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The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life.

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Presentation on theme: "The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life."— Presentation transcript:

1 The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life


3 WHY DO WE NEED NRP ? At least 10 % of all newborns require some assistance at birth i.e. the initial steps of resuscitation And 1% require extensive resuscitation There are 1 million deaths per year resulting from Birth Asphyxia (WHO, 1995) A significant number will have respiratory problems and a large # will have seizures and later problems such as CP which means that one could possibly affect the outcomes of several million newborn infants every year

4 NRP IN THE U.S.A. 1960’s Mushrooming of neonatal and high risk OB care
1970’s Regionalization of Perinatal Care Community Hospitals played pivotal role in neonatal resuscitation NIH funding of 5 educational grants to address neonatal resuscitation training American Academy of Pediatrics (AAP) forms group to address training

5 NRP IN THE U.S.A. AAP and the American Heart Association led NRP development NRP faculty approach was tiered- National, Regional and Hospital Based 1987- A Standardized National Neonatal Resuscitation Program built on Consensus rolled out in the USA

6 NRP in the U.S.A. Key Factors Sustaining It
“ The most critical ingredient for the success of NRP….the goodwill and altruism of a broad and diverse group…this continues to sustain the program…” Need for Continuing Education and Maintenance of Competency Linked to Accreditation of Institutions Standard of Care and Medico-Legal concerns

7 NRP IN THE U.S.A. (cont’d) From 1987 until 2000, changes in NRP were largely the result of feedback from practitioners not necessarily based on evidence What is Evidence Based Medicine ? “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”

8 Definition of Evidence
Webster’s - something that furnishes proof Definition is subjective to interpretation Wide latitude as to what constitutes proof Can be reflected in guidelines and recommendations U.S. Preventive Services Task force developed Classification Schema for Quality of evidence

9 Evidence Based Medicine in NRP
Ten major questions were reviewed Extensive literature search on each topic Each article was assigned a level of evidence based on study design and methodology

10 EBM - Steps in Evaluation Level of Evidence
Level 1 = large randomized clinical trials or meta analyses of multiple randomized clinical trials Level 4 = Historic, non-randomized, cohort or case control studies Level 8 = Rational conjecture (common sense), common accepted practice before evidence based guidelines

11 EBM - Next Step Critically evaluate the quality of each source in terms of research design and methods. Scale: Excellent to unsatisfactory Evaluate direction of the study results and the statistics Scale: Supportive, neutral, opposing proposal

12 Final Step Determine the class of recommendation
Class I - definitely recommended Class II - acceptable and useful Class II a - Acceptable and useful, very good evidence provides support Class II b - Acceptable and useful, fair to good evidence provides support Class III - Not acceptable, not useful, may be harmful

13 NRP 2000 IN THE U.S.A. International Guidelines 2000 Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care formulated new evidence based recommendations for NRP Members included : AAP NRP Steering Committee, AHA and the Pediatric Working Group of the International Liaison Committee on Resuscitation (ILCOR)

Handling of infants with amniotic stained fluid stained Prevent heat loss and avoid hyperthermia Use of 100% oxygen only Potential use of laryngeal mask and exhaled CO2 detectors Change in chest compression method and simplified rate response

Early administration of epinephrine Albumin no longer the fluid of choice; isotonic crystalloid solution is Potential for use of intraosseous route When resuscitation may not be initiated or may be discontinued in the delivery room


17 Neonatal Resuscitation Program: Curriculum
Dmytro Dobrianskyi, MD, PhD Keti Nemsadze, MD, PhD

18 Program Components Neonatal Resuscitation Program (NRP) developed in U.S. by the AHA and the AAP was used as a model in the NIS. Main features of the Program Implementation based on perinatal regions Self-study textbook Appropriateness for all professional levels Adaptability for local practice Formats of the NRP course Self-study Small group 1- or 2-day course

19 Program Components Educational resources of the original Program
Self-study textbook Educational video Approximately 300 slides Skill stations (course training equipment) Instructor’s Manual NRP test package Standardized final written evaluation and practical tests

