Development and implementation of educational modules on management of neonates with critical congenital heart disease in the delivery room (LEARN-CHD)

Development and implementation of educational modules on management of neonates with critical congenital heart disease in the delivery room (LEARN-CHD) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Development and implementation of educational modules on management of neonates with critical congenital heart disease in the delivery room (LEARN-CHD) Noorjahan Ali, Brenda Law, Alyssa Thomas, Philip Levy, Ruby Gupta, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8058742/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Neonates with congenital heart disease may require delivery room interventions beyond standard care. Because existing guidelines and educational programs rarely address these needs, we developed and evaluated targeted educational modules. Methods Teams were randomized to online eLearning modules or directed readings. Individual pre-/post-knowledge scores were compared. Team performance was tested in simulated delivery scenarios including abruption, hypoplastic left heart syndrome, d-transposition of great arteries and congenital complete heart block. Results 32 teams from 9 centers participated. The module group had improved knowledge scores (mean change 6% vs -0.3% e-Learning group, p = 0.01). Simulation performance was similar between groups except for hypoplastic left heart syndrome, where module groups scored lower, performing less bag-mask ventilation before intubation (82% vs 88%, p < 0.05). Conclusion eLearning modules were well-accepted and improved knowledge scores. Simulation performance was similar between groups. Ongoing educational development of CCHD DR adaptations and their incorporation within standard NRP is required. Health sciences/Health care/Paediatrics Health sciences/Health care/Health services Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Annually, ~ 10,000 infants are born in the US with critical congenital heart disease (CCHD), and are at risk for hemodynamic instability, needing early intervention. 1 Despite advances in prenatal imaging, these infants remain at risk for perinatal morbidity and mortality. 2 Optimal delivery room (DR) stabilization is therefore essential, as low 5-minute Apgar scores predict worse preoperative and overall outcomes. 3 – 4 International guidelines and educational programs such as the Neonatal Resuscitation Program (NRP) emphasize respiratory transition in delivery room care. 5 , 6 However, infants with CCHD may require additional physiology-specific modifications, such as adjusted oxygen and heart rate targets, hemodynamic assessment, medication use, and other tailored interventions. 7 – 11 At the time of this study, NRP lacked guidance for DR management of neonates with CCHD. Consequently, healthcare professionals (HCPs) rely on personal experience, institutional protocols, or literature, potentially resulting in practice variability and suboptimal resuscitation. This problem is further exacerbated when infants with CCHD are not antenatally diagnosed or are delivered outside of tertiary centers due to preterm delivery, inequities in prenatal care, and geographic factors. Thus, CCHD-specific DR resuscitation guidance must be accessible, standardized, and easily applied in diverse practice settings. To address this educational gap, accessible, online video eLearning modules on CCHD management (CHD-eL) were created to supplement current NRP education. To assess the efficacy of these modules, a multi-centered randomized study was performed comparing neonatal HCPs exposed to either directed CCHD readings (CHD-dr group, control group) or CCHD eLearning modules (CHD-eL group, experimental group) using pre- and post-exposure knowledge testing and post-exposure team-based simulations as performance metrics. It was hypothesized that eLearning modules would be acceptable to participants, result in higher post-exposure knowledge scores, and improve team performance in simulated resuscitations as evidenced by improved overall resuscitation checklist scores and lower incidence of critical errors. The secondary aim was to elucidate common errors and practice variations in the DR resuscitation of three representative CCHDs: hypoplastic left heart syndrome (HLHS), d-transposition of the great arteries with intact ventricular septum (d-TGA IVS), and congenital complete heart block (CCHB). METHODS This was a multi-centered educational intervention study with simulation-based evaluation. The detailed study protocol is published. 12 The study was approved by the UT Southwestern Institutional Review Board (STU 2021 − 0457). Participation was voluntary and informed consent was obtained after the study was explained to all participants. The study flow diagram is shown in Fig. 1 . Participants, Simulation Teams, and Randomization NRP-trained HCPs involved in delivery room resuscitations —including physicians, fellows, residents, APPs (advanced practice providers such as neonatal nurse practitioners and physician assistants), registered nurses (RNs), and registered respiratory therapists (RRTs)—were eligible to participate with informed consent. Site-based, three HCP teams were formed, each led by a physician or APP and supported by two members (RN/RRT), reflecting common team compositions. Demographic and baseline resuscitation experience surveys were collected. Teams were randomized to either the CHD-eL group or CHD-dr group. Participants individually completed a pre-intervention knowledge test and then received their assigned educational materials one week prior to simulation evaluation. Educational Interventions For the CHD-eL group, four eLearning modules were presented as narrated videos addressing DR resuscitation of neonates with CCHD. Three cardiac lesions (TGA-IVS, HLHS, and CCHB) were chosen to represent CHDs with distinct differences in physiology-specific assessments and interventions required in the DR. The eLearning modules’ educational content was developed using peer-reviewed literature and expert opinion of the research team, a group encompassing a cross section of 10 North American NICUs. Both eLearning modules and selected articles were peer-reviewed within the research team for content and educational format. eLearning modules focused on clinically relevant, lesion-specific information centered on transitional physiology, with implications for clinical care through adherence and/or adaptations to the NRP algorithm. (Table 1 ) For the CHD-dr group, participants received links to peer-reviewed articles addressing the same lesions and containing the same overall information. Articles were identified using common search terms in accessible medical databases, suggested by peers who attend deliveries. Articles were approved by a group of clinicians representing a cross section of North American NICUs. 13 – 15 The estimated time needed to review four eLearning modules or to read three articles was the same (1.5-2 hours). Table 1 Educational Delivery and Simulation Testing eLearning Module or Directed Reading And Simulated Delivery Room (DR) Testing Scenario E Module Learning Objectives Simulated DR Testing Scenario Components (In addition to teamwork, skills, tasks and communication) Critical action indicators assessed in Simulated DR scenario (In addition to standard NRP, PPV and MRSOPA) eLearning Module : Fetal to neonatal circulation transition Directed Reading NRP Textbook DR Simulation : Abruption Scenario (Standard NRP Scenario for Team Baseline Performance) Understand fetal and neonatal circulation Describe changes in circulation at birth Outline normal newborn circulation Demonstrate Standard NRP preparation, knowledge and algorithm performance Recognize and respond to secondary apnea and persistent bradycardia Require initial NRP assess & stabilize, PPV, MRSOPA, CPR, intubation, IV/UVC, epinephrine, fluid for unstable infant with DR significant abruption Plans specific to abruption including no delayed cord clamping Optimizes mask ventilation with corrective steps Performs good quality chest compressions without delay Obtains IV access Provides bolus epi per NRP Provides bolus fluids per NRP eLearning Module : Hypoplastic Left Heart Syndrome (HLHS) Directed Reading Pruetz JD.Delivery room emergencies in critical congenital heart diseases. Semin Fetal Neonatal Med. 2019 Dec;24(6):101034. DR Simulation : HLHS Scenario Single ventricle lesions and physiology Importance of atrial- level and ductus arteriosus shunts in single ventricle management Modification in DR targeted oxygen saturation goals for single ventricle neonates Oxygen titration in single ventricle Role of prostaglandin and side effects Additional questions, preparation, knowledge, management for HLHS in DR Integration of standard NRP for HLHS DR stabilization Recognize modification in goal targeted saturations Need for venous access and prostaglandin Cognisant of prostin- induced apnea with need for PPV, MRSOPA and ventilation support Discusses plan specific: HLHS Recognize need for prostaglandin Saturation goals 75–85% Avoids excess oxygen Recognize apnea associated with prostaglandin Utilize MRSOPA and provide adequate PPV prior to intubation eLearning Module : D-Transposition of the Great Arteries (TGA) Directed Reading Wernovsky G. Transposition of the Great Arteries and Common Variants. Pediatr Crit Care Med. 2016;17 (8,S1):S337-43. Testing Simulation : TGA with intact ventricular septum (IVS) and restrictive atrial septum (RAS) TGA physiology in fetal and neonatal circulation Importance of unrestricted atrial septum and patent ductus arteriosus in fetal-neonatal transition Modification in DR TGA targeted oxygen saturation goals and oxygen titration Recognize hemodynamic compromise DR management of TGA IVS + RAS including recognition for emergent BAS services if unstable High-risk fetal elements (IVS and RAS) indicate need for additional preparation, knowledge, management for TGA in DR Initial NRP stabilization for respiratory distress and hypoxia TGA oxygen saturation goals and oxygen titration Need for intubation, lines and medications for clinical decompensation (hypoxia + hemodynamic) from inadequate intracardiac mixing. Decompensates and needs BAS Discusses plan specific to TGA-IVS Recognizes need for prostaglandin Saturation goals 75–85% Recognize no oxygen restrictions Recognize need to reduce metabolic demand (intubate, sedate, paralyze) Interventions to increase intracardiac mixing (NS bolus, higher PGE, iNO) Recognize the need for emergent BAS as critical intervention eLearning Module : Congenital Complete (Third Degree) Heart Block Directed Reading Jaeggi E. Fetal and Neonatal Arrhythmias. Clin Perinatol.2016;43 (1) :99–112. Testing Simulation : Unstable Congenital Complete Heart Block (CCHB) CCHB etiology and physiology Importance of