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
2 NEONATAL RESUSCITATION PROGRAM (NRP) AN OVERVIEW SUDHAKAR G. EZHUTHACHAN, MD, DCH, FAAPHEAD, DIVISION OF NEONATOLOGYHENRY FORD HEALTH SYSTEMDETROIT , MI
3 WHY DO WE NEED NRP ?At least 10 % of all newborns require some assistance at birth i.e. the initial steps of resuscitationAnd 1% require extensive resuscitationThere 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 CareCommunity Hospitals played pivotal role in neonatal resuscitationNIH funding of 5 educational grants to address neonatal resuscitation trainingAmerican Academy of Pediatrics (AAP) forms group to address training
5 NRP IN THE U.S.A.AAP and the American Heart Association led NRP developmentNRP faculty approach was tiered-National, Regional and Hospital Based1987- 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 CompetencyLinked to Accreditation of InstitutionsStandard 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 evidenceWhat 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 proofDefinition is subjective to interpretationWide latitude as to what constitutes proofCan be reflected in guidelines and recommendationsU.S. Preventive Services Task force developed Classification Schema for Quality of evidence
9 Evidence Based Medicine in NRP Ten major questions were reviewedExtensive literature search on each topicEach 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 trialsLevel 4 = Historic, non-randomized, cohort or case control studiesLevel 8 = Rational conjecture (common sense), common accepted practice before evidence based guidelines
11 EBM - Next StepCritically evaluate the quality of each source in terms of research design and methods.Scale: Excellent to unsatisfactoryEvaluate direction of the study results and the statisticsScale: Supportive, neutral, opposing proposal
12 Final Step Determine the class of recommendation Class I - definitely recommendedClass II - acceptable and usefulClass II a - Acceptable and useful, very good evidence provides supportClass II b - Acceptable and useful, fair to good evidence provides supportClass 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 NRPMembers 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 stainedPrevent heat loss and avoid hyperthermiaUse of 100% oxygen onlyPotential use of laryngeal mask and exhaled CO2 detectorsChange in chest compression method and simplified rate response
15 NRP 2000 GUIDELINES EVIDENCE BASED RECOMMENDATIONS Early administration of epinephrineAlbumin no longer the fluid of choice; isotonic crystalloid solution isPotential for use of intraosseous routeWhen resuscitation may not be initiated or may be discontinued in the delivery room
18 Program ComponentsNeonatal 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 ProgramImplementation based on perinatal regionsSelf-study textbookAppropriateness for all professional levelsAdaptability for local practiceFormats of the NRP courseSelf-studySmall group1- or 2-day course
19 Program Components Educational resources of the original Program Self-study textbookEducational videoApproximately 300 slidesSkill stations (course training equipment)Instructor’s ManualNRP test packageStandardized final written evaluation and practical tests
20 Program Components Didactic components of the original Program Student textbook provided prior to the course dateProvider Course consisting of 6 separate lessons, each covering a specific area of a neonatal resuscitationLectures and practical training at the skill stationsInstructor Course - to prepare those providers who would become “teachers”
21 Assess baby’s response to birth Establish effective ventilation Program ContentAssess baby’s response to birthAlways needed by newbornsInitial stepsEstablish effective ventilationBag and maskEndotracheal intubationNeeded less frequentlyProvide chestcompressionsRarely needed by newbornsAdministermedications
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 ParticipantsAnyone responsible for any part of a neonatal resuscitation is an appropriate candidate for a provider course.Historically, only physicians were considered participants in resuscitationCurrently, neonatologists, obstetricians, midwives, nurses, anesthesiologists and pediatricians have been included in the provider courses.
