Bio

Clinical Focus


  • Neonatology
  • Patient Simulation
  • Neonatal-Perinatal Medicine

Academic Appointments


Administrative Appointments


  • Clinical Instructor, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Stanford (2013 - Present)

Honors & Awards


  • ROSE Award (Recognition of Service Excellence), Lucile Packard Children's Hospital, Stanford University (2011)
  • Member, Stanford Society of Physician Scholars (2010)
  • Pete Harman Fellow in Neonatology, Stanford University (2010)

Boards, Advisory Committees, Professional Organizations


  • Consultant, Center for Fetal and Maternal Health, Stanford (2014 - Present)
  • Coordinator, Fetal Center, El Camino Hospital (2014 - Present)
  • Coordinator, Transport Follow Up, El Camino Hospital NICU (2014 - Present)
  • Member, NICU Partnership Council, El Camino Hospital (2014 - Present)
  • NICU Liasion, Department of Pediatrics, El Camino Hospital (2014 - Present)
  • Fellow, American Academy of Pediatrics (2012 - Present)
  • Instructor, Neonatal Resuscitation Program (2009 - Present)
  • Faculty, Center for Advanced Pediatric and Perinatal Education (CAPE) at Stanford (2009 - 2012)

Professional Education


  • Board Certification: Neonatal-Perinatal Medicine, American Board of Pediatrics (2014)
  • Board Certification, American Board of Pediatrics, Neonatal-Perinatal Medicine (2014)
  • Fellowship:Stanford University School of Medicine (2012) CA
  • Board Certification: Pediatrics, American Board of Pediatrics (2009)
  • Residency:Lucile Packard Children's Hospital (2009) CA
  • Medical Education:University of California San Diego (2006) CA

Community and International Work


  • Volunteer Physician, Nepal

    Topic

    Neonatology

    Partnering Organization(s)

    Lucile Packard Children's Hospital

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    Yes

  • Volunteer Physician, Guatemala

    Topic

    Pediatrics

    Partnering Organization(s)

    Lucile Packard Children's Hospital

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    Yes

  • Volunteer Physician, Ecuador

    Topic

    Pediatrics

    Partnering Organization(s)

    Child Family Health International

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Research & Scholarship

Current Research and Scholarly Interests


My particular area of research interest lies in using simulation methodology to understand the cognitive, technical and behavioral skills needed during neonatal resuscitation. First, I wanted to understand how accurate human senses are in the detection of neonatal heart rate during simulated resuscitation. As providers of neonatal resuscitation we are taught an algorithm that presumes we are able to precisely detect a newborn’s heart rate and, based on that value, respond appropriately according to set guidelines. But what if the accuracy of the current standard is deficient and providers either fail to perform appropriate interventions or perform inappropriate interventions? Using simulation based methodology I was the principle investigator in a prospective, randomized controlled trial investigating how accurate certified providers of neonatal resuscitation are at determining heart rate when faced with various resuscitation scenarios. I found that providers were inaccurate in their heart rate determination ~40% of the time using either auscultation of the chest or palpation of umbilical pulsations. It is time to study other means of heart rate determination in the delivery room (oximetry, ECG leads) because the accuracy of the current standard is deficient and results in errors of omission (lack of appropriate interventions) and commission (inappropriate interventions). This work was published in the journal Resuscitation.

Next, I wanted to investigate a way to optimize the organization of equipment and supplies required when responding to neonatal resuscitations in our hospital. There have been several emergent resuscitations I have responded to during my fellowship where I was frustrated at the lack of appropriate equipment at my disposal and/or the delay in obtaining such equipment. At Lucile Packard Children’s Hospital (LPCH) supplies for certain resuscitations must be obtained from up to four different places, taking on average 6-8 minutes. After surveying medical directors in NICUs across the United States I found that, although 75% of NICUs have all of their supplies located in one area, it takes an average of 5 minutes (range 1-30 minutes) to gather this equipment. Such preparation times are too long to allow for an efficient, timely resuscitation. I believed that creation of a resuscitation cart specifically designed for neonates of various sizes and with differing disease states could greatly improve our ability to respond to and appropriately care for these newborns. As such, my co-fellow and I designed a neonatal resuscitation cart (NRC) based on the ABC’s (airway, breathing, circulation) of resuscitation. Using simulation-based methodology, we performed a prospective, randomized, controlled, crossover trial design to compare the utility of a NRC with the current standard at LPCH. We found that use of a supply cart designed specifically for use during neonatal resuscitation (NRC) allowed healthcare professionals to more quickly acquire equipment and supplies and institute indicated resuscitation procedures when compared to our current standard. We believe that this is likely to result in improved human performance during actual neonatal resuscitations and potentially better patient outcomes. I was the principle investigator on this project and our work has been published in BMJ Quality and Safety. The NRCs are now in use in our delivery rooms and NICUs at LPCH.