fetal clinical information to predict instability risk Need for additional equipment, medications, and expertise Recognition of hemodynamic compromise in NRP when HR targets affected by CCHB Outline DR management of CCHB for stable and unstable patients Fetal HR indicates need for monitoring medications, equipment, skills and alternate HR targets in addition to standard NRP Standard NRP for stabilization including PPV and MRSOPA Escalate interventions and monitoring as perfusion, pulses or BP changes from stable to unstable with unchanged HR Venous access for chronotropic med Anticipation for intubation to decrease metabolic demand Possible external pacing if chronotropes do not stabilize Discusses plan specific to CCHB Recognizes that lower heart rate tolerated if hemodynamics stable and need additional measures to assess hemodynamic stability Optimizes ventilation prior to CCHB measures Initiates chronotropic med infusion with signs of some instability (or external pacing) Does not do CPR or bolus epi for low HR Considers intubation, decreasing metabolic demand or external pacing as next steps if needed Individual Assessment and Feedback: Pre-post Knowledge Testing and Acceptability Survey Participants completed an 18-item pre-intervention test assessing knowledge of CCHD physiology, NRP algorithm, and CCHD-specific adaptations. Questions were developed by experts with multiple choice question design experience. Following the educational intervention and prior to simulation testing, the same test was administered again to evaluate change in individual knowledge. Those in the eLearning group also completed a survey on eLearning modules’ acceptability and implementation barriers. 16 Team-based Simulation Performance: Simulation Scenarios and Environment Simulations were conducted in site-specific clinical or simulation spaces using available manikins, vital sign displays, and medical equipment. Minimum fidelity requirements included vital sign monitoring and a manikin capable of intubation and UVC placement. Teams were oriented to the environment and operated as they would during actual resuscitations at their institutions. Four scenarios were simulated. (Table 1 ) All sessions were video recorded for centralized analysis. Teams were debriefed between each scenario. However, CCHD-specific questions and discussion were deferred until completion of all simulation scenarios and surveys, at which time participants had a summative debriefing session in which all CCHD questions could be answered by the facilitator. Data Analysis Pre- and post-intervention knowledge testing and surveys were conducted via REDCap (Research Electronic Data Capture). Video recordings of simulations (excluding debriefings) were analyzed by a team of 4 investigators from 3 institutions. Reviewers analyzed all videos in independent pairs to score team performance using pre-determined scenario-specific checklists modified from an NRP adherence checklist. 17 , 18 Scenario-specific checklists were developed using NRP algorithms, expert consensus, and relevant literature, then refined through pilot video review feedback. 8 , 13 , 15 , 18 Prior to video scoring, reviewers standardized their understanding of the checklists and ratings scales using study pilot scenario videos and discussed until consensus was achieved. Each checklist item was scored as: 0 (not performed), 1 (incomplete or incorrect sequence), or 2 (competent and correctly sequenced). Major scoring discrepancies were resolved via consensus. Final scores included: (1) raw scores by reviewer pairs, (2) averaged raw scores, and (3) percentage of maximum score. Intervention timing and descriptive notes on actions and errors were recorded for thematic analysis. Statistical Analysis and Sample Size Statistical analysis was completed on an intention-to-treat basis. Data are presented as mean (standard deviation) if normally distributed and median (interquartile range) if skewed. Student’s t-test was used for normally distributed data and non-parametric tests (Independent Samples Median and Mann-Whitney) test for skewed data. 2-way ANOVA was used to compare both group allocation and reviewer pair scoring to determine if there were major reviewer discrepancies, and to compare the effect of discipline and group assignment to pre/post knowledge test score differences. Fisher’s exact test was used to test proportions. A p-value of < 0.05 was considered significant. A sample of 36 teams was planned. Previously published observational and simulation studies using NRP checklists to evaluate performance demonstrated mean scores of 80–90%, with standard deviation (SD) ranging from 5 to 15%. 19–21 Approximating a mean checklist score of 90%, with a SD of 7.5%, a sample size of 36 teams will detect a 5% difference in checklist scores with a power of 0.8 and an alpha of 0.05. Given the complexity of the scenarios, approximating a lower mean checklist score of 80%, with a SD of 15%, a sample size of 36 teams will detect a 10% difference with a power of 0.8 and an alpha of 0.05. RESULTS Nine tertiary neonatal centers participated (eight in the United States and one in Canada). All centers managed delivery of neonates with CCHD; however, none had pre-existing formalized education programs for DR management of these patients. Centers contributed a minimum of 1 team and a maximum of 5, with most contributing at least 2 teams. In total, 104 participants were grouped into 32 teams, including 14 neonatologists, 17 neonatal fellows, 3 senior pediatric residents, 16 NNP/ APPs, 33 RNs, and 21 RRTs. (Table 2 ) The study ran from October 2022 to October 2023 and was terminated prior to recruitment of planned sample size due to difficulty with ongoing recruitment. Table 2 – Demographics Total Articles N (% of total) Modules N (% of total) Number of Participating Sites 9 Number of Teams 32 14 (44) 18 (56) Number of Participants 104 47 (45) 57 (55) Total Articles N (% of group allocation) Modules N (% of group allocation) Participant’s discipline RT 21 10 (21) 11 (19) RN 33 17 (36) 16 (28) APP 16 8 (17) 8 (14) NICU fellow 17 7 (15) 10 (18) Neonatologist 14 5 (11) 9 (16) Pediatric Resident 3 0(0) 3 (5) Resuscitation training and experience NRP certified 104 47 (100) 57 (100) Most recent NRP within last 2 years 101 45 (96) 56 (98) Participated in delivery room resuscitation 99 43 (92) 56 (98) Participated in NICU resuscitation 101 45 (96) 56 (98) Completed cardiac stable course 22 10 (21) 12 (21) Attended CCHD deliveries 90 42 (89) 48 (84) Participated in CCHD DR resuscitation 81 38 (81) 43 (75) Participated in CCHD DR simulation 35 15 (32) 20 (35) Pre/Post Knowledge Test 96% of the pre-intervention and 86% of the post-intervention knowledge tests were completed. Incomplete tests were 2 in each group for pre-intervention and four CHD-dr group and eight CHD-eL group post-intervention. Pre-knowledge test scores were similar between groups (mean CDH-dr 61% [SD 13.8] vs CHD-eL group 58% [SD 12.4], p = 0.22). 81% of participants had matched pre- and post-intervention knowledge tests and were analyzed. HCPs in the CHD-eL group demonstrated more improvement in knowledge test scores after the education compared to those in the CHD-dr group (mean improvement 6% vs -0.3%, p < 0.05) Fig. 2 a. Both groups (CHD-dr group vs CHD-eL group) and participant discipline (neonatologist or APP, neonatal fellow, RN, or RRT) had a statistically significant effect on change in post-test scores (p < 0.05 for group assignment and p = 0.05 for discipline). All disciplines had more improvement in post-intervention scores in the eLearning group compared to the control group, but the difference in mean percent change in test scores between groups was most prominent among nurses (CHD-eL group: 11.5% [SD11.7] vs CHD-dr group: 3.85% [SD12.3], p = 0.11) and respiratory therapists (CHD-eL group: 6.8% [SD14.1] vs CHD-dr group: -7.6% [SD11.1], p < 0.05) compared with neonatal prescribers (neonatologists, APPs and fellows) (CHD-eL group: 2.1% [SD10.0] vs CHD-dr group: 0% [SD7.1], p = 0.5). (Fig. 2 b.) RRTs benefited the most from any education; when compared with prescribers, RRTs had a statistically higher mean improvement (mean difference 6.8%, 95% CI 0.26 versus 13.3, p < 0.05). (Fig. 2 .) Module Acceptability In the CHD-eL group, 39 participants (68.4%) completed the acceptability survey. Most (89.7%) agreed that a structured DR approach to CCHD is important, though only 33.3% found their current educational strategy effective. The eLearning module was rated effective for teaching CCHD DR management (92.3%) and superior to traditional training (87.2%). Two-thirds felt the content was accessible without extensive cardiac background, and 97.4% reported confidence in applying the material. All respondents indicated intent to use the education in future practice (Fig. 3 a). Reported barriers to implementation included limited time (31%), resource demands (44%), and insufficient team knowledge (46%). No respondents cited institutional policy, educational prioritization, team engagement, or relevance as barriers (Fig. 3 b) Team-based Simulation Performance Team-based simulation performance is summarized in Table 3 . Overall, technical performance as evaluated by adherence to performance checklists was similar between groups except for the HLHS scenario. Among both CHD-eL group and CHD-dr group, adherence scores were lower for TGA-IVS and CCHB scenarios compared with abruption and HLHS. Table 3 Team Simulation Technical Performance 1 Checklist Adherence Scores – mean (SD) - % total score assessed Scenario Overall CHD-dr group CHD-eL group p-value 2 Abruption 87.3% (7.2) 87.3% (6.9) 87.3% (7.6) 0.976 HLHS 84.8% (8.3) 88.2% (5.6) 82.1% (9.1) 0.003 TGA-IVS 76.9% (10.1) 76.1% (9.2) 77.5% (10.9) 0.578 Heart Block 77.1% (10.9) 76.7% (10.2) 77.4% (11.6) 0.801 Critical Actions 3 Scenario Critical Action Overall CHD-dr group CHD-eL group p-value 4 Abruption Verbalizes No delayed cord clamping? 9/30 4/13 5/17 1 Optimize mask ventilation with corrective steps? 26/32 13/14 15/18 0.613 Performs good quality chest compressions without delay? 26/32 12/14 14/18 0.672 Obtains IV access? 31/32 14/14 17/18 1 Bolus Epi per NRP algorithm 29/32 12/14 17/18 0.568 Bolus saline per NRP algorithm 26/32 10/14 16/18 0.365 HLHS Recognize need for prostins? 30/32 14/14 16/18 0.492 Recognize 75–85% sats? 30/32 14/14 16/18 0.492 Avoid excess O2? 22/32 11/14 11/18 0.446 Recognize prostin-associated apnea? 27/29 13/13 14/16 0.488 Attempt PPV prior to intubation? 20/32 12/14 8/18 0.028 TGA-IVS with restrictive atrial septum Recognize need for prostin 31/32 14/14 17/18 1 Recognize sat goals 75–85% 23/30 9/13 14/17 0.741 Recognize O2 need not be restricted 23/32 10/13 13/18 1 Attempt interventions to reduce metabolic demand 10/32 1/14 9/18 0.032 Attempt medical interventions to increase mixing 17/32 8/14 9/18 0.735 Recognize the need for emergent balloon atrial septostomy 19/32 10/14 9/18 0.289 Congenital Complete Heart Block Optimize ventilation prior to CHB-specific management? 