24 NRP InstructorsThe 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
27 NRP InstructorsTo become an NRP instructor, a person must meet the following eligibility requirements:Be a physician or nurse from critical care nursery settingHave 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 InstructorsIt 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 andits 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 practiceWorking 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 solveParticipants 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 skillsMedical 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 UnionImportanceImportant not only for a depressed infant but every newborn.Making decisions about further steps of resuscitation happens hereThis step requires only a few seconds, so mastering the sequence of the skills is very important.Prevention of heat loss mostly was neglectedSuctioning 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 preventionOpening of airwaysAssessment of the infantPosition the infantSuctioning mouth, then noseBreathingHeart rateColorPlace on warmerDry the newbornRemove wet towelif needed intubate andsuctioning tracheaif necessary provide tactile stimulation and give free flow oxygen
37 Importance Common practice in Former Soviet Union Station 2 - Support BreathingImportance Common practice in Former Soviet UnionHarmful methods and prolonged tactile stimulation were usedSupport breathing was based on medicationsVentilation with bag and mask was rare, mostly initiating breathing was conducted mouth-to-mouth breathingSupporting oxygenation,establishment of spontaneousbreathing and timely prevention of hypoxiagetting acquainted with the equipment and how it workslearning how to ventilate safelyidentification of indications for chest compression
38 Performing ventilation Station 2 - Support BreathingSelection of appropriate equipment and ensure it is functioningPerforming ventilationAdequate rateAdequate pressureAssessment of adequate ventilationAssessment of HRDecision of next steps of resuscitation
39 Station 3 - Support Circulation Common Practice in Former Soviet UnionImportanceProvision of artificial heart rateRestoring circulationEnsuring adequate oxygen supplyChest compression was initiated primarily after cardiac arrestChest compressions were never combined with ventilationSometimes harmful methods of compression were used
40 Station 3 - Support Circulation Techniqueposition the infantfirm support for the back,neck slightly extended2 finger techniquethumb techniqueadequate location, depth and ratecoordination of chest compression ventilationassessment of HR in sec.
41 Station 4 - Endotracheal Intubation Importance Common practice in Former Soviet UnionIdentification of indicationsIntubation often was not limited to 20 secThe indications were often ignoredIneffective bag and mask ventilationprolonged ventilationTracheal suctioningdiaphragmatic hernia
42 Station 4 - Endotracheal Intubation Selection and preparationof the equipmentTechniquePosition the infantInsertion of laryngoscope andvisualization of glottisInsertion of ET tubeChecking the tube placementSecuring the tubeSelection of the endotracheal tube sizeSelection and preparation of laryngoscopewith appropriate size of bladePreparation of suctioning andventilating equipment
43 Show me and I may not remember Tell me and I’ll forgotShow me and I may not rememberinvolve me, and I understand
44 Quality Assessment of NRP Sudhakar G. Ezhuthachan, MD, DCH, FAAP
45 Evaluation Strategies Evaluation of the course - maintaining course standardsEvaluation of clinical application of knowledgeEvaluation of patient outcomes
46 Evaluation by OthersU.S. NRP Steering Committee has just begun to discuss evaluation of the courseIllinois, 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 OthersKerala, India - Use of a standardized curriculum like NRP reduced perinatal asphyxia after deliveryZhuhai, 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 valueTotal live birthsResuscitationBag/ Mask Ventilation (2.1) (4.1) <0.001Intubations (2.2) (2.1) NSApgar score <41 min (4.5) (3.0) <0.0015 min (2.0) (1.0) <0.001OutcomeMAS 97 (1.9) (2.1) NSRespiratory distress (7.1) (5.7) <0.01Seizures (2.1) (0.7) <0.001Asphyxial Brain injury (2.0) (0.6) <0.001Total deaths (3.1) (2.4) <0.05
49 Early Attempts in Ukraine Data collected on every birth in maternity houses in western UkraineImplementation sets were used as incentiveData sent monthly to the NRP Training CenterCollection was tedious and not everyone participated
50 Rater (per 1000) of CNS Abnormalities in 7 day-old newborns in 3 hospitals
51 Evaluation of CoursesFirst courses were co-taught with US faculty in most CentersPeer review process currently being developed and is to be discussed at next Steering Committee MeetingKey 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 2001Institutions evaluated - 3 in 1999, 6 in 2001District as well as City sitesComponents 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 trainingNurses - 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 StaffMost had been trained in regional center, and one was an outreach courseStudent to instructor ratios appropriateAll hospitals have a process to notify the resuscitation team of a deliveryAll hospitals transferred high risk mothers appropriately as soon as possible to the City
55 EquipmentThe most crucial issue - one can educate a whole country, but without appropriate “tools”, clinical application is difficultImplementation sets distributed in 1997 were depletedEquipment is well taken care - “guarded”8 of 9 had excellent Delivery Room set upFeedback from staff on equipment was obtained
