NEW PROGRAM * NOUVEAU PROGRAMME

A practical program to maintain neonatalresuscitation skills

David E. Walker, BSc, MD, CCFP; Linda Balvert, RN

A primipara 19 years of age at 30 to 31 weeks'gestation was in advanced active labour whenshe arrived at Alexandra Marine and General

Hospital, a level I birthing facility in Goderich, Ont. Be-cause of the precipitate nature of her labour, there was

no opportunity to send her to the nearest level III hospi-tal, some 110 km away.

Staff prepared for the birth and anticipated the needfor resuscitation, support and, when the baby had be-come stable, transport. The vaginal birth 50 minutes

later was unremarkable. The baby girl cried sponta-neously, and she was moved to the preheated radiantwarmer. In 10 to 20 seconds she was dried, positionedand provided with suction of her mouth and nose. Thebaby's respirations were adequate, and her heart rate wasmore than 100 beats/min. She was acrocyanotic. A1-minute Apgar score of 7 was assigned. After 2 minutesher respirations were becoming increasingly labouredand irregular; bag and mask ventilation with 100% oxy-gen was started. The heart rate remained over 100beats/min and the baby's colour, which had becomepaler, improved. Intubation was attempted with an endo-tracheal tube of 3.0 mm internal diameter, prepared andprecut to 13 cm. This attempt was aborted because of in-ability to insert the tube within 20 seconds. The babywas given positive pressure ventilation with 100% oxy-gen between the first and a successful second attempt atintubation. An orogastric tube was inserted within 2minutes. An umbilical vein catheter was also inserted forintravenous access while staff awaited the transportteam. Unfortunately, during the insertion of the catheterthe endotracheal tube was inadvertently dislodged. Theapneic baby quickly became pale, and her heart rate fellbelow 60 beats/min. Fortunately, the situation wasquickly reversed. External cardiac massage was started,the endotracheal tube was removed, the baby was givenventilation with 100% oxygen, and the tube was re-placed and taped securely in place. Within 30 secondsthe baby's heart rate was over 100 beats/min, her colourwas pink, and she was making spontaneous movements.The transport team arrived 2 hours after the birth. Thebaby was stable, and she was being given ventilationwith 75% to 80% oxygen to maintain the oxygen satura-tion above 90%. The baby was kept warm by the radiant

Dr. Walker is chairman of the Maternal and Newborn Committee ofAlexandra Marine and General Hospital, Goderich, Ont., and a member ofthe Neonatal Resuscitation Program Advisory Group of the Heart and Stroke Foundation of Ontario, and Ms. Balvert is the head nurse forobstetrics and a member of the Maternal and Newborn Committee ofAlexandra Marine and General Hospital, Goderich, Ont.

Reprint requests to: Dr. David E. Walker, Alexandra Marine and General Hospital, 120 Napier St., Goderich, ON N7A IW5

CAN MED ASSOC J 1994; 151 (3) 299

Resume: La mise en oeuvre dans les hopitaux duprogramme de reanimation des nouveau-nes (PRN) aetabli une norme 'a l'egard des techniques de reani-mation des nouveau-nes. Malheureusement, les reani-mateurs perdent rapidement leur technique s'ils ne lapratiquent pas regulierement. Pour corriger le pro-bleme, les auteurs ont mis au point un programmepratique de maintien de la competence en reanima-tion des nouveau-nes des professionnels qui oeuvrentdans un hopital communautaire. Ce programme estbase sur les exercices reguliers, la creation d'un postede travail permanent, un systeme de scenarios pra-tiques fondees sur celles du PRN et des rappels nonfondes sur la confrontation. Parce qu'il met l'accentsur le maintien des competences, le systeme semblebenefique pour tous les participants, qui acquierentun sentiment de confiance et de competence, ap-prennent 'a travailler en equipe et a se respecter mu-tuellement. Apres une evaluation plus poussee, onpourra appliquer un tel programme 'a des hopitaux detoutes tailles.

<-- For prescribing information see page 368

warmer, a well-heated birthing area and warm, moistur-ized oxygen.

The physicians and nurses who cared for this infantfelt confident and organized in their approach to the re-suscitation. Three days before the birth they had at-tended the monthly hospital perinatal rounds, which hadincluded a review of neonatal resuscitation and a prac-tice session. While they awaited the birth they took theopportunity to "run through some scenarios" at theneonatal resuscitation workstation, which is set up per-manently in the birthing area.