14/32 6/14 8/18 1 Discuss plans specific to CHB? 23/30 8/13 15/17 0.190 Hemodynamic assessment other than Heart rate? 29/32 12/14 17/18 0.568 Isoproterenol or epinephrine infusion as initial treatment? 15/32 6/14 9/18 0.735 Consults cardiology? 26/32 10/14 16/18 0.365 Does NOT perform chest compressions 25/32 10/14 15/18 0.6689 Does NOT give bolus epinephrine? 17/31 9/14 8/17 0.473 Acknowledges pacing might be needed? 22/32 10/14 12/17 1 1 Results reported as mean (SD) or n/total assessable 2 2-way ANOVA by group allocation and reviewer (no difference in reviewer or interactions – not shown) 3 Some outcomes could not be assessed from simulation recordings 4 Fisher’s Exact test used for comparing proportions In the abruption scenario, team checklist scores were similar between intervention groups and adherence to NRP was high. Most teams progressed stepwise through the NRP algorithm by optimizing mask ventilation (81%), performing good quality chest compressions (81%), obtaining vascular access (97%), delivering bolus epinephrine (91%), and finally delivering saline bolus (81%). However, over 60% of teams did not specify that delayed cord clamping (DCC) is contraindicated in placental abruption. In the HLHS scenario, there was a statistically significant difference in adherence score (88.2% in the CHD-dr group vs 82.1% in the CHD-eL group, p < 0.05. This difference is due to teams in the CHD-dr group attempting PPV more often prior to proceeding to intubation in the setting of apnea occurring after prostaglandin (PGE) initiation (85.7% vs 44.4%, p < 0.05) The proportion of teams achieving other critical steps was similar (recognizing the need for PGE, setting 75–85% target saturations, avoiding excessive supplemental oxygen, diagnosing PGE-associated apnea). In the dTGA-IVS with restrictive atrial septal defect scenario, overall adherence was similar between groups (76.1% in the CHD-dr group vs 77.5% in the CHD-eL group p > 0.05. Similar proportions of teams in each group recognized the need for PGE, targeted a saturation goal of 75–85%, attempted medical interventions to increase mixing, and recognized the need for emergent balloon atrial septostomy (BAS). However, teams in the CHD-eL group more often performed interventions to reduce metabolic demand, as clinical instability progressed, such as provision of sedation or neuromuscular blockade (1/14 of teams in CHD-dr group, 9/18 of teams in CHD-eL group, p = 0.05). In the CCHB scenario, overall adherence was similar between groups (76.7% in the CHD-dr group vs 77.4% in the CHD-eL group, p = 0.801) However, nearly 20% of both groups incorrectly performed chest compressions for CCHB-associated bradycardia in a hemodynamically stable infant and prior to initiating any CCHB-specific interventions. When faced with a low heart rates and evidence of slowly declining hemodynamic status, nearly 50% of both groups did not utilize isoproterenol or epinephrine infusions as first-line interventions. Other Simulation Observations Practice variations were observed across institutions and teams. Team compositions varied in the presence of physicians, APPs, RRNs, and RTs, with physicians or APPs serving as team leaders. Staffing differences may reflect institutional norms and simulation recruitment. Although NRP recommends umbilical or intraosseous access for resuscitation, some teams opted for peripheral intravenous access. Approaches to CCHB management also differed; some institutions favoring external pacing over pharmacologic interventions. Cardiology consultation practices, medication dosing (e.g., prostaglandins, inotropes), and resuscitation protocols also varied. Activation of transport or external supports occurred pre-delivery at some sites, and post-stabilization at other sites. Despite standardized education, some teams followed internal protocols, intubating CCHD patients immediately rather than adhering to NRP’s stepwise approach following mask ventilation. DISCUSSION This appears to be the first multi-center, multi-disciplinary simulation study evaluating an educational intervention to enhance delivery room resuscitation of newborns with CCHD. The study demonstrated that e-Learning modules focused on CCHD-specific DR management were both highly acceptable across disciplines and superior to directed readings in improving knowledge. Participants consistently reported a lack of existing CCHD-specific DR training and emphasized that structured, lesion-based modules could be incorporated into existing NRP education. While e-Learning modules were superior in improving knowledge tests scores, particularly for nurses and respiratory therapists, the study did not demonstrate improvement in simulation performance. Study findings align with the current NRP educational strategy of reinforcing didactic individual learning (modules and readings) with hands-on practice, simulations, and structured debriefing. 22 – 27 While the modules provided participants with knowledge and mental models for DR resuscitation of CCHD infants in a format that is accessible, simulation remains essential for translating knowledge into practice. In addition to accessibility, effective CCHD DR education must also be standardized, comprehensible, and applicable to HCPs in a variety of practice settings. This is important as not all CCHD are diagnosed prenatally or delivered in specialized centers. Embedding CCHD modules into established platforms (e.g., NRP, AHA) may increase adoption by addressing resource, time, and institutional variability. Finally, sustainable improvements may also require system-level supports such as lesion-specific checklists and cognitive aids. 28 An Integrated Framework: Adapting NRP for CCHD The study identified a need for a pragmatic, DR and lesion-specific CCHD resuscitation framework that NRP-trained HCPs can incorporate into their practice. A recurring challenge for teams was an inability to integrate lesion-specific adaptations with core NRP steps, sometimes fixating on one at the expense of the other. Having knowledge about CCHD lesions alone was insufficient to guide HCPs in the DR; For example, in the HLHS scenario, eLearning-exposed teams often proceeded directly to intubation without adequate mask ventilation, suggesting an overemphasis on invasive airways. This underscores the need to integrate fundamental perinatal transition priorities (stimulation, thermoregulation, mask ventilation) with lesion-specific considerations. This integrated resuscitation framework should also include fundamental DR concepts such as consideration for other causes of neonatal compromise (i.e. sepsis, prematurity, asphyxia, or meconium aspiration). In contrast, despite CCHD knowledge, teams also demonstrated a fixation on deeply ingrained NRP mental models, such as reflexive use of chest compressions for HR < 60 bpm. In the CCHB scenario, many teams initiated compressions despite hemodynamic stability, while others failed to use isoproterenol or similar agents for unstable infants. Encouragingly, more eLearning-exposed teams recognized the role of interventions to reduce metabolic demand (e.g., sedation, neuromuscular blockade) in hemodynamically unstable d-TGA with restricted atrial septum. While insufficient alone to improve overall simulation performance, eLearning focused on an integrated NRP / CCHD framework may ultimately support better decision-making for these infants. Practice Variation and Other Challenges The study revealed key inter-institutional practice variations in DR management of infants with CCHD. Decisions on DCC, vascular access (UVC vs peripheral IV), and chest compression pause intervals (1 vs 2 minutes) varied widely. DCC clarification was often omitted by the team in abruption and CCHD scenarios. This underscores the need for clarification it's role in all deliveries, including CCHD, especially considering emerging data in the CCHD population. 29 , 30 Choice of vascular access appeared institution-specific, influenced by provider expertise, delivery setting, and transport needs. While NRP reserves UVC placement for emergencies, in CCHD stabilization, timely peripheral IV access may suffice for non-emergent medications such as PGE, highlighting the need to revisit current practice frameworks. 5 Finally, variation in CPR pulse and rhythm check intervals reflects the gray zone of applying neonatal versus pediatric resuscitation models in this population. 31–36 Strengths and Limitations Our study included a multicentered cohort of diverse multidisciplinary neonatal resuscitation teams currently practicing across North America. Results thus reflected actual practice variation enhancing the study's generalizability and applicability. Limitations include non-standardized simulation fidelity, which may have influenced performance, and a highly experienced participant cohort, limiting generalizability to less experienced teams or centers with fewer CCHD deliveries. The intervention’s impact may be greater in such settings. CONCLUSIONS CCHD-specific eLearning modules focused on delivery room management were well-received by multidisciplinary neonatal HCPs and led to improved post-intervention knowledge scores. However, simulation performance in CCHD-specific neonatal resuscitation scenarios was similar between groups. The development and implementation of comprehensive, physiology-based educational programs, integrated with team-based simulation practice and systems-level support, will be paramount to improving delivery room care for newborns with CCHD Abbreviations AHA American Heart Association ASD Atrial Septal Defect BAS Balloon Atrial Septostomy CCHD Critical Congenital Heart Disease CHD Congenital Heart Disease CHD eL = eLearning modules on CCHD management CHD dr = directed readings on CCHD management CCHB Congenital Complete Heart Block DCC Delayed Cord Clamping DR Delivery room d TGA IVS–d Transposition of Great Arteries with intact ventricular septum HCP Health Care Providers HLHS Hypoplastic Left Heart Syndrome NICU Neonatal Intensive Care Unit NRP Neonatal Resuscitation Program PALS Pediatric Advanced Life Support PGE Prostaglandin E PIV Peripheral Intravenous access PPV Positive Pressure Ventilation RRT Registered Respiratory Therapist RN Registered Nurse UVC Umbilical Venous Catheter Declarations Conflict of interest : None of the authors have any competing financial interests in relation to the work described. Funding Source: This work was supported by a Canadian NRP Research Grant. The granting agency had no role in the writing of the manuscript or in the decision to submit for publication. Author contribution: All authors have made substantial contributions to all of the following: (1) the conception and design of the manuscript, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. Acknowledgements: The authors would like to acknowledge the time and expertise of simulation consultants and study participants at participating institutions. Ethics The study was approved by the UT Southwestern Institutional Review Board (STU 2021 − 0457). References Oster M, Lee K, Honein M, Colarusso T, Shin M, Correa A. Temporal trends in survival for infants with critical congenital heart defects. Pediatrics . 