Introduction: Delivery room (DR) interventions for infants with congenital diaphragmatic hernia (CDH) are not well described. This study sought to describe timing and order of DR interventions and identify system factors impacting CDH DR resuscitations using a human factors framework. Methods: This was a single-center observational study of video-recorded CDH DR resuscitations documenting timing and order of interventions. The team used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify system factors impacting DR resuscitations and time to invasive ventilation. Results: We analyzed 31 video-recorded CDH resuscitations. We observed variability in timing and order of resuscitation tasks. The “Internal Environment” and “Tasks” components of the SEIPS model were prominent factors affecting resuscitation efficiency; significant room and bed spatial constraints exist, and nurses have a significant task burden. Additionally, endotracheal tube preparation was a prominent barrier to timely invasive ventilation. Conclusion: Video review revealed variation in event timing and order during CDH resuscitations. Standardization of the room setup, equipment, and event order and reallocation of tasks facilitate more efficient intubation and ventilation, representing targets for CDH DR improvement initiatives. This work emphasizes the utility of rigorous human factors review to identify areas for improvement during DR resuscitation.

1.
Shanmugam
H
,
Brunelli
L
,
Botto
LD
,
Krikov
S
,
Feldkamp
ML
.
Epidemiology and prognosis of congenital diaphragmatic hernia: a population-based cohort study in Utah
.
Birth Defects Res
.
2017
;
109
(
18
):
1451
9
.
2.
Lally
KP
.
Congenital diaphragmatic hernia: the past 25 (or so) years
.
J Pediatr Surg
.
2016
;
51
(
5
):
695
8
.
3.
Congenital Diaphragmatic Hernia Study Group
;
Lally
KP
,
Lally
PA
,
Lasky
RE
,
Tibboel
D
,
Jaksic
T
, et al
.
Defect size determines survival in infants with congenital diaphragmatic hernia
.
Pediatrics
.
2007
;
120
(
3
):
e651
e657
.
4.
Kardon
G
,
Ackerman
KG
,
Mcculley
DJ
,
Shen
Y
,
Wynn
J
,
Shang
L
, et al
.
Congenital diaphragmatic hernias: from genes to mechanisms to therapies
.
Dis Model Mech
.
2017
;
10
(
8
):
955
70
.
5.
Skari
H
,
Bjornland
K
,
Haugen
G
,
Egeland
T
,
Emblem
R
.
Congenital diaphragmatic hernia: a meta-analysis of mortality factors
.
J Pediatr Surg
.
2000
;
35
(
8
):
1187
97
.
6.
Schultz
CM
,
Digeronimo
RJ
,
Yoder
BA
;
Congenital Diaphragmatic Hernia Study Group
.
Congenital diaphragmatic hernia: a simplified postnatal predictor of outcome
.
J Pediatr Surg
.
2007
;
42
(
3
):
510
6
.
7.
Salas
AA
,
Bhat
R
,
Dabrowska
K
,
Leadford
A
,
Anderson
S
,
Harmon
CM
, et al
.
The value of Pa(CO2) in relation to outcome in congenital diaphragmatic hernia
.
Am J Perinatol
.
2014
;
31
(
11
):
939
46
.
8.
Khmour
AY
,
Konduri
GG
,
Sato
TT
,
Uhing
MR
,
Basir
MA
.
Role of admission gas exchange measurement in predicting congenital diaphragmatic hernia survival in the era of gentle ventilation
.
J Pediatr Surg
.
2014
;
49
(
8
):
1197
201
.
9.
Abbas
PI
,
Cass
DL
,
Olutoye
OO
,
Zamora
IJ
,
Akinkuotu
AC
,
Sheikh
F
, et al
.
Persistent hypercarbia after resuscitation is associated with increased mortality in congenital diaphragmatic hernia patients
.
J Pediatr Surg
.
2015
;
50
(
5
):
739
43
.
10.
International Ergonomics Association
.
Definition and domains of ergonomics
. www.iea.cc (Accessed September 23, 2019).
11.
Holden
RJ
,
Carayon
P
,
Gurses
AP
,
Hoonakker
P
,
Hundt
AS
,
Ozok
AA
, et al
.
Seips 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients
.
Ergonomics
.
2013
;
56
(
11
):
1669
86
.