20 Program Components Didactic components of the original Program
Student textbook provided prior to the course date Provider Course consisting of 6 separate lessons, each covering a specific area of a neonatal resuscitation Lectures and practical training at the skill stations Instructor Course - to prepare those providers who would become “teachers”

21 Assess baby’s response to birth Establish effective ventilation
Program Content Assess baby’s response to birth Always needed by newborns Initial steps Establish effective ventilation Bag and mask Endotracheal intubation Needed less frequently Provide chest compressions Rarely needed by newborns Administer medications

22 Program Components - NIS
All original educational NRP material was translated from English and distributed in the NIS (Russian, Ukrainian, Georgian). NRP Training Centers were established. Provider Training Course Standards are absolutely the same as the requirements in the U.S. The first courses in the NIS were co-taught with U.S. partners. Program components and course formats used in the NIS were adapted to meet the needs of the Regions.

23 Program Participants Anyone responsible for any part of a neonatal resuscitation is an appropriate candidate for a provider course. Historically, only physicians were considered participants in resuscitation Currently, neonatologists, obstetricians, midwives, nurses, anesthesiologists and pediatricians have been included in the provider courses.

24 NRP Instructors The key person in the NRP is an instructor, who is responsible not only for provider training but for implementation of the Program in every institution with delivery or newborn services. To accomplish this the number of instructors need to be quite high to ensure the program will succeed in reaching all caregivers

25 Organization of NRP Instructors in the USA

26 Organization of NRP Instructors in the NIS

27 NRP Instructors To become an NRP instructor, a person must meet the following eligibility requirements: Be a physician or nurse from critical care nursery setting Have training and experience in the hospital care of newborns in a delivery room or critical care nursery setting. Have educational or clinical responsibilities within a hospital or other appropriate medical facility (eg, medical school, nursing school). Have a provider training or take an NRP Instructor Course that includes the provider component.

28 NRP Instructors It is important to emphasize that in the NIS settings, not all academicians can be instructors and conduct the NRP course because of it’s significant practical nature. To achieve the objectives of the Program, practical clinicians must be widely involved into instructor activity.

29 Instructor Training in the NIS
Instructors were trained as providers by US faculty, Provider Course (8 hours). Instructor Course was used to provide physicians with knowledge of adult learning theory, principles of teaching and information on conducting a course (4 hours) To enhance the level of expertise of instructors, a Train the Trainer (TOT) Course was developed. Content of TOT includes basic physiological issues related to the care of high risk infants and is an additional resource to the original program.

30 Importance of the Skill Stations
The theoretical and practical knowledge of NRP and its implementation in maternity houses, significantly improves the quality of health care services contributing to desirable outcomes

31 Importance of the Skill Stations
Education on practical skills enables participants to establish newly acquired knowledge in everyday practice Working with small groups makes it possible to assess individuals, identify areas needing improvement and focus on these areas. Participants become familiar with equipment that is necessary for resuscitation and encounter simulated situations for practice. Improved skills, increases ones confidence in performing resuscitation correctly and efficiently

32 Importance of the Skill Stations
Participants observe each others mistakes as well as ways to problem solve Participants develop skills related to selection and functioning of appropriate equipment. Each skills station builds on the previous one, which gives participants the opportunity to master skills. This decreases the frequency of complications during resuscitation and enhance desirable outcomes. The performance check list gives the instructor an objective tool to evaluate participant’s knowledge, decision making and comfort with newly acquired skills

33 The weak points of education in Former Soviet Union
Education was based only on theoretical issues. Practical skills were not taught. No equipment and manikins were available for teaching practical skills Medical staff were unfamiliar with equipment necessary newborn resuscitation and often could not use existing equipment despite the indications. The first attempt at resuscitation usually was performed directly on a patient, therefore often delayed, performed incorrectly, resulting in frequent complications and resuscitation failure.