2013;131(5):e1502-8 Donofrio MT, Levy RJ, Schuette JJ, et al. 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Cheng A, Magid DJ, Auerbach M, et al. Part 6: Resuscitation Education Science: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation . 2020;142(16_suppl_2):S551-S579 Anderson TM, Secrest K, Krein SL, et al Best Practices for Education and Training of Resuscitation Teams for in-Hospital Cardiac Arrest. Circulation. Cardiovascular Quality and Outcomes. 2021;14(12):e008587. Thomas AR, Bowen C, Abdulhayoglu E, Brennick E, Woo K, Everett MF et.al. Structured pre-delivery huddles enhance confidence in managing newborns with critical congenital heart disease in the delivery room. J Perinatol. 2024 Dec 10: 10.1038/s41372-024-02196-8 . Marzec L, Zettler E, Cua CL, Rivera BK, Pasquali S, Katheria A, Backes CH. Timing of umbilical cord clamping among infants with congenital heart disease. Prog Pediatr Cardiol. 2020;59:101318. Fite EL, Rivera BK, McNabb R, Smith CV, Hill KD, Katheria A, Maitre N, Backes CH. Umbilical cord clamping among infants with a prenatal diagnosis of congenital heart disease. Semin Perinatol. 2023;47(4):151747. Halling C, Raymond T, Brown LS, Ades A, Foglia EE, Allen E, Wyckoff MH; American Heart Association’s Get With The Guidelines–Resuscitation Investigators. Neonatal delivery room CPR: An analysis of the Get with the Guidelines®-Resuscitation Registry. Resuscitation . 2021;158:236–242 Ali N, Sawyer T. Special consideration in neonatal resuscitation. Semin Perinatol. 2022;46(6):151626. Ali N, Sawyer T. Beyond the delivery room: Resuscitation in the neonatal intensive care unit. Semin Perinatol . 2024;48(8):151984. Ali N, Lam T, Gray MM, Clausen D, Riley M, Grover TR, Sawyer T. Cardiopulmonary resuscitation in quaternary neonatal intensive care units: a multicenter study. Resuscitation. 2021;159:77–84. Sawyer T, McBride ME, Ades A, Kapadia VS, Leone TA, et.al A. Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants: On Behalf of the American Heart Association Emergency Cardiovascular Care Committee and the American Academy of Pediatrics. Pediatrics. 2024 Ali N, Sawyer T, Barry J, Grover T, Ades A. Resuscitation practices for infants in the NICU, PICU and CICU: results of a national survey. J Perinatol. 2017;37(2):172–176. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 02 Dec, 2025 Review # 2 received at journal 02 Dec, 2025 Reviewer # 2 agreed at journal 01 Dec, 2025 Review # 1 received at journal 12 Nov, 2025 Reviewer # 1 agreed at journal 12 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Submission checks completed at journal 10 Nov, 2025 First submitted to journal 07 Nov, 2025 Editor assigned by journal 07 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8058742","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":543527649,"identity":"05512f95-9216-4ebb-91a8-3cc1bbba53a6","order_by":0,"name":"Noorjahan 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1","display":"","copyAsset":false,"role":"figure","size":335963,"visible":true,"origin":"","legend":"\u003cp\u003eConsort flow diagram. Flow of participants through randomization and analysis.\u003c/p\u003e","description":"","filename":"Figure1LEARNCHD.png","url":"https://assets-eu.researchsquare.com/files/rs-8058742/v1/6464ff1e6efd00b2e4a5a525.png"},{"id":96555802,"identity":"94588551-4b0d-4268-bdbe-245c57db0d40","added_by":"auto","created_at":"2025-11-23 11:40:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":135826,"visible":true,"origin":"","legend":"\u003cp\u003ea – Comparison of pre- and post- intervention knowledge test scores by allocated group.\u003c/p\u003e\n\u003cp\u003eb – Comparison of pre- and post- intervention knowledge test scores across disciplines.\u003c/p\u003e","description":"","filename":"Figure2LEARNCHD.png","url":"https://assets-eu.researchsquare.com/files/rs-8058742/v1/dba1118613ef4262696d886b.png"},{"id":96604342,"identity":"dd84b914-463f-44af-854c-ee967a9debb0","added_by":"auto","created_at":"2025-11-24 09:13:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":267030,"visible":true,"origin":"","legend":"\u003cp\u003ea: Educational module acceptability - participants ratings of modules acceptability and feasibility\u003c/p\u003e\n\u003cp\u003eb: perceived barriers of module acceptability – participants ratings of perceived barriers of modules acceptability\u003c/p\u003e","description":"","filename":"Figure3LEARNCHD.png","url":"https://assets-eu.researchsquare.com/files/rs-8058742/v1/25d452c6c4b36cd214684612.png"},{"id":96913114,"identity":"fb3c6b67-209c-4e15-910e-3b4e11887fbe","added_by":"auto","created_at":"2025-11-27 13:52:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2641046,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8058742/v1/9dcb5ea2-b9d7-4838-8f6b-e9c7b12966e8.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Development and implementation of educational modules on management of neonates with critical congenital heart disease in the delivery room (LEARN-CHD)","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAnnually, ~\u0026thinsp;10,000 infants are born in the US with critical congenital heart disease (CCHD), and are at risk for hemodynamic instability, needing early intervention.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Despite advances in prenatal imaging, these infants remain at risk for perinatal morbidity and mortality.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Optimal delivery room (DR) stabilization is therefore essential, as low 5-minute Apgar scores predict worse preoperative and overall outcomes.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eInternational guidelines and educational programs such as the Neonatal Resuscitation Program (NRP) emphasize respiratory transition in delivery room care.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e However, infants with CCHD may require additional physiology-specific modifications, such as adjusted oxygen and heart rate targets, hemodynamic assessment, medication use, and other tailored interventions.\u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e At the time of this study, NRP lacked guidance for DR management of neonates with CCHD. Consequently, healthcare professionals (HCPs) rely on personal experience, institutional protocols, or literature, potentially resulting in practice variability and suboptimal resuscitation. This problem is further exacerbated when infants with CCHD are not antenatally diagnosed or are delivered outside of tertiary centers due to preterm delivery, inequities in prenatal care, and geographic factors. Thus, CCHD-specific DR resuscitation guidance must be accessible, standardized, and easily applied in diverse practice settings.\u003c/p\u003e\u003cp\u003eTo address this educational gap, accessible, online video eLearning modules on CCHD management (CHD-eL) were created to supplement current NRP education. To assess the efficacy of these modules, a multi-centered randomized study was performed comparing neonatal HCPs exposed to either directed CCHD readings (CHD-dr group, control group) or CCHD eLearning modules (CHD-eL group, experimental group) using pre- and post-exposure knowledge testing and post-exposure team-based simulations as performance metrics. It was hypothesized that eLearning modules would be acceptable to participants, result in higher post-exposure knowledge scores, and improve team performance in simulated resuscitations as evidenced by improved overall resuscitation checklist scores and lower incidence of critical errors. The secondary aim was to elucidate common errors and practice variations in the DR resuscitation of three representative CCHDs: hypoplastic left heart syndrome (HLHS), d-transposition of the great arteries with intact ventricular septum (d-TGA IVS), and congenital complete heart block (CCHB).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis was a multi-centered educational intervention study with simulation-based evaluation. The detailed study protocol is published.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The study was approved by the UT Southwestern Institutional Review Board (STU 2021\u0026thinsp;\u0026minus;\u0026thinsp;0457). Participation was voluntary and informed consent was obtained after the study was explained to all participants. The study flow diagram is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants, Simulation Teams, and Randomization\u003c/h2\u003e\u003cp\u003eNRP-trained HCPs involved in delivery room resuscitations \u0026mdash;including physicians, fellows, residents, APPs (advanced practice providers such as neonatal nurse practitioners and physician assistants), registered nurses (RNs), and registered respiratory therapists (RRTs)\u0026mdash;were eligible to participate with informed consent. Site-based, three HCP teams were formed, each led by a physician or APP and supported by two members (RN/RRT), reflecting common team compositions. Demographic and baseline resuscitation experience surveys were collected. Teams were randomized to either the CHD-eL group or CHD-dr group. Participants individually completed a pre-intervention knowledge test and then received their assigned educational materials one week prior to simulation evaluation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEducational Interventions\u003c/h3\u003e\n\u003cp\u003eFor the CHD-eL group, four eLearning modules were presented as narrated videos addressing DR resuscitation of neonates with CCHD. Three cardiac lesions (TGA-IVS, HLHS, and CCHB) were chosen to represent CHDs with distinct differences in physiology-specific assessments and interventions required in the DR. The eLearning modules\u0026rsquo; educational content was developed using peer-reviewed literature and expert opinion of the research team, a group encompassing a cross section of 10 North American NICUs. Both eLearning modules and selected articles were peer-reviewed within the research team for content and educational format. eLearning modules focused on clinically relevant, lesion-specific information centered on transitional physiology, with implications for clinical care through adherence and/or adaptations to the NRP algorithm. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) For the CHD-dr group, participants received links to peer-reviewed articles addressing the same lesions and containing the same overall information. Articles were identified using common search terms in accessible medical databases, suggested by peers who attend deliveries. Articles were approved by a group of clinicians representing a cross section of North American NICUs.