Projects


  • NICHD Trial, Research site coordinator, El Camino Hospital (2014)

    Research site coordinator for NICHD trial entitled "A Randomized Controlled Trial of the Effect of Hydrocortisone on Survival without Bronchopulmonary Dysplasia and on Neurodevelopmental Outcomes at 22-26 Months of Age in Intubated Infants <30 Weeks Gestational Age".

    Location

    Mountain View, CA

  • Principal Investigator, ET-1 and BNP as Predictors of Pulmonary HTN Risk in Premature Infants with BPD, Stanford University (2011 - 2013)

    Principal Investigator, Endothelin-1 (ET-1) and Brain Natriuretic Peptide (BNP) Levels as Predictors of Pulmonary Hypertension Risk in Premature Infants with Bronchopulmonary Dysplasia (BPD)”. Vera Moulton Wall Center, Stanford University School of Medicine. 2011

    Location

    Palo Alto, CA

Teaching

Graduate and Fellowship Programs


Publications

Journal Articles


  • Using Simulation to Study Difficult Clinical Issues Prenatal Counseling at the Threshold of Viability Across American and Dutch Cultures SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE Geurtzen, R., Hogeveen, M., Rajani, A. K., Chitkara, R., Antonius, T., Van Heijst, A., Draaisma, J., Halamek, L. P. 2014; 9 (3): 167-173

    Abstract

    Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists.We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation.American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues.Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.

    View details for DOI 10.1097/SIH.0000000000000011

    View details for Web of Science ID 000337146100005

    View details for PubMedID 24401918

  • The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: Implications for delivery of care, training and technology design RESUSCITATION Chitkara, R., Rajani, A. K., Oehlert, J. W., Lee, H. C., Epi, M. S., Halamek, L. P. 2013; 84 (3): 369-372

    Abstract

    Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than ± 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation.Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochran's Q and chi square test were used to compare HR detection by method and across scenarios.Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination.Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.

    View details for DOI 10.1016/j.resuscitation.2012.07.035

    View details for Web of Science ID 000318164200028

  • Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial BMJ QUALITY & SAFETY Chitkara, R., Rajani, A. K., Lee, H. C., Hansen, S. F., Halamek, L. P. 2013; 22 (2): 124-129

    Abstract

    To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC).A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test.Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use.The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.

    View details for DOI 10.1136/bmjqs-2012-001336

    View details for Web of Science ID 000314211900005

  • Newborn with prenatally diagnosed choroidal fissure cyst and panhypopituitarism and review of the literature. AJP reports Chitkara, R., Rajani, A., Bernstein, J., Shah, S., Hahn, J. S., Barnes, P., Hintz, S. R. 2011; 1 (2): 111-114

    Abstract

    Little has been reported on fetal diagnosis of choroidal fissure cysts and prediction of the clinical complications that can result. We describe the case of a near-term male infant with prenatally diagnosed choroidal fissure cyst and bilateral clubfeet. His prolonged course in the neonatal intensive care nursery was marked by severe panhypopituitarism, late-onset diabetes insipidus, placement of a cystoperitoneal shunt, and episodes of sepsis. Postnatal genetic evaluation also revealed an interstitial deletion involving most of band 10q26.12 and the proximal half of band 10q26.13. The patient had multiple readmissions for medical and surgical indications and died at 6 months of age. This case represents the severe end of the spectrum of medical complications for children with choroidal fissure cysts. It highlights not only the importance of comprehensive evaluation and multidisciplinary management and counseling in such cases, but also the need for heightened vigilance in these patients.

