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

2. NEONATAL RESUSCITATION PROGRAM (NRP) AN OVERVIEW
SUDHAKAR G. EZHUTHACHAN, MD, DCH, FAAP
HEAD, DIVISION OF NEONATOLOGY
HENRY FORD HEALTH SYSTEM
DETROIT , MI

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)

14. NRP 2000 GUIDELINES EVIDENCE BASED RECOMMENDATIONS
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

15. NRP 2000 GUIDELINES EVIDENCE BASED RECOMMENDATIONS
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

16. FIRST IMPRESSIONS

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.

48. IMPACT OF NRP EDUCATION at 10 centers in INDIA
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

60. THE EFFECTS OF LOW TEMPERATURE ON AN INFANT
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 Center9

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 / Teaching14

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