\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The estimated time needed to review four eLearning modules or to read three articles was the same (1.5-2 hours).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEducational Delivery and Simulation Testing\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eeLearning Module or Directed Reading\u003c/p\u003e\u003cp\u003eAnd\u003c/p\u003e\u003cp\u003eSimulated Delivery Room (DR) Testing Scenario\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE Module Learning Objectives\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSimulated DR Testing Scenario Components\u003c/p\u003e\u003cp\u003e(In addition to teamwork, skills, tasks and communication)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCritical action indicators assessed in Simulated DR scenario\u003c/p\u003e\u003cp\u003e(In addition to standard NRP, PPV and MRSOPA)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eeLearning Module\u003c/span\u003e: Fetal to neonatal circulation transition\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDirected Reading\u003c/span\u003e\u003c/p\u003e\u003cp\u003eNRP Textbook\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDR Simulation\u003c/span\u003e: Abruption Scenario\u003c/p\u003e\u003cp\u003e(Standard NRP Scenario for Team Baseline Performance)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnderstand fetal and neonatal circulation\u003c/p\u003e\u003cp\u003eDescribe changes in circulation at birth\u003c/p\u003e\u003cp\u003eOutline normal newborn circulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDemonstrate Standard NRP preparation, knowledge and algorithm performance\u003c/p\u003e\u003cp\u003eRecognize and respond to secondary apnea and persistent bradycardia\u003c/p\u003e\u003cp\u003eRequire initial NRP assess \u0026amp; stabilize, PPV, MRSOPA, CPR, intubation, IV/UVC, epinephrine, fluid for unstable infant with DR significant abruption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePlans specific to abruption including no delayed cord clamping\u003c/p\u003e\u003cp\u003eOptimizes mask ventilation with corrective steps\u003c/p\u003e\u003cp\u003ePerforms good quality chest compressions without delay\u003c/p\u003e\u003cp\u003eObtains IV access\u003c/p\u003e\u003cp\u003eProvides bolus epi per NRP\u003c/p\u003e\u003cp\u003eProvides bolus fluids per NRP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eeLearning Module\u003c/span\u003e:\u003c/p\u003e\u003cp\u003eHypoplastic Left Heart Syndrome (HLHS)\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDirected Reading\u003c/span\u003e\u003c/p\u003e\u003cp\u003ePruetz JD.Delivery room emergencies in critical congenital heart diseases. Semin Fetal Neonatal Med. 2019 Dec;24(6):101034.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDR Simulation\u003c/span\u003e: HLHS Scenario\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle ventricle lesions and physiology\u003c/p\u003e\u003cp\u003eImportance of atrial- level and ductus arteriosus shunts in single ventricle management\u003c/p\u003e\u003cp\u003eModification in DR targeted oxygen saturation goals for single ventricle neonates\u003c/p\u003e\u003cp\u003eOxygen titration in single ventricle\u003c/p\u003e\u003cp\u003eRole of prostaglandin and side effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdditional questions, preparation, knowledge, management for HLHS in DR\u003c/p\u003e\u003cp\u003eIntegration of standard NRP for HLHS DR stabilization\u003c/p\u003e\u003cp\u003eRecognize modification in goal targeted saturations\u003c/p\u003e\u003cp\u003eNeed for venous access and prostaglandin\u003c/p\u003e\u003cp\u003eCognisant of prostin- induced apnea with need for PPV, MRSOPA and ventilation support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiscusses plan specific: HLHS\u003c/p\u003e\u003cp\u003eRecognize need for prostaglandin\u003c/p\u003e\u003cp\u003eSaturation goals 75\u0026ndash;85%\u003c/p\u003e\u003cp\u003eAvoids excess oxygen\u003c/p\u003e\u003cp\u003eRecognize apnea associated with prostaglandin\u003c/p\u003e\u003cp\u003eUtilize MRSOPA and provide adequate PPV prior to intubation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eeLearning Module\u003c/span\u003e:\u003c/p\u003e\u003cp\u003eD-Transposition of the Great Arteries (TGA)\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDirected Reading\u003c/span\u003e\u003c/p\u003e\u003cp\u003eWernovsky G. Transposition of the Great Arteries and Common Variants. Pediatr Crit Care Med. 2016;17 (8,S1):S337-43.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTesting Simulation\u003c/span\u003e: TGA with intact ventricular septum (IVS) and restrictive atrial septum (RAS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTGA physiology in fetal and neonatal circulation\u003c/p\u003e\u003cp\u003eImportance of unrestricted atrial septum and patent ductus arteriosus in fetal-neonatal transition\u003c/p\u003e\u003cp\u003eModification in DR TGA targeted oxygen saturation goals and oxygen titration\u003c/p\u003e\u003cp\u003eRecognize hemodynamic compromise\u003c/p\u003e\u003cp\u003eDR management of TGA IVS\u0026thinsp;+\u0026thinsp;RAS including recognition for emergent BAS services if unstable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh-risk fetal elements (IVS and RAS) indicate need for additional preparation, knowledge, management for TGA in DR\u003c/p\u003e\u003cp\u003eInitial NRP stabilization for respiratory distress and hypoxia\u003c/p\u003e\u003cp\u003eTGA oxygen saturation goals and oxygen titration\u003c/p\u003e\u003cp\u003eNeed for intubation, lines and medications for clinical decompensation (hypoxia\u0026thinsp;+\u0026thinsp;hemodynamic) from inadequate intracardiac mixing.\u003c/p\u003e\u003cp\u003eDecompensates and needs BAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiscusses plan specific to TGA-IVS\u003c/p\u003e\u003cp\u003eRecognizes need for prostaglandin\u003c/p\u003e\u003cp\u003eSaturation goals 75\u0026ndash;85%\u003c/p\u003e\u003cp\u003eRecognize no oxygen restrictions\u003c/p\u003e\u003cp\u003eRecognize need to reduce metabolic demand (intubate, sedate, paralyze)\u003c/p\u003e\u003cp\u003eInterventions to increase intracardiac mixing (NS bolus, higher PGE, iNO)\u003c/p\u003e\u003cp\u003eRecognize the need for emergent BAS as critical intervention\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eeLearning Module\u003c/span\u003e:\u003c/p\u003e\u003cp\u003eCongenital Complete (Third Degree) Heart Block\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDirected Reading\u003c/span\u003e\u003c/p\u003e\u003cp\u003eJaeggi E. Fetal and Neonatal Arrhythmias. Clin Perinatol.2016;43 (1) :99\u0026ndash;112.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTesting Simulation\u003c/span\u003e: Unstable Congenital Complete Heart Block (CCHB)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCCHB etiology and physiology\u003c/p\u003e\u003cp\u003eImportance of fetal clinical information to predict instability risk\u003c/p\u003e\u003cp\u003eNeed for additional equipment, medications, and expertise\u003c/p\u003e\u003cp\u003eRecognition of hemodynamic compromise in NRP when HR targets affected by CCHB\u003c/p\u003e\u003cp\u003eOutline DR management of CCHB for stable and unstable patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFetal HR indicates need for monitoring medications, equipment, skills and alternate HR targets in addition to standard NRP\u003c/p\u003e\u003cp\u003eStandard NRP for stabilization including PPV and MRSOPA\u003c/p\u003e\u003cp\u003eEscalate interventions and monitoring as perfusion, pulses or BP changes from stable to unstable with unchanged HR\u003c/p\u003e\u003cp\u003eVenous access for chronotropic med\u003c/p\u003e\u003cp\u003eAnticipation for intubation to decrease metabolic demand\u003c/p\u003e\u003cp\u003ePossible external pacing if chronotropes do not stabilize\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiscusses plan specific to CCHB\u003c/p\u003e\u003cp\u003eRecognizes that lower heart rate tolerated if hemodynamics stable and need additional measures to assess hemodynamic stability\u003c/p\u003e\u003cp\u003eOptimizes ventilation prior to CCHB measures\u003c/p\u003e\u003cp\u003eInitiates chronotropic med infusion with signs of some instability (or external pacing)\u003c/p\u003e\u003cp\u003eDoes not do CPR or bolus epi for low HR\u003c/p\u003e\u003cp\u003eConsiders intubation, decreasing metabolic demand or external pacing as next steps if needed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eIndividual Assessment and Feedback: Pre-post Knowledge Testing and Acceptability Survey\u003c/h3\u003e\n\u003cp\u003eParticipants completed an 18-item pre-intervention test assessing knowledge of CCHD physiology, NRP algorithm, and CCHD-specific adaptations. Questions were developed by experts with multiple choice question design experience. Following the educational intervention and prior to simulation testing, the same test was administered again to evaluate change in individual knowledge. Those in the eLearning group also completed a survey on eLearning modules\u0026rsquo; acceptability and implementation barriers.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eTeam-based Simulation Performance: Simulation Scenarios and Environment\u003c/h3\u003e\n\u003cp\u003eSimulations were conducted in site-specific clinical or simulation spaces using available manikins, vital sign displays, and medical equipment. Minimum fidelity requirements included vital sign monitoring and a manikin capable of intubation and UVC placement. Teams were oriented to the environment and operated as they would during actual resuscitations at their institutions. Four scenarios were simulated. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) All sessions were video recorded for centralized analysis.\u003c/p\u003e\u003cp\u003eTeams were debriefed between each scenario. However, CCHD-specific questions and discussion were deferred until completion of all simulation scenarios and surveys, at which time participants had a summative debriefing session in which all CCHD questions could be answered by the facilitator.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003ePre- and post-intervention knowledge testing and surveys were conducted via REDCap (Research Electronic Data Capture). Video recordings of simulations (excluding debriefings) were analyzed by a team of 4 investigators from 3 institutions. Reviewers analyzed all videos in independent pairs to score team performance using pre-determined scenario-specific checklists modified from an NRP adherence checklist.