NEW PROGRAM * NOUVEAU PROGRAMME

A practical program to maintain neonatal resuscitation skills

David E. Walker, BSc, MD, CCFP; Linda Balvert, RN
Resume: La mise en oeuvre dans les hopitaux du programme de reanimation des nouveau-nes (PRN) a etabli une norme 'a l'egard des techniques de reanimation des nouveau-nes. Malheureusement, les reanimateurs perdent rapidement leur technique s'ils ne la pratiquent pas regulierement. Pour corriger le probleme, les auteurs ont mis au point un programme pratique de maintien de la competence en reanimation des nouveau-nes des professionnels qui oeuvrent dans un hopital communautaire. Ce programme est base sur les exercices reguliers, la creation d'un poste de travail permanent, un systeme de scenarios pratiques fondees sur celles du PRN et des rappels non fondes sur la confrontation. Parce qu'il met l'accent sur le maintien des competences, le systeme semble benefique pour tous les participants, qui acquierent un sentiment de confiance et de competence, apprennent 'a travailler en equipe et a se respecter mutuellement. Apres une evaluation plus poussee, on pourra appliquer un tel programme 'a des hopitaux de toutes tailles.
later was unremarkable. The baby girl cried spontaneously, and she was moved to the preheated radiant warmer. In 10 to 20 seconds she was dried, positioned and provided with suction of her mouth and nose. The baby's respirations were adequate, and her heart rate was more than 100 beats/min. She was acrocyanotic. A 1-minute Apgar score of 7 was assigned. After 2 minutes her respirations were becoming increasingly laboured and irregular; bag and mask ventilation with 100% oxygen was started. The heart rate remained over 100 beats/min and the baby's colour, which had become paler, improved. Intubation was attempted with an endotracheal tube of 3.0 mm internal diameter, prepared and precut to 13 cm. This attempt was aborted because of inability to insert the tube within 20 seconds. The baby was given positive pressure ventilation with 100% oxygen between the first and a successful second attempt at intubation. An orogastric tube was inserted within 2 minutes. An umbilical vein catheter was also inserted for intravenous access while staff awaited the transport team. Unfortunately, during the insertion of the catheter the endotracheal tube was inadvertently dislodged. The apneic baby quickly became pale, and her heart rate fell below 60 beats/min. Fortunately, the situation was quickly reversed. External cardiac massage was started, the endotracheal tube was removed, the baby was given ventilation with 100% oxygen, and the tube was replaced and taped securely in place. Within 30 seconds the baby's heart rate was over 100 beats/min, her colour was pink, and she was making spontaneous movements. The transport team arrived 2 hours after the birth. The baby was stable, and she was being given ventilation with 75% to 80% oxygen to maintain the oxygen saturation above 90%. The baby was kept warm by the radiant

primipara 19 years of age at 30 to 31 weeks' gestation was in advanced active labour when she arrived at Alexandra Marine and General Hospital, a level I birthing facility in Goderich, Ont. Because of the precipitate nature of her labour, there was no opportunity to send her to the nearest level III hospital, some 110 km away. Staff prepared for the birth and anticipated the need for resuscitation, support and, when the baby had become stable, transport. The vaginal birth 50 minutes

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

Reprint requests to: Dr. David E. Walker, Alexandra Marine and General Hospital, 120 Napier St., Goderich, ON N7A I W5
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warmer, a well-heated birthing area and warm, moisturized oxygen. The physicians and nurses who cared for this infant felt confident and organized in their approach to the resuscitation. Three days before the birth they had attended the monthly hospital perinatal rounds, which had included a review of neonatal resuscitation and a practice session. While they awaited the birth they took the opportunity to "run through some scenarios" at the neonatal resuscitation workstation, which is set up permanently in the birthing area. Life support is needed in the birthing room or nursery for 6% of all newborns and for a much higher percentage of low-birth-weight newborns.' All of those involved in delivery, including physicians, nurses, anesthetists and respiratory therapists, must possess the skills needed to perform neonatal resuscitation. In hospitals in which the number of births is relatively low or physicians attend few births, neonatal resuscitation skills may be used infrequently. Because the response must be swift and accurate if resuscitation is needed, staff must maintain these skills in the meantime. Canadian guidelines for neonatal resuscitation have existed since 1989.2 These guidelines have been supported by all professional groups involved in resuscitation. There is also a training program, the Neonatal Resuscitation Program (NRP), contained in an excellent education manual endorsed by the Canadian Paediatric Society, the Heart and Stroke Foundation of Canada, the American Heart Association and the American Academy of Pediatrics.3 The manual follows a self-paced learning format. It begins with an introductory section including pathophysiology followed by a series of lessons on the different activities associated with neonatal resuscitation. Each lesson builds on the skills learned in the previous one. Lessons include initial evaluation and management of newborns at risk, preparation and use of equipment for assisted ventilation, performance of chest compression and endotracheal intubation, and the use of drugs for severely ill infants. To achieve the CMA's stated goal of every hospital being able to provide effective newborn resuscitation4 it was necessary to establish provincial training programs. Training programs that follow the NRP have been set up in regional perinatal centres in each province through the Heart and Stroke Foundation. Instructors at the regional perinatal centres provide training for hospital-based instructors, who, in turn, train NRP providers.5 In Ontario, for example, the NRP Advisory Group of the Heart and Stroke Foundation of Ontario oversees and promotes such training programs. There is still wide variation in the implementation of training programs from region to region in Ontario. According to the Review of Maternal and Newborn Hospital Services in Ontario,6 the proportion of hospitals in a region that have guidelines for neonatal resuscitation
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ranges from 16.7% to 73.2%. There is also wide regional variation in the number of hospitals that have completed staff training. In southwest Ontario, where Alexandra Marine and General Hospital is located, more than 700 providers and 100 instructors have been trained. Still, many medical personnel have not yet taken provider courses. Ways of promoting provider courses to them are sought. Many of the providers in the region have been reregistered after 2 years. A review of articles about the NRP showed that most deal with the establishment of the program.` In a review of early experience with the NRP, Byrd' concluded that there are four successful features of the program: it addresses a topic of concern to all institutions regardless of size (neonatal resuscitation), the material permits full staff participation, the training of hospitalbased instructors creates enthusiasm and promotes the continuity of the program, and the use of regional centre faculty to train the hospital-based instructors strengthens relationships and communication. Singhal and associates' investigated changes in attitudes and resources (written protocols and resuscitation equipment) after the introduction of the NRP. Trainees from 35 hospitals participated in NRP workshops. They were asked to fill out questionnaires before and after the workshops. Results from these surveys showed that participants' beliefs and attitudes toward resuscitation, and especially their confidence, changed significantly. Two studies have evaluated and assessed adherence to the standards for neonatal resuscitation.""' McCulloch and Vidyasagarl' concluded that the educational materials of the NRP provide standards for the management of newborn infants. They used the NRP standards successfully to assess the quality of neonatal resuscitation in the birthing areas of their study hospital. They concluded that education, followed by systematic, continuing evaluation of birthing area personnel, improves professional