Life support is needed in the birthing room or nurs-ery for 6% of all newborns and for a much higher per-centage of low-birth-weight newborns.' All of thoseinvolved in delivery, including physicians, nurses, anes-thetists and respiratory therapists, must possess the skillsneeded to perform neonatal resuscitation.

In hospitals in which the number of births is rela-tively low or physicians attend few births, neonatal re-suscitation skills may be used infrequently. Because theresponse must be swift and accurate if resuscitation isneeded, staff must maintain these skills in the meantime.

Canadian guidelines for neonatal resuscitation haveexisted since 1989.2 These guidelines have been sup-ported by all professional groups involved in resuscita-tion. There is also a training program, the Neonatal Re-suscitation Program (NRP), contained in an excellenteducation manual endorsed by the Canadian PaediatricSociety, the Heart and Stroke Foundation of Canada, theAmerican Heart Association and the American Academyof Pediatrics.3

The manual follows a self-paced learning format. Itbegins with an introductory section including pathophys-iology followed by a series of lessons on the differentactivities associated with neonatal resuscitation. Eachlesson builds on the skills learned in the previous one.Lessons include initial evaluation and management ofnewborns at risk, preparation and use of equipment forassisted ventilation, performance of chest compressionand endotracheal intubation, and the use of drugs for se-verely ill infants.

To achieve the CMA's stated goal of every hospitalbeing able to provide effective newborn resuscitation4 itwas necessary to establish provincial training programs.Training programs that follow the NRP have been set upin regional perinatal centres in each province through theHeart and Stroke Foundation. Instructors at the regionalperinatal centres provide training for hospital-based in-structors, who, in turn, train NRP providers.5 In Ontario,for example, the NRP Advisory Group of the Heart andStroke Foundation of Ontario oversees and promotessuch training programs.

There is still wide variation in the implementationof training programs from region to region in Ontario.According to the Review of Maternal and Newborn Hos-pital Services in Ontario,6 the proportion of hospitals in aregion that have guidelines for neonatal resuscitation

ranges from 16.7% to 73.2%. There is also wide regionalvariation in the number of hospitals that have completedstaff training.

In southwest Ontario, where Alexandra Marine andGeneral Hospital is located, more than 700 providers and100 instructors have been trained. Still, many medicalpersonnel have not yet taken provider courses. Ways ofpromoting provider courses to them are sought. Many ofthe providers in the region have been reregistered after 2years.

A review of articles about the NRP showed thatmost deal with the establishment of the program.` In areview of early experience with the NRP, Byrd' con-cluded that there are four successful features of the pro-gram: it addresses a topic of concern to all institutionsregardless of size (neonatal resuscitation), the materialpermits full staff participation, the training of hospital-based instructors creates enthusiasm and promotes thecontinuity of the program, and the use of regional centrefaculty to train the hospital-based instructors strengthensrelationships and communication.

Singhal and associates' investigated changes in atti-tudes and resources (written protocols and resuscitationequipment) after the introduction of the NRP. Traineesfrom 35 hospitals participated in NRP workshops. Theywere asked to fill out questionnaires before and after theworkshops. Results from these surveys showed that par-ticipants' beliefs and attitudes toward resuscitation, andespecially their confidence, changed significantly.

Two studies have evaluated and assessed adherenceto the standards for neonatal resuscitation.""' McCullochand Vidyasagarl' concluded that the educational materi-als of the NRP provide standards for the management ofnewborn infants. They used the NRP standards success-fully to assess the quality of neonatal resuscitation in thebirthing areas of their study hospital. They concludedthat education, followed by systematic, continuing eval-uation of birthing area personnel, improves professionalperformance.

Dunn and associates" undertook a randomized con-trolled trial to evaluate a neonatal resuscitation educationprogram. Half of the 190 nurses involved were assignedto the experimental group and half to the control group.Directly after they took the program the nurses in the ex-perimental group had significantly improved knowledgeand skill performance. Six months later their knowledgewas maintained but their skill performance was not. Theinvestigators also found a significant relation betweenthe subjects' self-rated knowledge level and their resultson knowledge testing. Since all of the subjects failed the6-month skill test, although 23% had rated themselves ascompetent, the skill self-rating appeared to have minimalvalue. The investigators concluded that future studiesshould focus on ways to increase the retention of skills.

Moser and Coleman'" showed similar results intheir review of retention of skills in adult cardiopul-monary resuscitation. Retention of skills was poor in all

300 CAN MED ASSOCJ 1994; 151 (3) LE Ic''AOUJT 199)4

groups, with significant loss after only several weeks.Skills consistently returned to pretraining levels 1 yearafter training. Furthermore, the perception of this skillloss was poor; physicians, in particular, overestimatedtheir performance skills. Frequent use of skills did notappear to improve retention significantly. Only practicewith correction of errors had a proven benefit.