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Scenario-specific checklists were developed using NRP algorithms, expert consensus, and relevant literature, then refined through pilot video review feedback.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Prior to video scoring, reviewers standardized their understanding of the checklists and ratings scales using study pilot scenario videos and discussed until consensus was achieved. Each checklist item was scored as: 0 (not performed), 1 (incomplete or incorrect sequence), or 2 (competent and correctly sequenced). Major scoring discrepancies were resolved via consensus. Final scores included: (1) raw scores by reviewer pairs, (2) averaged raw scores, and (3) percentage of maximum score. Intervention timing and descriptive notes on actions and errors were recorded for thematic analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis and Sample Size\u003c/h2\u003e\u003cp\u003eStatistical analysis was completed on an intention-to-treat basis. Data are presented as mean (standard deviation) if normally distributed and median (interquartile range) if skewed. Student\u0026rsquo;s t-test was used for normally distributed data and non-parametric tests (Independent Samples Median and Mann-Whitney) test for skewed data. 2-way ANOVA was used to compare both group allocation and reviewer pair scoring to determine if there were major reviewer discrepancies, and to compare the effect of discipline and group assignment to pre/post knowledge test score differences. Fisher\u0026rsquo;s exact test was used to test proportions. A p-value of \u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e\u003cp\u003eA sample of 36 teams was planned. Previously published observational and simulation studies using NRP checklists to evaluate performance demonstrated mean scores of 80\u0026ndash;90%, with standard deviation (SD) ranging from 5 to 15%.\u003csup\u003e19\u0026ndash;21\u003c/sup\u003e Approximating a mean checklist score of 90%, with a SD of 7.5%, a sample size of 36 teams will detect a 5% difference in checklist scores with a power of 0.8 and an alpha of 0.05. Given the complexity of the scenarios, approximating a lower mean checklist score of 80%, with a SD of 15%, a sample size of 36 teams will detect a 10% difference with a power of 0.8 and an alpha of 0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eNine tertiary neonatal centers participated (eight in the United States and one in Canada). All centers managed delivery of neonates with CCHD; however, none had pre-existing formalized education programs for DR management of these patients. Centers contributed a minimum of 1 team and a maximum of 5, with most contributing at least 2 teams. In total, 104 participants were grouped into 32 teams, including 14 neonatologists, 17 neonatal fellows, 3 senior pediatric residents, 16 NNP/ APPs, 33 RNs, and 21 RRTs. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) The study ran from October 2022 to October 2023 and was terminated prior to recruitment of planned sample size due to difficulty with ongoing recruitment.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u0026ndash; Demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eArticles N (% of total)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModules N (% of total)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Participating Sites\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Teams\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (56)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Participants\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57 (55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eArticles N (% of group allocation)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eModules N (% of group allocation)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipant\u0026rsquo;s discipline\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (19)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRN\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (28)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAPP\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNICU fellow\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (18)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeonatologist\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePediatric Resident\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResuscitation training and experience\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNRP certified\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMost recent NRP within last 2 years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56 (98)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipated in delivery room resuscitation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56 (98)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipated in NICU resuscitation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (96)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56 (98)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCompleted cardiac stable course\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (21)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAttended CCHD deliveries\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (84)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipated in CCHD DR resuscitation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43 (75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipated in CCHD DR simulation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePre/Post Knowledge Test\u003c/h3\u003e\n\u003cp\u003e96% of the pre-intervention and 86% of the post-intervention knowledge tests were completed. Incomplete tests were 2 in each group for pre-intervention and four CHD-dr group and eight CHD-eL group post-intervention. Pre-knowledge test scores were similar between groups (mean CDH-dr 61% [SD 13.8] vs CHD-eL group 58% [SD 12.4], p\u0026thinsp;=\u0026thinsp;0.22). 81% of participants had matched pre- and post-intervention knowledge tests and were analyzed. HCPs in the CHD-eL group demonstrated more improvement in knowledge test scores after the education compared to those in the CHD-dr group (mean improvement 6% vs -0.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003ea. Both groups (CHD-dr group vs CHD-eL group) and participant discipline (neonatologist or APP, neonatal fellow, RN, or RRT) had a statistically significant effect on change in post-test scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for group assignment and p\u0026thinsp;=\u0026thinsp;0.05 for discipline). All disciplines had more improvement in post-intervention scores in the eLearning group compared to the control group, but the difference in mean percent change in test scores between groups was most prominent among nurses (CHD-eL group: 11.5% [SD11.7] vs CHD-dr group: 3.85% [SD12.3], p\u0026thinsp;=\u0026thinsp;0.11) and respiratory therapists (CHD-eL group: 6.8% [SD14.1] vs CHD-dr group: -7.6% [SD11.1], p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared with neonatal prescribers (neonatologists, APPs and fellows) (CHD-eL group: 2.1% [SD10.0] vs CHD-dr group: 0% [SD7.1], p\u0026thinsp;=\u0026thinsp;0.5). (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eb.) RRTs benefited the most from any education; when compared with prescribers, RRTs had a statistically higher mean improvement (mean difference 6.8%, 95% CI 0.26 versus 13.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eModule Acceptability\u003c/h2\u003e\u003cp\u003eIn the CHD-eL group, 39 participants (68.4%) completed the acceptability survey. Most (89.7%) agreed that a structured DR approach to CCHD is important, though only 33.3% found their current educational strategy effective. The eLearning module was rated effective for teaching CCHD DR management (92.3%) and superior to traditional training (87.2%). Two-thirds felt the content was accessible without extensive cardiac background, and 97.4% reported confidence in applying the material. All respondents indicated intent to use the education in future practice (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003ea).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eReported barriers to implementation included limited time (31%), resource demands (44%), and insufficient team knowledge (46%). No respondents cited institutional policy, educational prioritization, team engagement, or relevance as barriers (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eb)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTeam-based Simulation Performance\u003c/h2\u003e\u003cp\u003eTeam-based simulation performance is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Overall, technical performance as evaluated by adherence to performance checklists was similar between groups except for the HLHS scenario. Among both CHD-eL group and CHD-dr group, adherence scores were lower for TGA-IVS and CCHB scenarios compared with abruption and HLHS.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTeam Simulation Technical Performance\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eChecklist Adherence Scores \u0026ndash; mean (SD) - % total score assessed\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eScenario\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCHD-dr group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCHD-eL group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAbruption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.3% (7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.3% (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.3% (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.976\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHLHS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84.8% (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e88.2% (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82.1% (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTGA-IVS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.9% (10.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.1% (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77.5% (10.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.578\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHeart Block\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.1% (10.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.7% (10.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77.4% (11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.801\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCritical Actions\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eScenario\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eCritical Action\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eCHD-dr group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eCHD-eL group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e \u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eAbruption\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVerbalizes No delayed cord clamping?