56 PerformanceObservation of deliveries and preparation for deliveries yielded positive application of principlesDocumentation in the medical record substantiated this findingMock 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 principlesManagement of infants with meconium stained amniotic fluid needed reinforcementThermal 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 rapidlyHypothermia reduces the ability of the infant to respond to resuscitation effortsHypothermia 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 AcidosisCold StressDeathConvulsionsHYPOTHERMIAPulmonary VesselSpasmLow GlucoseMoreHypothermiaLack ofOxygenMore AcidProduction
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%Excellent30%Good53%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 proceduresThe 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 results19961997- Passed- Failed2000
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 networksCreation of departments specializing in care of children who had problems at birthIncreasing the role of mid-level medical personnel in providing NR
80 Measures to Improve Neonatal Care Analysis of legal and ethical aspects of this issueResearch (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 DepartmentMinistry of Health of Ukraine
87 List of Legal and Regulatory Documents, National, State and Target Programs in the Scope of Maternal and Child Health Care in UkraineLong-term Program to improve status of women, family, Maternal and Child CareComplex Program to resolve disability problemNational Program “Children of Ukraine”Additional activities to support implementation of the National Program “Children of Ukraine” up until CY 2005National Program on “Reproductive Health”
88 Key Objectives of the National Program “Children of Ukraine” Improvement of medical care to pregnant women and newbornsMorbidity 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 neonatologistsTeach Ukrainian InstructorsDevelop and equip Training CentersStart mass dissemination of neonatal resuscitation principles among medical staffApply new medical techniques in neonatologyCreate a distinctively new system of health care delivery to newborns
92 Standardized Approach to Training First Training Center was created through an AIHA partnershipReplication of this model was used to open 5 additional centersInstructor training program was developed to help standardize the course format and prepare instructorsInstructor training model has been used to train instructors from many countries.
93 Standardized Approach to Training First courses were co-taught with U.S. facultyNow, Ukrainian faculty assist with co-teaching in other new centersInstructor:Student ratio maintained, 1:4-5Certificates only issued if written exam and skill stations were independently completed
94 Number of Specialists Trained in Training Centers
96 Neonatal Mortality in Regions where there are Training Centers
97 The following issues remain unresolved: Legalizing the work of the centersCertification - national issuesStandardization 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 UkraineRegular scientific forums on issues of primary newborn resuscitationInvolvement of international experts in the development of national neonatology standards
99 Neonatal Resuscitation in Slovakia 1992..2001 Peter Krcho MD,PhDNICU Perinatal Center Kosice Slovakia1
100 Situation before The newborns were not resuscitated by neonatal team Airway management Р not adequate and lateThe majority of cases did not receive adequate care... High neonatal mortality2
101 Our Priorities in 1992Early detection of the problems after delivery in newbornsEarly resuscitation with bag and maskBetter selection of the kind of follow up intervention that is necessarySTART with better CPR especially in perinatal centersCPR managed by neonatal physicians and nurses not by anesthesiologistsIT WAS THE BEGINNING OF THE REGIONALIZATION PROCESS3
102 Present ... Better collaboration between the units EBM interventions are now clearIn most severe cases still intrauterine transport is the best ...4
103 What are our priorities now Better intervention in all casesIntrauterine transport to the perinatal centerDecrease of NM in the whole region especially in newborns under 1499gDelivery of high risk pregnancies in regional center,... under 999g5
104 Continue with ...After 9 years of CPR projects we need to continue retrainingUpdating the training modalityUse 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 teachingEvery neonatal physicians and nurses in contact with newbornsresuscitation dolls, photodocumentation and direct participation in transport, or resuscitation in delivery roomIt has impacted networking, better confidence for the center7
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
113 Sustainability Issues Ministry level support to “legalize”center activities and trainingAffiliation of centers with academic institutionsIncorporation of NRP into CME to ensure standardizationDevelopment of a recertification process to ensure skills are maintained
114 Sustainability Issues Quality monitoring of courses to ensure the certification process is legitimateDevelopment of an outreach plan to ensure widespread disseminationDevelopment of additional centers in large countriesObtaining 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 MinistryDevelopment 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 $7,000.00Office Equipment, furniture $Educational materials $2,000.00Training by US TrainersOne 2 person trip $10,000.00TOTAL $28,200.00
117 NRP TC Maintenance Costs Telephone and connections $1,680.00Equipment resupply, manuals, office supplies, printing $5,100.00Outreach courses and quality assessment visits $5,260.00Yearly total per center $12,040.00
118 The Future of NRP in the Former Soviet Union NRP Steering Committee formed in 2000Encourage collaboration between centersEstablish standards for NRP Courses in these countriesLearn from each other
119 The Future of NRP in the Former Soviet Union Collectively address problems of sustainabilityQuality assessment plan implementedImplementation of new evidence based medicine guidelines, beginning with faculty training, Fall 2001