34 Station I -Initial steps of resuscitation
Common practice in Former Soviet Union Importance Important not only for a depressed infant but every newborn. Making decisions about further steps of resuscitation happens here This step requires only a few seconds, so mastering the sequence of the skills is very important. Prevention of heat loss mostly was neglected Suctioning was not different in cases of clear or meconium stained amniotic fluid. Assessment of the infant was based on Apgar score assessed at I minute of life.

35 Lesson 1:Initial steps of Resuscitation
Heat loss prevention Opening of airways Assessment of the infant Position the infant Suctioning mouth, then nose Breathing Heart rate Color Place on warmer Dry the newborn Remove wet towel if needed intubate and suctioning trachea if necessary provide tactile stimulation and give free flow oxygen


37 Importance Common practice in Former Soviet Union
Station 2 - Support Breathing Importance Common practice in Former Soviet Union Harmful methods and prolonged tactile stimulation were used Support breathing was based on medications Ventilation with bag and mask was rare, mostly initiating breathing was conducted mouth-to-mouth breathing Supporting oxygenation, establishment of spontaneous breathing and timely prevention of hypoxia getting acquainted with the equipment and how it works learning how to ventilate safely identification of indications for chest compression

38 Performing ventilation
Station 2 - Support Breathing Selection of appropriate equipment and ensure it is functioning Performing ventilation Adequate rate Adequate pressure Assessment of adequate ventilation Assessment of HR Decision of next steps of resuscitation

39 Station 3 - Support Circulation
Common Practice in Former Soviet Union Importance Provision of artificial heart rate Restoring circulation Ensuring adequate oxygen supply Chest compression was initiated primarily after cardiac arrest Chest compressions were never combined with ventilation Sometimes harmful methods of compression were used

40 Station 3 - Support Circulation
Technique position the infant firm support for the back, neck slightly extended 2 finger technique thumb technique adequate location, depth and rate coordination of chest compression ventilation assessment of HR in sec.

41 Station 4 - Endotracheal Intubation
Importance Common practice in Former Soviet Union Identification of indications Intubation often was not limited to 20 sec The indications were often ignored Ineffective bag and mask ventilation prolonged ventilation Tracheal suctioning diaphragmatic hernia

42 Station 4 - Endotracheal Intubation
Selection and preparation of the equipment Technique Position the infant Insertion of laryngoscope and visualization of glottis Insertion of ET tube Checking the tube placement Securing the tube Selection of the endotracheal tube size Selection and preparation of laryngoscope with appropriate size of blade Preparation of suctioning and ventilating equipment

43 Show me and I may not remember
Tell me and I’ll forgot Show me and I may not remember involve me, and I understand

44 Quality Assessment of NRP
Sudhakar G. Ezhuthachan, MD, DCH, FAAP

45 Evaluation Strategies
Evaluation of the course - maintaining course standards Evaluation of clinical application of knowledge Evaluation of patient outcomes

46 Evaluation by Others U.S. NRP Steering Committee has just begun to discuss evaluation of the course Illinois, USA - Marked reduction in high risk infants with low apgars scores at 1 min. Of infants with low 1 min scores, more improved by 5 mins, in the group studied after the implementation of the NRP course

47 Evaluation by Others Kerala, India - Use of a standardized curriculum like NRP reduced perinatal asphyxia after delivery Zhuhai, China - Neonatal Mortality (perinatally) was reduced by 3 times after NRP curriculum was introduced.

Pre training (3 m) Post training p value Total live births Resuscitation Bag/ Mask Ventilation (2.1) (4.1) <0.001 Intubations (2.2) (2.1) NS Apgar score <4 1 min (4.5) (3.0) <0.001 5 min (2.0) (1.0) <0.001 Outcome MAS 97 (1.9) (2.1) NS Respiratory distress (7.1) (5.7) <0.01 Seizures (2.1) (0.7) <0.001 Asphyxial Brain injury (2.0) (0.6) <0.001 Total deaths (3.1) (2.4) <0.05