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9/30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOptimize mask ventilation with corrective steps?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.613\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerforms good quality chest compressions without delay?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.672\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObtains IV access?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBolus Epi per NRP algorithm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.568\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBolus saline per NRP algorithm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.365\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eHLHS\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize need for prostins?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.492\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize 75\u0026ndash;85% sats?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.492\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvoid excess O2?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.446\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize prostin-associated apnea?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27/29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14/16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.488\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttempt PPV prior to intubation?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eTGA-IVS with restrictive atrial septum\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize need for prostin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize sat goals 75\u0026ndash;85%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23/30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.741\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize O2 need not be restricted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttempt interventions to reduce metabolic demand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.032\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAttempt medical interventions to increase mixing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.735\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognize the need for emergent balloon atrial septostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.289\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003e\u003cb\u003eCongenital\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eComplete Heart Block\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOptimize ventilation prior to CHB-specific management?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiscuss plans specific to CHB?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23/30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8/13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHemodynamic assessment other than Heart rate?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.568\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIsoproterenol or epinephrine infusion as initial treatment?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.735\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsults cardiology?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.365\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoes NOT perform chest compressions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15/18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6689\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoes NOT give bolus epinephrine?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17/31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.473\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcknowledges pacing might be needed?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22/32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10/14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e1 Results reported as mean (SD) or n/total assessable\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e2 2-way ANOVA by group allocation and reviewer (no difference in reviewer or interactions \u0026ndash; not shown)\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e3 Some outcomes could not be assessed from simulation recordings\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e4 Fisher\u0026rsquo;s Exact test used for comparing proportions\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn the abruption scenario, team checklist scores were similar between intervention groups and adherence to NRP was high. Most teams progressed stepwise through the NRP algorithm by optimizing mask ventilation (81%), performing good quality chest compressions (81%), obtaining vascular access (97%), delivering bolus epinephrine (91%), and finally delivering saline bolus (81%). However, over 60% of teams did not specify that delayed cord clamping (DCC) is contraindicated in placental abruption.\u003c/p\u003e\u003cp\u003eIn the HLHS scenario, there was a statistically significant difference in adherence score (88.2% in the CHD-dr group vs 82.1% in the CHD-eL group, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. This difference is due to teams in the CHD-dr group attempting PPV more often prior to proceeding to intubation in the setting of apnea occurring after prostaglandin (PGE) initiation (85.7% vs 44.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) The proportion of teams achieving other critical steps was similar (recognizing the need for PGE, setting 75\u0026ndash;85% target saturations, avoiding excessive supplemental oxygen, diagnosing PGE-associated apnea).\u003c/p\u003e\u003cp\u003eIn the dTGA-IVS with restrictive atrial septal defect scenario, overall adherence was similar between groups (76.1% in the CHD-dr group vs 77.5% in the CHD-eL group p\u0026thinsp;\u0026gt;\u0026thinsp;0.05. Similar proportions of teams in each group recognized the need for PGE, targeted a saturation goal of 75\u0026ndash;85%, attempted medical interventions to increase mixing, and recognized the need for emergent balloon atrial septostomy (BAS). However, teams in the CHD-eL group more often performed interventions to reduce metabolic demand, as clinical instability progressed, such as provision of sedation or neuromuscular blockade (1/14 of teams in CHD-dr group, 9/18 of teams in CHD-eL group, p\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eIn the CCHB scenario, overall adherence was similar between groups (76.7% in the CHD-dr group vs 77.4% in the CHD-eL group, p\u0026thinsp;=\u0026thinsp;0.801) However, nearly 20% of both groups incorrectly performed chest compressions for CCHB-associated bradycardia in a hemodynamically stable infant and prior to initiating any CCHB-specific interventions. When faced with a low heart rates and evidence of slowly declining hemodynamic status, nearly 50% of both groups did not utilize isoproterenol or epinephrine infusions as first-line interventions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eOther Simulation Observations\u003c/h2\u003e\u003cp\u003ePractice variations were observed across institutions and teams. Team compositions varied in the presence of physicians, APPs, RRNs, and RTs, with physicians or APPs serving as team leaders. Staffing differences may reflect institutional norms and simulation recruitment. Although NRP recommends umbilical or intraosseous access for resuscitation, some teams opted for peripheral intravenous access. Approaches to CCHB management also differed; some institutions favoring external pacing over pharmacologic interventions. Cardiology consultation practices, medication dosing (e.g., prostaglandins, inotropes), and resuscitation protocols also varied. Activation of transport or external supports occurred pre-delivery at some sites, and post-stabilization at other sites. Despite standardized education, some teams followed internal protocols, intubating CCHD patients immediately rather than adhering to NRP\u0026rsquo;s stepwise approach following mask ventilation.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis appears to be the first multi-center, multi-disciplinary simulation study evaluating an educational intervention to enhance delivery room resuscitation of newborns with CCHD. The study demonstrated that e-Learning modules focused on CCHD-specific DR management were both highly acceptable across disciplines and superior to directed readings in improving knowledge. Participants consistently reported a lack of existing CCHD-specific DR training and emphasized that structured, lesion-based modules could be incorporated into existing NRP education.\u003c/p\u003e\u003cp\u003eWhile e-Learning modules were superior in improving knowledge tests scores, particularly for nurses and respiratory therapists, the study did not demonstrate improvement in simulation performance. Study findings align with the current NRP educational strategy of reinforcing didactic individual learning (modules and readings) with hands-on practice, simulations, and structured debriefing.\u003csup\u003e\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e While the modules provided participants with knowledge and mental models for DR resuscitation of CCHD infants in a format that is accessible, simulation remains essential for translating knowledge into practice. In addition to accessibility, effective CCHD DR education must also be standardized, comprehensible, and applicable to HCPs in a variety of practice settings. This is important as not all CCHD are diagnosed prenatally or delivered in specialized centers. Embedding CCHD modules into established platforms (e.g., NRP, AHA) may increase adoption by addressing resource, time, and institutional variability. Finally, sustainable improvements may also require system-level supports such as lesion-specific checklists and cognitive aids.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAn Integrated Framework: Adapting NRP for CCHD\u003c/h2\u003e\u003cp\u003eThe study identified a need for a pragmatic, DR and lesion-specific CCHD resuscitation framework that NRP-trained HCPs can incorporate into their practice. A recurring challenge for teams was an inability to integrate lesion-specific adaptations with core NRP steps, sometimes fixating on one at the expense of the other. Having knowledge about CCHD lesions alone was insufficient to guide HCPs in the DR; For example, in the HLHS scenario, eLearning-exposed teams often proceeded directly to intubation without adequate mask ventilation, suggesting an overemphasis on invasive airways. This underscores the need to integrate fundamental perinatal transition priorities (stimulation, thermoregulation, mask ventilation) with lesion-specific considerations. This integrated resuscitation framework should also include fundamental DR concepts such as consideration for other causes of neonatal compromise (i.e. sepsis, prematurity, asphyxia, or meconium aspiration).