intervention. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) on a 100-point scale. The study protocol extended over six months and involved three phases: 1) a baseline on-site assessment of pediatric readiness and simulated quality of care, 2) pediatric readiness interventions, and 3) a follow-up on-site assessment of WPRS. The intervention phase included a benchmarking performance report, resources toolkits, and ongoing interactions between general emergency departments and academic medical centers.RESULTS: Thirty-six general emergency departments were enrolled, and 34 (94%) completed the study. Four EDs (11%) were located in Canada, and the rest were in the U.S. The mean improvement in WPRS was 16.3 (p<0.001) from a baseline of 62.4 (SEM=2.2) to 78.7 (SEM=2.1), with significant improvement in the domains of administration/coordination of care; policies, protocol and procedures; and quality improvement. Six EDs (17%) were fully adherent to the protocol timeline.CONCLUSION: Implementing a collaborative intervention model including simulation and quality improvement initiatives is associated with improvement in weighted pediatric readiness scores (WPRS) when disseminated to a diverse group of general emergency departments partnering with their regional pediatric academic medical centers. This work provides evidence that innovative collaboration facilitated by academic medical centers can serve as an effective strategy to improve pediatric readiness and processes of care.

View details for DOI 10.1016/j.jpeds.2020.10.040

View details for PubMedID 33137316

Abstract

The American Heart Association (AHA) recommends first defibrillation energy dose of 2 joules/kilogram (J/kg) for pediatric cardiac arrest with ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT). However, optimal first energy dose remains unclear.METHODS: Using AHA Get With the Guidelines-Resuscitation (GWTG-R) database, we identified children 12 yo with IHCA due to VF/pVT. Primary exposure was energy dose in J/kg. We categorized energy doses: 1.7-2.5J/kg as reference (reflecting 2J/kg intended dose),<1.7J/kg and >2.5J/kg. We compared survival for reference doses to all other doses. We constructed models to test association of energy dose with survival; adjusting for age, location, illness category, initial rhythm and vasoactive medications.RESULTS: We identified 301 patients 12 yo with index IHCA and initial VF/pVT. Survival to discharge was significantly lower with energy doses other than 1.7-2.5J/kg. Individual dose categories of<1.7J/kg or >2.5J/kg were not associated with differences in survival. For patients with initial VF, doses >2.5J/kg had worse survival compared to reference. For all patients 18 yo (n=422), there were no differences in survival between dosing categories. However, all 18 with initial VF receiving >2.5J/kg had worse survival.CONCLUSIONS: First energy doses other than 1.7-2.5J/kg are associated with lower rate of survival to hospital discharge in patients 12 yo with initial VF/pVT, and first doses >2.5J/kg had lower survival rates in all patients 18 yo with initial VF. These results support current AHA guidelines for first pediatric defibrillation energy dose of 2J/kg.

View details for DOI 10.1016/j.resuscitation.2020.05.048

View details for PubMedID 32522702

Abstract

The aim of this study was to evaluate the current infrastructure and practice characteristics of pediatric extracorporeal membrane oxygenation (ECMO) programs. A 40-question survey of center-specific demographics, practice structure, program experience, and support network utilized to cannulate and maintain a pediatric patient on ECMO was designed via a web-based survey tool. The survey was distributed to pediatric ECMO programs in the United States and Canada. Of the 101 centers that were identified to participate, 41 completed the survey. The majority of responding centers are university affiliated (73%) and have an intensive care unit (ICU) with 15-25 beds (58%). Extracorporeal membrane oxygenation has been offered for >10 years in 85% of the centers. The median number of total cannulations per center in 2017 was 15 (interquartile range [IQR] = 5-30), with the majority occurring in the cardiovascular intensive care unit (median = 13, IQR = 5-25). Fifty-seven percent of responding centers offer ECPR, with a median number of four cases per year (IQR = 2-7). Most centers cannulate in an operating room or ICU; 11 centers can cannulate in the pediatric ED. Sixty-three percent of centers have standardized protocols for postcannulation management. The majority of protocols guide anticoagulation, sedation, or ventilator management; left ventricle decompression and reperfusion catheter placement are the least standardized procedures. The majority of pediatric ECMO centers have adopted the infrastructure recommendations from the Extracorporeal Life Support Organization. However, there remains broad variability of practice characteristics and organizational infrastructure for pediatric ECMO centers across the United States and Canada.