49 Early Attempts in Ukraine
Data collected on every birth in maternity houses in western Ukraine Implementation sets were used as incentive Data sent monthly to the NRP Training Center Collection was tedious and not everyone participated

50 Rater (per 1000) of CNS Abnormalities in 7 day-old newborns in 3 hospitals

51 Evaluation of Courses First courses were co-taught with US faculty in most Centers Peer review process currently being developed and is to be discussed at next Steering Committee Meeting Key elements - instructor : student ratio, ensuring students have opportunity to be prepared, monitoring of exams, performance at skills stations

52 Evaluation of Clinical Application
Site visits conducted in Ukraine in May 1999, March 2001 Institutions evaluated - 3 in 1999, 6 in 2001 District as well as City sites Components evaluated - preparation of staff, equipment, performance of staff, knowledge base, clinical outcomes

53 Preparation of Staff Staff Trained Neonatologists - 100%
Obstetricians - 56% (in 2 places, 100%) Anesthesiologists - not active in training Nurses - 69% (2 places 100%, many who are not trained have been educated by MDs) Midwives - 50% (most deal only with mother while others resuscitate infant)

54 Preparation of Staff Most had been trained in regional center, and one was an outreach course Student to instructor ratios appropriate All hospitals have a process to notify the resuscitation team of a delivery All hospitals transferred high risk mothers appropriately as soon as possible to the City

55 Equipment The most crucial issue - one can educate a whole country, but without appropriate “tools”, clinical application is difficult Implementation sets distributed in 1997 were depleted Equipment is well taken care - “guarded” 8 of 9 had excellent Delivery Room set up Feedback from staff on equipment was obtained

56 Performance Observation of deliveries and preparation for deliveries yielded positive application of principles Documentation in the medical record substantiated this finding Mock Codes may be helpful to aid in assessing and reinforcing knowledge

57 Knowledge of Staff Pretests were used in Georgia -data pending
90% of institutions yielded good understanding of most principles Management of infants with meconium stained amniotic fluid needed reinforcement Thermal management issues uncovered in 2 institutions -water baths

58 Clinical Outcomes Mortality is multifactorial and takes time to impact
Morbidities related to temperature and low apgar scores show improvement

59 Low Temperature and the Newborn
A wet newborn loses heat very rapidly Hypothermia reduces the ability of the infant to respond to resuscitation efforts Hypothermia uses up energy (glucose) and oxygen, both needed by the brain. Effective temperature maintenance is critical for both survival and reducing morbidity

Acidosis Cold Stress Death Convulsions HYPOTHERMIA Pulmonary Vessel Spasm Low Glucose More Hypothermia Lack of Oxygen More Acid Production

61 Numbers of Neonates Transferred with Hypothermia i. e
Numbers of Neonates Transferred with Hypothermia i.e Temperature Lower than 35° C

62 Reduction in % of Infants admitted to LOCH with Severe Perinatal Asphyxia

63 Incidence of Severe Asphyxia in Infants admitted to LOCH

64 Implementation Phases and Effectiveness of the Neonatal Resuscitation Program in Russia O. N. Belova

65 The NRP Program has been operating as part of the Russian-American Partnership in Russia since years

66 Order of Ministry of Health of the Russian Federation No
Order of Ministry of Health of the Russian Federation No Improvement of Primary and Resuscitation Care for Neonates in the Delivery Room became effective on 12/28/95. More than 5 years have passed

67 The results of the implementation of the NRP protocol were summarized at the conference on Primary and Resuscitation Care for Neonates in the Delivery Room. Results of the Implementation of the Order of the Russian Ministry of Health No Problems. Outlook for Growth. Samara, October 2000

68 Rating of the Results of the PNR Program by Respondents
17% Excellent 30% Good 53% Satisfactory

69 Changes in Statistical Indicators as a Result of the Implementation of the NRP Protocol
Find it difficult to respond - 25% See positive changes in statistical indicators - 62% Do not associate the positive changes with the effect of the order - 2% Do not see an association between indicators and negative changes - 2% Did not respond - 9%