12.
DeKoninck
P
,
Gratacos
E
,
Van Mieghem
T
,
Richter
J
,
Lewi
P
,
Ancel
AM
, et al
.
Results of Fetal Endoscopic Tracheal Occlusion for congenital diaphragmatic hernia and the set up of the randomized controlled TOTAL trial
.
Early Hum Dev
.
2011
;
87
(
9
):
619
24
.
13.
Gien
J
,
Palmer
C
,
Liechty
K
,
Kinsella
JP
.
Early abnormalities in gas exchange in infants with congenital diaphragmatic hernia
.
J Pediatr
.
2022
;
243
:
188
92
.
14.
Foglia
EE
,
Ades
A
,
Hedrick
HL
,
Rintoul
N
,
Munson
DA
,
Moldenhauer
J
, et al
.
Initiating resuscitation before umbilical cord clamping in infants with congenital diaphragmatic hernia: a pilot feasibility trial
.
Arch Dis Child Fetal Neonatal Ed
.
2020
;
105
(
3
):
322
6
.
15.
O’Rourke-Potocki
A
,
Ali
K
,
Murthy
V
,
Milner
A
,
Greenough
A
.
Resuscitation of infants with congenital diaphragmatic hernia
.
Arch Dis Child Fetal Neonatal Ed
.
2017
;
102
(
4
):
F320
3
.
16.
Te Pas
AB
,
Kamlin
CO
,
Dawson
JA
,
O'Donnell
C
,
Sokol
J
,
Stewart
M
, et al
.
Ventilation and spontaneous breathing at birth of infants with congenital diaphragmatic hernia
.
J Pediatr
.
2009
;
154
(
3
):
369
73
.
17.
Fishman
CE
,
Weinberg
DD
,
Murray
A
,
Foglia
EE
.
Accuracy of real-time delivery room resuscitation documentation
.
Arch Dis Child Fetal Neonatal Ed
.
2020
;
105
(
2
):
222
4
.
18.
Avila-Alvarez
A
,
Davis
PG
,
Kamlin
CO
,
Thio
M
.
Documentation during neonatal resuscitation: a systematic review
.
Arch Dis Child Fetal Neonatal Ed
.
2021
;
106
(
4
):
376
80
.
19.
Carayon
P
,
Hundt
AS
,
Alvarado
CJ
,
Springman
S
,
Borgsdorf
A
,
Jenkins
L
.
Implementing a systems engineering intervention for improving safety in outpatient surgeries
. In:
Henriksen
K
,
Battles
J
,
Marks
E
,
Lewin
D
, editors.
Advances in patient safety: from research to implementation (volume 3: implementation issues)
.
Rockville (MD)
:
Agency for Healthcare Research and Quality (US)
;
2005
.
20.
Kolodzey
L
,
Trbovich
P
,
Kashfi
A
,
Grantcharov
TP
.
System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety
.
Ann Surg
.
2020
;
272
(
6
):
1164
70
.
21.
Gurses
AP
,
Kim
G
,
Martinez
EA
,
Marsteller
J
,
Bauer
L
,
Lubomski
LH
, et al
.
Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study
.
BMJ Qual Saf
.
2012
;
21
(
10
):
810
8
.
22.
Martinez
EA
,
Thompson
DA
,
Errett
NA
,
Kim
GR
,
Bauer
L
,
Lubomski
LH
, et al
.
Review article: high stakes and high risk: a focused qualitative review of hazards during cardiac surgery
.
Anesth Analg
.
2011
;
112
(
5
):
1061
74
.
23.
Wiegmann
DA
,
Eggman
AA
,
ElBardissi
AW
,
Parker
SH
,
Sundt
TM
.
Improving cardiac surgical care: a work systems approach
.
Appl Ergon
.
2010
;
41
(
5
):
701
12
.
24.
Boet
S
,
Burns
JK
,
Brehaut
J
,
Britton
M
,
Grantcharov
T
,
Grimshaw
J
, et al
.
Analyzing interprofessional teamwork in the operating room: an exploratory observational study using conventional and alternative approaches
.
J Interprof Care
.
2023
;
37
(
5
):
715
24
.
25.
Lane-Fall
MB
,
Koilor
CB
,
Givan
K
,
Klaiman
T
,
Barg
FK
.