Staff at the Alexandra Marine and General Hospitalagreed that the NRP set a laudable standard for all hospi-tals with birthing facilities, but they anticipated that skillmaintenance might be difficult in a small hospital.Therefore, they created a practical program to maintainneonatal resuscitation skills.

The Alexandra Marine and General Hospital is acommunity hospital with 50 acute care beds that serves apopulation of 7500. It is located 110 km northwest ofLondon, Ont., which is the regional centre for south-western Ontario. There are between 100 and 135 birthsper year at the hospital.

Two hospital-based NRP instructors were trained inLondon in July 1990. The first provider course wasgiven at the hospital in November 1990. Within 18months all obstetric nurses, supervisors and operatingroom nurses were registered. Five of the seven physi-cians providing obstetric care and one of two anes-thetists have completed provider courses. All providerswho have been registered for 2 years have completedreregistration requirements.

The hospital's Maternal and Newborn Committeesought input from both nurses and physicians, through asurvey and round-table discussion at perinatal rounds, toidentify the obstacles to maintaining neonatal resuscita-tion skills.

Nurses identified several obstacles. They were notalways able to attend formal review sessions, such asthose conducted during rounds, because of shift work.Because of staff cutbacks and increased workload,nurses found it difficult to make the time to practise theirskills during shifts. They cherished any breaks theymight have. Most worked part-time and were infre-quently involved with births. They all found formalpractice and test sessions stressful, especially when per-formed with physicians.

Some of the obstacles identified by physicians werethe following. Most felt constrained by lack of time andfelt that they were "spread too thinly." Maintenance ofskills for neonatal resuscitation, although felt to be veryimportant, was just one of many continuing medical edu-cation demands. In general, physicians did not like to beput on the spot and preferred to avoid formal sessions inwhich they might have to perform, especially withnurses present. They recognized that lack of practice dueto inadequate caseloads was a major problem. Manyphysicians who attended few births felt that they did notneed the course.

Having identified these obstacles, we realized thatconvenience and minimizing of stress were important.

With these in mind, we designed a program to provideways of maintaining confidence and competence for allneonatal resuscitation providers.

Program description

The practical program to maintain neonatal resusci-tation skills is based on the following elements: reviewand practice, a dedicated workstation and area, a methodfor correction of errors and audit, and a method for re-minders and motivation.

Practise, practise, practise - regularly

Before studying for the NRP provider level, manyhealth care professionals were sceptical of the programor felt they already possessed the knowledge and skillsneeded for effective neonatal resuscitation. It rapidly be-came apparent from the training manual and the providercourse that the simplicity and the reproducibility of skillperformance flow from regular practice. If regular prac-tice is lacking, there is a rapid loss of these aspects ofskills. Regular practice builds not only competence butalso cooperation, mutual respect and a team approachamong physicians and nurses.

At the Alexandra Marine and General Hospital pro-fessionals practise as part of perinatal rounds, during in-formal sessions with a "buddy" and during formal re-view and reregistration exercises.

Once a month the Maternal and Newborn Commit-tee organizes rounds that bring together physicians andnurses involved with obstetric and newborn care. Topicsof interest and case presentations generate discussion.Every 3 months, at least a portion of this time is used bythe hospital-based instructor to demonstrate neonatal re-suscitation and to update staff on any practice changes.Such sessions are called megacode reviews (the mega-code is the algorithm that summarizes the steps ofneonatal resuscitation). Providers must attend one suchsession yearly to qualify for reregistration. At such ses-sions, there is an opportunity to practise informally inpairs with the use of predesigned scenarios picked atrandom.

Informal, nonstructured practice sessions are possi-ble at any time with the use of a permanent, fully set-upworkstation (Fig. 1). This type of session works bestwith two "buddies" who alternately select scenariosfrom the NRP-Skill Maintenance Scenarios, created byus and based on the NRP megacode and the course ma-terial dealing with medications."3"3 In the absence of a"buddy," solo practice is still beneficial. This type oflearning is completely self-directed and, therefore, notstressful.

Practice also occurs at structured reregistration ses-sions. Although they are valuable, these sessions are nota substitute for regular practice. In our hospital, pro-viders who do not practise regularly (a minimum of one

301CAN MED ASSOC J 1994; 151 (3)AUGUST 1, 1994

practice session every 6 months) are ineligible to rereg-ister and are requested to complete the NRP trainingcourse again.