70 Positive Changes in Statistical Indicators
Perinatal mortality - 22% Early neonatal mortality - 43% Infant mortality - 18% Death due to asphyxia, RDS, including low birth weight infants - 10% Neonatal mortality - 6%

71 Changes in Indicators of Early Neonatal Mortality in the Russian Federation

72 Change in the type of primary resuscitation and state of neonates during in Maternity Hospital No. 27 in the city of Moscow (%)


74 Causes of Problems in Implementing the PNR Protocol
Health care organizers regard level of knowledge of Order No. 372 as adequate - 6% Lack of understanding by local organization - 5% Disagreement with requirements of protocol % Other %

75 The results of a questionnaire showed that only 63% of neonatologists have mastered neonatal resuscitation procedures The order of the Ministry of Health of the Russian Federation No Improvement of Primary and Resuscitation Care for Neonates in the Delivery Room became effective almost five years ago.

76 Knowledge of neonatologists on the type of primary resuscitation care to be given to neonates based on pretest results 1996 1997 - Passed - Failed 2000

77 In the opinion of 44% of the respondents, the primary reason for this is the absence of NRP training
NRP resource training centers operate only in 5 regions within Russia

78 Excerpt from the decree of the Board of the Ministry of Health of Russia of January 9, 2001 Infant Mortality and Ways to Reduce It: 9.6. To organize ongoing seminars for neonatologists on topics in primary neonatal resuscitation care

79 Measures to Improve Neonatal Care
Development/improvement of perinatal networks Creation of departments specializing in care of children who had problems at birth Increasing the role of mid-level medical personnel in providing NR

80 Measures to Improve Neonatal Care
Analysis of legal and ethical aspects of this issue Research (asphyxia, meconium aspiration, NR in children with ELBW, infection control during NR, oxygen therapy)

81 A tree has grown from the seed planted by AIHA, USAID, and the Russian and American partners. And then...

82 Neonatal Resuscitation Program in Ukraine: Results of Implementation
Goyda N. M.D., Ph.D. Head, Medical Services Department Ministry of Health of Ukraine

83 Key Indicators of Health of Children
( )

84 Ratio of Stillbirth and Early Neonatal Mortality Causes

85 Primary Disability Causes Ratio
in Children 0-16

86 Key Demographic Indicators

87 List of Legal and Regulatory Documents, National, State and Target Programs in the Scope of Maternal and Child Health Care in Ukraine Long-term Program to improve status of women, family, Maternal and Child Care Complex Program to resolve disability problem National Program “Children of Ukraine” Additional activities to support implementation of the National Program “Children of Ukraine” up until CY 2005 National Program on “Reproductive Health”

88 Key Objectives of the National Program “Children of Ukraine”
Improvement of medical care to pregnant women and newborns Morbidity prevention and delivery of up-to-date medical care to children

89 Decree of Ministry of Health January 5, 1996
“Organization of medical service for newborns in Ukraine”

90 Three-Level System of Care of Newborns in Ukraine
Level I - Resuscitation of newborns in a delivery room right after the delivery, which is primary resuscitation aimed at developing an adequate postnatal adaptation of a baby from the very first second of his life. Level II - Resuscitating in Newborn Departments at Maternity Hospitals and delivering intensive care. Level III - Delivering medical care to newborns in ICUs at Pediatric Regional and Multi-Specialty Pediatric City Hospitals.

91 Implementing The Neonatal Resuscitation Program has made it possible for Ukraine to:
Study the experience of U.S. leading neonatologists Teach Ukrainian Instructors Develop and equip Training Centers Start mass dissemination of neonatal resuscitation principles among medical staff Apply new medical techniques in neonatology Create a distinctively new system of health care delivery to newborns

92 Standardized Approach to Training
First Training Center was created through an AIHA partnership Replication of this model was used to open 5 additional centers Instructor training program was developed to help standardize the course format and prepare instructors Instructor training model has been used to train instructors from many countries.