View details for DOI 10.1097/MAT.0000000000001311

View details for PubMedID 33181543

Abstract

This 2019 focused update to the American Heart Association pediatric advanced life support guidelines follows the 2018 and 2019 systematic reviews performed by the Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation. It aligns with the continuous evidence review process of the International Liaison Committee on Resuscitation, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update provides the evidence review and treatment recommendations for advanced airway management in pediatric cardiac arrest, extracorporeal cardiopulmonary resuscitation in pediatric cardiac arrest, and pediatric targeted temperature management during post-cardiac arrest care. The writing group analyzed the systematic reviews and the original research published for each of these topics. For airway management, the writing group concluded that it is reasonable to continue bag-mask ventilation (versus attempting an advanced airway such as endotracheal intubation) in patients with out-of-hospital cardiac arrest. When extracorporeal membrane oxygenation protocols and teams are readily available, extracorporeal cardiopulmonary resuscitation should be considered for patients with cardiac diagnoses and in-hospital cardiac arrest. Finally, it is reasonable to use targeted temperature management of 32C to 34C followed by 36C to 37.5C, or to use targeted temperature management of 36C to 37.5C, for pediatric patients who remain comatose after resuscitation from out-of-hospital cardiac arrest or in-hospital cardiac arrest.

View details for DOI 10.1161/CIR.0000000000000731

View details for Web of Science ID 000508367200006

View details for PubMedID 31722551

Abstract

This 2019 focused update to the American Heart Association pediatric basic life support guidelines follows the 2019 systematic review of the effects of dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) on survival of infants and children with out-of-hospital cardiac arrest. This systematic review and the primary studies identified were analyzed by the Pediatric Task Force of the International Liaison Committee on Resuscitation. It aligns with the International Liaison Committee on Resuscitation's continuous evidence review process, with updates published when the International Liaison Committee on Resuscitation completes a literature review based on new published evidence. This update summarizes the available pediatric evidence supporting DA-CPR and provides treatment recommendations for DA-CPR for pediatric out-of-hospital cardiac arrest. Four new pediatric studies were reviewed. A systematic review of this data identified the association of a significant improvement in the rates of bystander CPR and in survival 1 month after cardiac arrest with DA-CPR. The writing group recommends that emergency medical dispatch centers offer DA-CPR for presumed pediatric cardiac arrest, especially when no bystander CPR is in progress. No recommendation could be made for or against DA-CPR instructions when bystander CPR is already in progress.

View details for DOI 10.1161/CIR.0000000000000736

View details for Web of Science ID 000508367200007

View details for PubMedID 31722546

Abstract

Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation.Methods: After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing.Results: After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified.Conclusions: iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

