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Congratulations to Brenda Law for completing her MSc and successfully defending her Thesis

Approximately 10% of infants will require resuscitation at birth. Resuscitations are performed by nurses, physicians, midwives, and other Health Care Providers (HCPs), and include tasks such as vital signs monitoring and mask ventilation. Rarely, more advanced skills such as endotracheal intubation and chest compressions are needed. Programs such as Neonatal Resuscitation Program (NRP) provides standardized education and algorithms for health care providers (HCPs), outlining the equipment required, the sequence of tasks, and the decision- making process. However, despite education, experience, and algorithms, neonatal resuscitation remains a stressful endeavour prone to human error. Human factors and ergonomics is the study of human-system interactions and may reveal non-technical contributions to human performance. In this thesis, the effect of human factors on the performance of neonatal resuscitation was examined in a number of observational and simulation studies.

First, a review of the literature supports the hypothesis that neonatal resuscitation is affected by physical ergonomics (physical forces, equipment, resuscitation room), cognitive ergonomics (perception, situation awareness, decision-making, training), and organization ergonomics (teamwork, communication). Neonatal resuscitation is further affected by societal, cultural, and legal factors.

Second, in randomized crossover simulation study involving 30 health care providers, we demonstrated that ergonomic equipment organization improved time to completion of a neonatal resuscitation simulation via faster equipment acquisition speed (176±21.6s using an ergonomic equipment box vs. 192.6±20.2s using a standard equipment bag, p<0.0001).

Third, in a pilot observational study, we obtained six eye-tracking recordings in the delivery room, and demonstrated that mobile eye-tracking glasses can be used to examine the visual attention of health care providers performing neonatal resuscitations. Analysis revealed that, during neonatal resuscitation, health care providers have frequent shifts in gaze (saccades, 0.5 per sec) and divided their visual attention between the infant (35%, IQR=8%) and vital signs monitors (33%, IQR=10%).

Fourth, in a randomized simulation study, we used an objective situation awareness measure (Situation Awareness Global Assessment Tool, SAGAT), eye-tracking, and a standardized resuscitation checklist to compare the performance of 30 health care providers when leading a neonatal resuscitation using one of two different vital signs monitor positions. We demonstrated that SAGAT could be adapted for use to evaluate human performance during neonatal resuscitation. However, we did not demonstrate any difference in visual attention, SAGAT scores, or checklist scores between the central or peripheral monitor positions.

Finally, in an observational study of 24 endotracheal intubations in the neonatal intensive care unit, we used eye-tracking glasses to capture the visual attention of intubators and to study verbal communication between team members. Visual attention during intubations differs from visual attention during neonatal resuscitation in the delivery room; during intubations, more visual attention was directed at the infant (median 50%, IQR 39-61%), but saccades were similar. Team communication of both verbal medication orders and vital signs revealed the use of non-standard and potentially ambiguous language.

Using observations in the clinical environment, mobile eye-tracking glasses, and high- fidelity simulation, we examined physical, cognitive, and organizational ergonomic factors during neonatal resuscitations. Better understanding of these non-technical factors might improve resuscitation of newborns, and ultimately improve neonatal outcomes.

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