Patient- and team-level characteristics associated with handoff protocol fidelity in a hybrid implementation study: results from a qualitative comparative analysis
.
Jt Comm J Qual Patient Saf
.
2023
;
49
(
8
):
356
64
.
26.
Reuland
C
,
Shi
G
,
Deatras
M
,
Ang
M
,
Evangelista
PPG
,
Shilkofski
N
.
A qualitative study of barriers and facilitators to Pediatric Early Warning Score (PEWS) implementation in a resource-limited setting
.
Front Pediatr
.
2023
;
11
:
1127752
.
27.
Berman
L
,
Kavalier
M
,
Gelana
B
,
Tesfaw
G
,
Siraj
D
,
Shirley
D
, et al
.
Utilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia
.
PLoS One
.
2021
;
16
(
10
):
e0258662
.
28.
Chui
MA
,
Mott
DA
,
Maxwell
L
.
A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach
.
Res Soc Adm Pharm
.
2012
;
8
(
3
):
206
16
.
29.
Robertson
SK
,
Manson
K
,
Fioratou
E
.
IMCI and ETAT integration at a primary healthcare facility in Malawi: a human factors approach
.
BMC Health Serv Res
.
2018
;
18
(
1
):
1014
.
30.
Herrick
HM
,
Lorch
S
,
Hsu
JY
,
Catchpole
K
,
Foglia
EE
.
Impact of flow disruptions in the delivery room
.
Resuscitation
.
2020
;
150
:
29
35
.
31.
van den Hout
L
,
Schaible
T
,
Cohen-Overbeek
TE
,
Hop
W
,
Siemer
J
,
van de Ven
K
, et al
.
Actual outcome in infants with congenital diaphragmatic hernia: the role of a standardized postnatal treatment protocol
.
Fetal Diagn Ther
.
2011
;
29
(
1
):
55
63
.
32.
Yang
MJ
,
Fenton
S
,
Russell
K
,
Yost
CC
,
Yoder
BA
.
Left-sided congenital diaphragmatic hernia: can we improve survival while decreasing ECMO
.
J Perinatol
.
2020
;
40
(
6
):
935
42
.
33.
Lazar
DA
,
Cass
DL
,
Rodriguez
MA
,
Hassan
SF
,
Cassady
CI
,
Johnson
YR
, et al
.
Impact of prenatal evaluation and protocol-based perinatal management on congenital diaphragmatic hernia outcomes
.
J Pediatr Surg
.
2011
;
46
(
5
):
808
13
.
34.
Jancelewicz
T
,
Brindle
ME
,
Guner
YS
,
Lally
PA
,
Lally
KP
,
Harting
MT
, et al
.
Toward standardized management of congenital diaphragmatic hernia: an analysis of practice guidelines
.
J Surg Res
.
2019
;
243
:
229
35
.
35.
Puligandla
PS
,
Skarsgard
ED
.
The canadian pediatric surgery network congenital diaphragmatic hernia evidence review project: developing national guidelines for care
.
Paediatr Child Health
.
2016
;
21
(
4
):
183
6
.
36.
Reynolds
R
,
Pilcher
J
,
Ring
A
,
Johnson
R
,
McKinley
P
.
The golden hour: care of the lbw infant during the first hour of life one unit’s experience
.
Neonatal Netw
.
2009
;
28
(
4
):
211
58
.
37.
Kusuda
S
,
Hirano
S
,
Nakamura
T
.
Creating experiences from active treatment towards extremely preterm infants born at less than 25 weeks in Japan
.
Semin Perinatol
.
2022
;
46
(
1
):
151537
.
38.
Pavlek
LR
,
Mueller
C
,
Jebbia
MR
,
Kielt
MJ
,
Nelin
LD
,
Shepherd
EG
, et al
.
Perspectives on developing and sustaining a small baby program
.
Semin Perinatol
.
2022
;
46
(
2
):
151548
.
39.
Dagle
JM
,
Rysavy
MA
,
Hunter
SK
,
Colaizy
TT
,
Elgin
TG
,
Giesinger
RE
, et al
.
Cardiorespiratory management of infants born at 22 weeks’ gestation: the Iowa approach
.
Semin Perinatol
.
2022
;
46
(
1
):
151545
.
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