View details for DOI 10.1097/pq9.0000000000000222

View details for PubMedID 32010849

View details for DOI 10.1542/hpeds.2019-0030

View details for PubMedID 31492686

View details for Web of Science ID 000498593402110

Abstract

To assess the relationship between quantitative and perceived cardiopulmonary resuscitation performance when healthcare providers have access to and familiarity with audiovisual feedback devices.Prospective observational study.In situ simulation events throughout a pediatric quaternary care center where the use of continuous audiovisual feedback devices during cardiopulmonary resuscitation is standard.Healthcare providers who serve as first responders to in-hospital cardiopulmonary arrest.High-fidelity simulation of resuscitation with continuous audiovisual feedback.Objective data was collected using accelerometer-based measurements from a cardiopulmonary resuscitation defibrillator/monitor. After the simulation event but before any debriefing, participants completed self-evaluation forms to assess whether they believed the cardiopulmonary resuscitation performed met the American Heart Association guidelines for chest compression rate, chest compression depth, chest compression fraction, chest compression in target, and duration of preshock pause and postshock pause. An association coefficient (kappa) was calculated to determine degree of agreement between perceived performance and the quantitative performance data that was collected from the CPR defibrillator/monitor. Data from 27 mock codes and 236 participants was analyzed. Average cardiopulmonary resuscitation performance was chest compression rate 106 10 compressions per minute; chest compression depth 2.05 0.6 in; chest compression fraction 74% 10%; chest compression in target 22% 21%; preshock pause 8.6 7.2 seconds; and postshock pause 6.4 8.9 seconds. When all healthcare providers were analyzed, the association coefficient () for chest compression rate ( = 0.078), chest compression depth ( = 0.092), chest compression fraction ( = 0.004), preshock pause ( = 0.321), and postshock pause ( = 0.40) was low, with no variable achieving moderate agreement ( > 0.4).Cardiopulmonary resuscitation performance during mock codes does not meet the American Heart Association's quality recommendations. Healthcare providers have poor insight into the quality of cardiopulmonary resuscitation during mock codes despite access to and familiarity with continuous audiovisual feedback.

View details for DOI 10.1097/PCC.0000000000002058

View details for PubMedID 31232856

View details for Web of Science ID 000529883400032

Abstract

Pediatric in-hospital cardiac arrest cardiopulmonary resuscitation quality metrics have been reported in few children less than 8 years. Our objective was to characterize chest compression fraction, rate, depth, and compliance with 2015 American Heart Association guidelines across multiple pediatric hospitals.Retrospective observational study of data from a multicenter resuscitation quality collaborative from October 2015 to April 2017.Twelve pediatric hospitals across United States, Canada, and Europe.In-hospital cardiac arrest patients (age < 18 yr) with quantitative cardiopulmonary resuscitation data recordings.None.There were 112 events yielding 2,046 evaluable 60-second epochs of cardiopulmonary resuscitation (196,669 chest compression). Event cardiopulmonary resuscitation metric summaries (median [interquartile range]) by age: less than 1 year (38/112): chest compression fraction 0.88 (0.61-0.98), chest compression rate 119/min (110-129), and chest compression depth 2.3cm (1.9-3.0cm); for 1 to less than 8 years (42/112): chest compression fraction 0.94 (0.79-1.00), chest compression rate 117/min (110-124), and chest compression depth 3.8cm (2.9-4.6cm); for 8 to less than 18 years (32/112): chest compression fraction 0.94 (0.85-1.00), chest compression rate 117/min (110-123), chest compression depth 5.5cm (4.0-6.5cm). "Compliance" with guideline targets for 60-second chest compression "epochs" was predefined: chest compression fraction greater than 0.80, chest compression rate 100-120/min, and chest compression depth: greater than or equal to 3.4cm in less than 1 year, greater than or equal to 4.4cm in 1 to less than 8 years, and 4.5 to less than 6.6cm in 8 to less than 18 years. Proportion of less than 1 year, 1 to less than 8 years, and 8 to less than 18 years events with greater than or equal to 60% of 60-second epochs meeting compliance (respectively): chest compression fraction was 53%, 81%, and 78%; chest compression rate was 32%, 50%, and 63%; chest compression depth was 13%, 19%, and 44%. For all events combined, total compliance (meeting all three guideline targets) was 10% (11/112).Across an international pediatric resuscitation collaborative, we characterized the landscape of pediatric in-hospital cardiac arrest chest compression quality metrics and found that they often do not meet 2015 American Heart Association guidelines. Guideline compliance for rate and depth in children less than 18 years is poor, with the greatest difficulty in achieving chest compression depth targets in younger children.

View details for PubMedID 29533355

View details for DOI 10.1097/01.ccm.0000528352.47794.aa

View details for Web of Science ID 000436794300297