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Effect of monitor positioning on visual attention and situation awareness during neonatal resuscitation: a randomised simulation study
  1. Brenda Hiu Yan Law1,2,
  2. Po-Yin Cheung1,2,
  3. Sylvia van Os2,
  4. Caroline Fray2,
  5. Georg M Schmölzer1,2
  1. 1 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
  2. 2 Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
  1. Correspondence to Dr Brenda Hiu Yan Law, Department of Pediatrics, University of Alberta, Edmonton, Alberta T5H 3V9, Canada; blaw2{at}


Objectives To compare situation awareness (SA), visual attention (VA) and protocol adherence in simulated neonatal resuscitations using two different monitor positions.

Design Randomised controlled simulation study.

Settings Simulation lab at the Royal Alexandra Hospital, Edmonton, Canada.

Participants Healthcare providers (HCPs) with Neonatal Resuscitation Program (NRP) certification within the last 2 years and trained in neonatal endotracheal intubations.

Intervention HCPs were randomised to either central (eye-level on the radiant warmer) or peripheral (above eye-level, wall-mounted) monitor positions. Each led a complex resuscitation with a high-fidelity mannequin and a standardised assistant. To measure SA, situation awareness global assessment tool (SAGAT) was used, where simulations were paused at three predetermined points, with five questions asked each pause. Videos were analysed for SAGAT and adherence to a NRP checklist. Eye-tracking glasses recorded participants’ VA.

Main outcome measure The main outcome was SA as measured by composite SAGAT score. Secondary outcomes included VA and adherence to NRP checklist.

Results Thirty simulations were performed; 29 were completed per protocol and analysed. Twenty-two eye-tracking recordings were of sufficient quality and analysed. Median composite SAGAT was 11.5/15 central versus 11/15 peripheral, p=0.56. Checklist scores 46/50 central versus 46/50 peripheral, p=0.75. Most VA was directed at the mannequin (30.6% central vs 34.1% peripheral, p=0.76), and the monitor (28.7% central vs 20.5% peripheral, p=0.06).

Conclusions Simulation, SAGAT and eye-tracking can be used to evaluate human factors of neonatal resuscitation. During simulated neonatal resuscitation, monitor position did not affect SA, VA or protocol adherence.

  • neonatal resuscitation
  • human factors
  • situation awareness
  • visual attention

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  • Contributors Conception and design: GMS and BHYL. Collection and assembly of data; analysis and interpretation of the data; drafting of the article; critical revision of the article for important intellectual content; final approval of the article: GMS, BHYL, P-YC, CF and SvO.

  • Funding We would like to thank the public for donation to our funding agencies: GMS is a recipient of the Heart and Stroke Foundation/University of Alberta Professorship of Neonatal Resuscitation and a Heart and Stroke Foundation Canada and a Heart and Stroke Foundation Alberta New Investigator Award. This research has also been facilitated by the Women and Children’s Health Research Institute through the generous support of the Stollery Children’s Hospital Foundation. The authors have no financial relationships relevant to this article to disclose. No current funding source for this study. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Competing interests None declared.

  • Ethics approval The Royal Alexandra Hospital Research Committee and the Health Ethics Research Board, University of Alberta (Pro00071387) approved the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Deidenitifed data, including abstracted visual attention metrics, collated SAGAT scores, NRP checklist scores and participant survey results are available upon request.

  • Collaborators Karsten Loepelmann.

  • Patient consent for publication Parental/guardian consent obtained.