Neonatal resuscitations are challenging to any mixed ED with rotating medical staff. Covid-19 decimated nursing numbers and reduced training to a standstill. New doctors and nurses find pediatric resuscitations (simulations and in real cases) challenging as there are complex algorithms/calculations as well as preparing and operating systems such as a Drager ResuscitaireR.

Training rotating or new staff for rare complex resuscitations can be time and resource consuming with little yield.

We describe our experience of applying incremental measures after almost every simulation to improve team performance and knowledge.

This is an ongoing audit of simulations and cases for neonatal / infant resuscitations using our pediatric bay and Drager ResuscitaireR system. Our main aim was to improve:

1. Nursing preparation time / competence for:

- Pediatric / neonatal drug doses

- Drager ResuscitaireR system setup

2. Medical staff competence for:

- Neonatal resuscitation algorithms

- Drager ResuscitaireR usage (PPV/Ventilator setup)

Two ED consultants ran “in-situ” simulations and recorded gaps/errors (including feedback in debrief). Any measures deemed fixable were implemented ASAP. Improvement was made if error was not repeated in subsequent two independent simulations.

Audits of five real cases and fifteen simulations revealed gaps (e.g. dose miscalculations, equipment unfamiliarity) which were corrected by simple measures after each discovery. These include:

1. Neonatal resuscitation checklist with steps to setup the Resuscitaire

2. Weight-based resuscitation cards / pre-made packs of equipment instead of manual calculations

3. Position markers for "ideal" ResuscitaireR ventilator settings

4. Step by step ResuscitaireR numbered markers on machine

We found improvements in knowledge gaps, task accomplishment rates, staff satisfaction, appreciation of deficits and in-situ simulation uptake. More gaps are found and resolved at every simulation.

A Human Factors approach with incremental adjustments and simple improvements with each simulation led to better team task accomplishment in complex preparation and resuscitation.