Prospective clinical audit of chloral hydrate administration practices in a neonatal unit

Aim: Chloral hydrate is generally considered a safe and effective single dosing procedural sedative for neonates in the clinical setting. However, its safety profile as a repetitive dosing maintenance sedative is largely unknown. This study aimed to document current administration practices of chloral hydrate in the Neonatal Unit, Royal Children's Hospital, Melbourne, Australia, over a 6-month period.

Methods: Patients who had been prescribed chloral hydrate during the specified audit period were recruited into the study and prospectively followed for a period of 28 days, or until they were discharged from the unit. Demographic data were collected on recruitment, and daily documentation of chloral hydrate administration was recorded.

Results: A total of 238 doses of chloral hydrate were administered to a cohort of 32 patients during the study period. The majority of the audited doses (84%) were ordered as repeating doses. Doses were more likely to be given at night than during the day, and the median dosage for repetitive dosing was found to be above the study site's recommended dosing range. Pre-dose and/or post-dose assessment of distress/agitation accompanied dosage approximately half of the time. The audit did not reveal any recognisable pattern of sedation maintenance or weaning process for patients who received multiple doses.

Conclusions: Health-care professionals caring for hospitalised infants should be made aware of the potential risks of chloral hydrate as a repetitive dosing sedative, and of the importance of systematically evaluating the appropriateness and effectiveness of utilising such pharmacological intervention for managing and treating distress.

Supervisor Continuity or Co-Location: Which Matters in Residency Education? Findings From a Qualitative Study of Remote Supervisor Family Physicians in Australia and Canada

Purpose: Changes to health care systems andworking hours have fragmentedresidents’ clinical experiences withpotentially negative effects ontheir development as professionals.Investigation of off-site supervision,which has been implemented in isolatedrural practice, could reveal importantbut less overt components of residencyeducation. 

Method: Insights from sociocultural learningtheory and work-based learning provideda theoretical framework. In 2011–2012,16 family physicians in Australia andCanada were asked in-depth how theyremotely supervised residents’ workand learning, and for their reflectionson this experience. The verbatiminterview transcripts and researchers’memos formed the data set. Templateanalysis produced a description andinterpretation of remote supervision. 

Results: Thirteen Australian family physiciansfrom five states and one territory, andthree Canadians from one province,participated. The main themes werehow remoteness changed the dynamicsof care and supervision; the importanceof ongoing, holistic, nonhierarchical,supportive supervisory relationships; andthat residents learned “clinical courage”through responsibility for patients’ careover time. Distance required supervisorsto articulate and pass on their expertiseto residents but made monitoringdifficult. Supervisory continuityencouraged residents to build on pastexperiences and confront deficiencies. 

Conclusions: Remote supervision enabled residents todevelop as clinicians and professionals.This questions the supremacy of co-locationas an organizing principle forresidency education. Future specialists maybenefit from programs that give themongoing and increasing responsibilityfor a group of patients and supportive.