Create a workstation

The creation of a workstation (Fig. 2) at whichall of the equipment is ready for use, night or day, in areadily accessible area is an essential part of this pro-gram. For busy physicians, nurses and respiratory thera-pists, having to get out mannequins, intubation equip-ment and so on is a serious disincentive to practising.For this reason, a spacious table approximately theheight of an infant warmer was set up with all of theequipment needed to conduct all of the scenarios in amegacode. Even oxygen and suction equipment are pro-vided to simulate the real resuscitation situation asclosely as possible. The table is on wheels so that it canbe moved conveniently to other areas for teaching andpractice.

The workstation must be located conveniently,close to the work area. In our hospital the workstation isset up in the birthing area so it is readily accessible tophysicians for practice while awaiting a birth and tonurses who have some time on a quiet shift.

A file-card box containing the NRP-Skill Mainte-nance Scenarios and a Provider Practice Record card foreach registered provider is kept at the workstation.

Created scenarios facilitate practiceand correction of errors

The eight NRP-Skill Maintenance Scenarios rangefrom the most easy to the most difficult, and four in-volve the presence of meconium.

The scenarios are classified as follows.Al: Active and healthy newborn - stimulation

with or without free-flow oxygen may be indicated.A2: Active and healthy newborn - meconium

present.Bi: Bag and mask ventilation indicated.B2: Bag and mask ventilation indicated - meco-

nium present.Cl: Chest compressions indicated.C2: Chest compressions indicated - meconium

present.DI: Drugs indicated.D2: Drugs indicated- meconium present.The clinical information to be given to providers

being tested is highlighted (Fig. 3). They must talk aboutwhat they are doing and ask for appropriate informationas they perform the scenario.

The scenarios provide an easy and organized ap-proach, facilitate informal testing and review forproviders and instructors, and provide a method for cor-recting errors. Providers who successfully contend withall eight of these scenarios will have a sound knowledgeof neonatal resuscitation. Providers have 2 years to com-plete all eight scenarios. Creating other scenarios withthe same format adds interest and fun to the program.

Post reminders in work areas

Signs posted in work areas ("ONLY YOU CAN,i , .: _ . .......... ~~-.sE .I.: . _~~~~iI

Fig. 1: Health care professionals practise neonatal resusci-tation techniques informally at a permanent workstationestablished for this purpose.

Fig. 2: At the workstation all equipment needed to prac-tise neonatal resuscitation, including mannequins andequipment for suction, intubation and ventilation withoxygen, is ready for use day and night.

302 CAN MED ASSOCJ 1994. 151 (3) I-E I 'AOUJT I1994

'.

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a ;

rewi.,

SAVE A NEWBORN - visit our NRP workstation")act as a reminder. We hope that such signs nudge theconscience better than written reminders, which are gen-erally received begrudgingly.

This program has been in place for more than 1year. Of the 30 providers registered 6 are physicians and24 are registered nurses. During the first year of the pro-gram monthly rounds included a review of the NRPmegacode and, on seven occasions, a practice session.The workstation has been used on 45 occasions to prac-tise 130 scenarios. Of the 30 providers 18 (60%) haveused all eight scenarios, 5 (17%) have used four toseven, and 7 (23%) have used fewer than four. Four(13%) have failed to maintain the minimum standard ofone practice session every 6 months.

Providers are given an outline of the program. TheProvider Practice Record cards kept in the file-card boxat the workstation furnish an easy method of evaluatingthe use of the workstation. They also indicate the fre-quency with which scenarios are used and by whom.The record cards include a column in which the providercan grade (on a scale from 0 to 5) his or her level of con-fidence after performing each scenario; this is intendedto improve providers' perception of their skills. It is theproviders' responsibility to keep their cards up to date.The date of practices, which scenarios have been per-formed and the date of attendance at megacode reviewsare important not only for self-audit but also to indicatewhether guidelines for reregistration have been met.

The hospital-based instructors are responsible forthe skill maintenance program. Their enthusiasm is es-sential and serves as a motivating force. They are also

responsible for maintaining the workstation and auditingits use. If providers do not meet the guidelines, a verbalor written reminder may be necessary.

Discussion

The establishment of active training programs forneonatal resuscitation based on national guidelines hasbeen recommended for all Ontario hospitals with obstet-ric units.

At our hospital the NRP is widely known, andneonatal resuscitation techniques are frequently prac-tised as a result of the practical reinforcement program.There are no published reports of similar programs. Thestrengths of this program are its simplicity and conve-nience. The scenarios are easy to use, and the program issimple to monitor.