93 Standardized Approach to Training
First courses were co-taught with U.S. faculty Now, Ukrainian faculty assist with co-teaching in other new centers Instructor:Student ratio maintained, 1:4-5 Certificates only issued if written exam and skill stations were independently completed

94 Number of Specialists Trained in
Training Centers

95 Perinatal and Newborn Mortality
in Ukraine ( )

96 Neonatal Mortality in Regions where there are Training Centers

97 The following issues remain unresolved:
Legalizing the work of the centers Certification - national issues Standardization of program throughout Ukraine

98 Suggestions with respect to further cooperation:
Support the creation of 8-10 additional Training Centers due to the vast area of Ukraine Regular scientific forums on issues of primary newborn resuscitation Involvement of international experts in the development of national neonatology standards

99 Neonatal Resuscitation in Slovakia 1992..2001
Peter Krcho MD,PhD NICU Perinatal Center Kosice Slovakia 1

100 Situation before The newborns were not resuscitated by neonatal team
Airway management Р not adequate and late The majority of cases did not receive adequate care... High neonatal mortality 2

101 Our Priorities in 1992 Early detection of the problems after delivery in newborns Early resuscitation with bag and mask Better selection of the kind of follow up intervention that is necessary START with better CPR especially in perinatal centers CPR managed by neonatal physicians and nurses not by anesthesiologists IT WAS THE BEGINNING OF THE REGIONALIZATION PROCESS 3

102 Present ... Better collaboration between the units
EBM interventions are now clear In most severe cases still intrauterine transport is the best ... 4

103 What are our priorities now
Better intervention in all cases Intrauterine transport to the perinatal center Decrease of NM in the whole region especially in newborns under 1499g Delivery of high risk pregnancies in regional center,... under 999g 5

104 Continue with ... After 9 years of CPR projects we need to continue retraining Updating the training modality Use better education techniques- Real time video , www based education, better selection of the NICU team ... ...skills, skills, skills... 6

105 How did we make it ... AAP/AHA training guidelines from 1992
Direct personal teaching Every neonatal physicians and nurses in contact with newborns resuscitation dolls, photodocumentation and direct participation in transport, or resuscitation in delivery room It has impacted networking, better confidence for the center 7

106 8

107 Intrauterine transport to the Perinatal Center

108 Statistical Proof 10

109 Still some severe problems...
Can we provide the best skills over 24 hours? Can we build the best team in region? Can we maintain the same level with the same equipment? Can we follow the progress of the world... 11

110 Case Р ULBWN 540g 12

111 Sustainability / Dissemination / Teaching

112 In Closing: Issues for the Future of NRP

113 Sustainability Issues
Ministry level support to “legalize”center activities and training Affiliation of centers with academic institutions Incorporation of NRP into CME to ensure standardization Development of a recertification process to ensure skills are maintained

114 Sustainability Issues
Quality monitoring of courses to ensure the certification process is legitimate Development of an outreach plan to ensure widespread dissemination Development of additional centers in large countries Obtaining basic resuscitation equipment for all institutions

115 Sustainability Issues
Technical support for centers to encourage continued networking and communication between hospitals, health departments and the Ministry Development of Perinatal Networks (regionalization) to support those infants who need continued care

116 NRP TC - Start Up Costs Medical equipment for skills
stations plus shipping $7,000.00 Office Equipment, furniture $ Educational materials $2,000.00 Training by US Trainers One 2 person trip $10,000.00 TOTAL $28,200.00

117 NRP TC Maintenance Costs
Telephone and connections $1,680.00 Equipment resupply, manuals, office supplies, printing $5,100.00 Outreach courses and quality assessment visits $5,260.00 Yearly total per center $12,040.00

118 The Future of NRP in the Former Soviet Union
NRP Steering Committee formed in 2000 Encourage collaboration between centers Establish standards for NRP Courses in these countries Learn from each other

119 The Future of NRP in the Former Soviet Union
Collectively address problems of sustainability Quality assessment plan implemented Implementation of new evidence based medicine guidelines, beginning with faculty training, Fall 2001


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