    View details for DOI 10.1055/s-0031-1293512

    View details for PubMedID 23705098

  • Comparison of Umbilical Venous and Intraosseous Access During Simulated Neonatal Resuscitation PEDIATRICS Rajani, A. K., Chitkara, R., Oehlert, J., Halamek, L. P. 2011; 128 (4): E954-E958

    Abstract

    Emergent umbilical venous catheter (UVC) placement for persistent bradycardia in the delivery room is a rare occurrence that requires significant skill and involves space constraints. Placement of an intraosseous needle (ION) in neonates has been well described. The ION is already used in the pediatric population and is placed at an anatomic location distant from where chest compressions are performed. In this study we compared time to placement, errors in placement, and perceived ease of use for UVCs and IONs in a simulated delivery room.Forty health care providers were recruited. Subjects were shown an instructional video of both techniques and allowed to practice placement. Subjects participated in 2 simulated neonatal resuscitations requiring intravenous epinephrine. In 1 scenario they were required to place a UVC and in the other an ION. Scenarios were recorded for later analysis of placement time and error rate. Subjects were surveyed regarding the perceived level of difficulty of each technique.The average time required for ION placement was 46 seconds faster than for UVC placement (P < .001). There was no significant difference in the number of errors between UVC and ION placement or in perceived ease of use.In a simulated delivery room setting, ION placement can be performed more quickly than UVC insertion without any difference in technical error rate or perceived ease of use. ION insertion should be considered when rapid intravenous access is required in the neonate at the time of birth, especially by health care professionals who do not routinely place UVCs.

    View details for DOI 10.1542/peds.2011-0657

    View details for Web of Science ID 000295406800022

    View details for PubMedID 21930542

  • A National Survey of Pediatric Residents and Delivery Room Training Experience JOURNAL OF PEDIATRICS Lee, H. C., Chitkara, R., Halamek, L. P., Hintz, S. R. 2010; 157 (1): 158-U211

    Abstract

    To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.

    View details for DOI 10.1016/j.jpeds.2010.01.029

    View details for Web of Science ID 000278649200037

    View details for PubMedID 20304418

  • A National Survey of Pediatric Residents and Delivery Room Training Experience Journal of Pediatrics Lee, H., Chitkara R, Halamek LP, Hintz SR 2010; 157 (1): 158-161
  • Delivery Room Management of the Newborn PEDIATRIC CLINICS OF NORTH AMERICA Rajani, A. K., Chitkara, R., Halamek, L. P. 2009; 56 (3): 515-?

    Abstract

    Neonatal resuscitation is an attempt to facilitate the dynamic transition from fetal to neonatal physiology. This article outlines the current practices in delivery room management of the neonate. Developments in cardiopulmonary resuscitation techniques for term and preterm infants and advances in the areas of cerebral resuscitation and thermoregulation are reviewed. Resuscitation in special circumstances (such as the presence of congenital anomalies) are also covered. The importance of communication with other members of the health care team and the family is discussed. Finally, future trends in neonatal resuscitation are explored.

    View details for DOI 10.1016/j.pcl.2009.03.003

    View details for Web of Science ID 000267523700006

    View details for PubMedID 19501690

  • Pediatric Resident Attendance at Deliveries Journal of Investigative Medicine Chitkara R, Lee HC, Hintz SR 2009; 57 (1): 504
  • Visual Diagnosis: Prenatally Diagnosed Abdominal Cystic Mass Neoreviews 2007 8: e554 Chitkara R, Lee HC 2007; 8: e554

Presentations


  • Using Simulation to Answer Clinically Important Questions

    Time Period

    1/2014

    Presented To

    International Meeting on Simulation in Healthcare (IMSH)

    Location

    San Francisco, CA

  • The Accuracy of Human Senses in the Detection of Neonatal Heart Rate during Standardized Simulated Resuscitation

    Time Period

    4/2013

    Presented To

    International Pediatric Simulation Symposia and Workshops (IPSSW)

    Location

    New York, NY

  • Comparing the Utility of a Novel Neonatal Resuscitation Cart with a Generic Code Cart using Simulation

    Time Period

    4/2013

    Presented To

    International Pediatric Simulation Symposia and Workshops (IPSSW)

    Location

    New York, NY

  • NRP 2010 Guidelines

    Time Period

    1/2011

    Presented To

    MCCPOP (Mid-Coastal California Perinatal Outreach Program)

    Location

    Monterey, CA

  • Pediatric Resident Attendance at Deliveries

    Time Period

    1/2009

    Presented To

    WSPR/WSMRF

    Location

    Monterey, CA

  • Newborn with Prenatally Diagnosed Choroidal Fissure Cyst, Panhypopituitarism

    Time Period

    1/2010

    Presented To

    WSPR/WSMRF

    Location

    Monterey, CA

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