\u003c/p\u003e\u003cp\u003eIn contrast, despite CCHD knowledge, teams also demonstrated a fixation on deeply ingrained NRP mental models, such as reflexive use of chest compressions for HR\u0026thinsp;\u0026lt;\u0026thinsp;60 bpm. In the CCHB scenario, many teams initiated compressions despite hemodynamic stability, while others failed to use isoproterenol or similar agents for unstable infants. Encouragingly, more eLearning-exposed teams recognized the role of interventions to reduce metabolic demand (e.g., sedation, neuromuscular blockade) in hemodynamically unstable d-TGA with restricted atrial septum. While insufficient alone to improve overall simulation performance, eLearning focused on an integrated NRP / CCHD framework may ultimately support better decision-making for these infants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePractice Variation and Other Challenges\u003c/h2\u003e\u003cp\u003eThe study revealed key inter-institutional practice variations in DR management of infants with CCHD. Decisions on DCC, vascular access (UVC vs peripheral IV), and chest compression pause intervals (1 vs 2 minutes) varied widely. DCC clarification was often omitted by the team in abruption and CCHD scenarios. This underscores the need for clarification it's role in all deliveries, including CCHD, especially considering emerging data in the CCHD population.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Choice of vascular access appeared institution-specific, influenced by provider expertise, delivery setting, and transport needs. While NRP reserves UVC placement for emergencies, in CCHD stabilization, timely peripheral IV access may suffice for non-emergent medications such as PGE, highlighting the need to revisit current practice frameworks.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Finally, variation in CPR pulse and rhythm check intervals reflects the gray zone of applying neonatal versus pediatric resuscitation models in this population. \u003csup\u003e31\u0026ndash;36\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eOur study included a multicentered cohort of diverse multidisciplinary neonatal resuscitation teams currently practicing across North America. Results thus reflected actual practice variation enhancing the study's generalizability and applicability. Limitations include non-standardized simulation fidelity, which may have influenced performance, and a highly experienced participant cohort, limiting generalizability to less experienced teams or centers with fewer CCHD deliveries. The intervention\u0026rsquo;s impact may be greater in such settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eCCHD-specific eLearning modules focused on delivery room management were well-received by multidisciplinary neonatal HCPs and led to improved post-intervention knowledge scores. However, simulation performance in CCHD-specific neonatal resuscitation scenarios was similar between groups. The development and implementation of comprehensive, physiology-based educational programs, integrated with team-based simulation practice and systems-level support, will be paramount to improving delivery room care for newborns with CCHD\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Heart Association\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAtrial Septal Defect\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBalloon Atrial Septostomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCCHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCritical Congenital Heart Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCongenital Heart Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eeL\u0026thinsp;=\u0026thinsp;eLearning modules on CCHD management\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edr\u0026thinsp;=\u0026thinsp;directed readings on CCHD management\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCCHB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCongenital Complete Heart Block\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDCC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDelayed Cord Clamping\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDelivery room\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ed\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTGA IVS\u0026ndash;d Transposition of Great Arteries with intact ventricular septum\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHCP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Care Providers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHLHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHypoplastic Left Heart Syndrome\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNRP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeonatal Resuscitation Program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePALS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePediatric Advanced Life Support\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePGE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProstaglandin E\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePeripheral Intravenous access\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePositive Pressure Ventilation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRRT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRegistered Respiratory Therapist\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRegistered Nurse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUVC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUmbilical Venous Catheter\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003e\u003cb\u003eConflict of interest\u003c/b\u003e:\u003c/h2\u003e\u003cp\u003eNone of the authors have any competing financial interests in relation to the work described.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Source:\u003c/h2\u003e\u003cp\u003eThis work was supported by a Canadian NRP Research Grant. The granting agency had no role in the writing of the manuscript or in the decision to submit for publication.\u003c/p\u003e\u003ch2\u003eAuthor contribution:\u003c/h2\u003e\u003cp\u003eAll authors have made substantial contributions to all of the following: (1) the conception and design of the manuscript, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eThe authors would like to acknowledge the time and expertise of simulation consultants and study participants at participating institutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e The study was approved by the UT Southwestern Institutional Review Board (STU 2021\u0026thinsp;\u0026minus;\u0026thinsp;0457).\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOster M, Lee K, Honein M, Colarusso T, Shin M, Correa A. Temporal trends in survival for infants with critical congenital heart defects. \u003cem\u003ePediatrics\u003c/em\u003e. 2013;131(5):e1502-8\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonofrio MT, Levy RJ, Schuette JJ, et al. Specialized delivery room planning for fetuses with critical congenital heart disease. \u003cem\u003eAm J Cardiol\u003c/em\u003e 2013;111:737\u0026ndash;47\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoos, V., Kocjancic, L., Berger, F. et al. Delivery room asphyxia in neonates with ductal-dependent congenital heart disease: a retrospective cohort study. \u003cem\u003eJ Perinatol\u003c/em\u003e 2019; 39, 1627\u0026ndash;1634\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatkins S, Sadler L, Cloete E, et al. 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Resuscitation practices for infants in the NICU, PICU and CICU: results of a national survey. \u003cem\u003eJ Perinatol.\u003c/em\u003e 2017;37(2):172\u0026ndash;176.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8058742/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8058742/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eNeonates with congenital heart disease may require delivery room interventions beyond standard care. Because existing guidelines and educational programs rarely address these needs, we developed and evaluated targeted educational modules.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eTeams were randomized to online eLearning modules or directed readings. Individual pre-/post-knowledge scores were compared. Team performance was tested in simulated delivery scenarios including abruption, hypoplastic left heart syndrome, d-transposition of great arteries and congenital complete heart block.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e32 teams from 9 centers participated. The module group had improved knowledge scores (mean change 6% vs -0.3% e-Learning group, p\u0026thinsp;=\u0026thinsp;0.01). Simulation performance was similar between groups except for hypoplastic left heart syndrome, where module groups scored lower, performing less bag-mask ventilation before intubation (82% vs 88%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eeLearning modules were well-accepted and improved knowledge scores. Simulation performance was similar between groups. Ongoing educational development of CCHD DR adaptations and their incorporation within standard NRP is required.\u003c/p\u003e","manuscriptTitle":"Development and implementation of educational modules on management of neonates with critical congenital heart disease in the delivery room (LEARN-CHD)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-23 11:40:15","doi":"10.21203/rs.3.rs-8058742/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-12-02T19:33:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-12-02T16:22:36+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-12-01T14:51:06+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-11-12T22:32:46+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-11-12T22:15:45+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-11-11T19:35:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-10T12:28:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Perinatology","date":"2025-11-07T16:01:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-07T16:01:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e0f150ec-afdf-48bc-9f05-01e6beb8ab6d","owner":[],"postedDate":"November 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":57825348,"name":"Health sciences/Health care/Paediatrics"},{"id":57825349,"name":"Health sciences/Health care/Health services"}],"tags":[],"updatedAt":"2026-03-11T15:40:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-23 11:40:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8058742","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8058742","identity":"rs-8058742","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}