The main limitation of this program is that its suc-cess depends primarily on the motivation of the providerbecause it is largely self-directed.

This program provides a basis for skill maintenancefor the NRP. We plan to evaluate the program in two re-gions of Ontario through a controlled study, endorsed bythe Neonatal Resuscitation Program Advisory Group ofthe Heart and Stroke Foundation of Ontario. The knowl-edge and skills of NRP providers in level I, II and IIIhospitals will be tested before and after training. Simi-larly matched neonatal resuscitation providers will be as-signed to study and control groups; the study group willfollow the practical program for skill maintenance, andthe control group will have no structured program. Thetwo groups will be retested 1 year later. If previous ob-

e SCENARIO BIHealthy full term pregnancy. No anticipated concerns.

Cord tightly around the neck once at birth. Amniotic fluid Is clear

Note time of birthPlace infant on preheated radiant warmerDry amniotic fluid from body and headRemove wet linen from contact with infantPosition infant on flat surface with neck slightly extendedSuction mouth, then noseEvaluate respirations (GASPING)Slap foot, flick heel, or rub back briefly (optional)Evaluate respirations (APNEIC)Indicate need for bag and mask ventilationSelect bag, connect to 02 source capable of delivering 90-100% 02

Select correct size maskTest bagCheck infant's positionVentilate for 15-30 seconds

* Rate: 40-60 times per minute* Pressure: a slight rise and fall of chest attained (normal 15-20 cm H20)

Evaluate if chest moving satisfactorily. Rise? (YES)

Note: Apparatus should be kept in full working order

CONTINUED ON BACKC N.R.P. - S.M.S., 1994

CAN MED ASSOC J 1994; 151 (3) * 303

Fig. 3: A portion of one of the Neonatal Resuscitation Program-Skill Maintenance Scenarios.

I

AUGUST 1, 1994

servations hold true and if this program is successful,there should be a significant observed difference in skilllevels between the two groups."

This practical program provides a model for futurestudies that seek to improve the retention of skills inthose trained in resuscitation.

Material support was received from Alexandra Marine andGeneral Hospital, Goderich, Ont.

We thank Dr. Graham W. Chance, chairman, Division ofNeonatal-Perinatal Medicine, St. Joseph's Health Centre,London, Ont., for his review and suggestions.

References

1. Guidelines for cardiopulmonary resuscitation a.id emergency car-diac care. Emergency Cardiac Care Committee and Subcommit-tees, American Heart Association. Part VII. Neonatal resuscita-tion. JAMA 1992; 268: 2276-2281

2. National Guidelines for Neonatal Resuscitation, Canadian Insti-tute of Child Health, Ottawa, 1989

3. Bloom RJ, Cropley C: Textbook ofNeonatal Resuscitation, Amer-ican Heart Association and American Academy of Pediatrics,Dallas, 1990

4. Special Committee on Obstetrical Care, Canadian Medical Asso-ciation: Obstetrics 1987: a report of the Canadian Medical Associ-ation on obstetrical care in Canada. Can Med Assoc J 1987; 136(6, suppl)

5. Chance GW: The national neonatal resuscitation program. OntMed Rev 1993; 60 (3): 3 1-32

6. Review of Maternal and Newborn Hospital Services in Ontario:Final Report of the Hospital Assessment Team, Ontario Ministryof Health, 1991: 91-93

7. Bailey C, Kattwinkel J: Establishing a neonatal resuscitation teamin community hospitals. Am J Perinatol 1993; 10: 294-298

8. Byrd FH: Early experience with the neonatal resuscitation pro-gram. Neonatal Netw 1990; 9 (3): 35-39

9. Singhal N, McMillan DD, Lockyer JM et al: Attitudinal and re-source changes after a neonatal resuscitation training program.Neonatal Netw 1992; 11 (4): 37-40

10. McCulloch KM, Vidyasagar D: Assessing adherence to standardsfor neonatal resuscitation taught throughout the perinatal referralarea. Pediatr Clin North Am 1993; 40: 431-438

11. Dunn S, Niday P, Watters NE et al: The provision and evaluationof a neonatal resuscitation program. J Contin Educ Nurs 1992; 23:118-126

12. Moser DK, Coleman S: Recommendations for improving car-diopulmonary skills retention. Heart Lung 1992; 21: 372-380

13. Provider Renewal Megacode, American Heart Association andAmerican Academy of Pediatrics, Dallas, 1993

Conferencescontinuedfrom page 296

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continued on page 322304 CAN MED ASSOC J 1994; 151 (3) LE 1'' AOU)T 1994