performance. Dunn and associates" undertook a randomized controlled trial to evaluate a neonatal resuscitation education program. Half of the 190 nurses involved were assigned to the experimental group and half to the control group. Directly after they took the program the nurses in the experimental group had significantly improved knowledge and skill performance. Six months later their knowledge was maintained but their skill performance was not. The investigators also found a significant relation between the subjects' self-rated knowledge level and their results on knowledge testing. Since all of the subjects failed the 6-month skill test, although 23% had rated themselves as competent, the skill self-rating appeared to have minimal value. The investigators concluded that future studies should focus on ways to increase the retention of skills. Moser and Coleman'" showed similar results in their review of retention of skills in adult cardiopulmonary resuscitation. Retention of skills was poor in all
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groups, with significant loss after only several weeks. Skills consistently returned to pretraining levels 1 year after training. Furthermore, the perception of this skill loss was poor; physicians, in particular, overestimated their performance skills. Frequent use of skills did not appear to improve retention significantly. Only practice with correction of errors had a proven benefit. Staff at the Alexandra Marine and General Hospital agreed that the NRP set a laudable standard for all hospitals with birthing facilities, but they anticipated that skill maintenance might be difficult in a small hospital. Therefore, they created a practical program to maintain neonatal resuscitation skills. The Alexandra Marine and General Hospital is a community hospital with 50 acute care beds that serves a population of 7500. It is located 110 km northwest of London, Ont., which is the regional centre for southwestern Ontario. There are between 100 and 135 births per year at the hospital. Two hospital-based NRP instructors were trained in London in July 1990. The first provider course was given at the hospital in November 1990. Within 18 months all obstetric nurses, supervisors and operating room nurses were registered. Five of the seven physicians providing obstetric care and one of two anesthetists have completed provider courses. All providers who have been registered for 2 years have completed reregistration requirements. The hospital's Maternal and Newborn Committee sought input from both nurses and physicians, through a survey and round-table discussion at perinatal rounds, to identify the obstacles to maintaining neonatal resuscitation skills. Nurses identified several obstacles. They were not always able to attend formal review sessions, such as those conducted during rounds, because of shift work. Because of staff cutbacks and increased workload, nurses found it difficult to make the time to practise their skills during shifts. They cherished any breaks they might have. Most worked part-time and were infrequently involved with births. They all found formal practice and test sessions stressful, especially when performed with physicians. Some of the obstacles identified by physicians were the following. Most felt constrained by lack of time and felt that they were "spread too thinly." Maintenance of skills for neonatal resuscitation, although felt to be very important, was just one of many continuing medical education demands. In general, physicians did not like to be put on the spot and preferred to avoid formal sessions in which they might have to perform, especially with nurses present. They recognized that lack of practice due to inadequate caseloads was a major problem. Many physicians who attended few births felt that they did not need the course. Having identified these obstacles, we realized that convenience and minimizing of stress were important.
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With these in mind, we designed a program to provide ways of maintaining confidence and competence for all neonatal resuscitation providers.

Program description
The practical program to maintain neonatal resuscitation skills is based on the following elements: review and practice, a dedicated workstation and area, a method for correction of errors and audit, and a method for reminders and motivation.

Practise, practise, practise - regularly

Before studying for the NRP provider level, many health care professionals were sceptical of the program or felt they already possessed the knowledge and skills needed for effective neonatal resuscitation. It rapidly became apparent from the training manual and the provider course that the simplicity and the reproducibility of skill performance flow from regular practice. If regular practice is lacking, there is a rapid loss of these aspects of skills. Regular practice builds not only competence but also cooperation, mutual respect and a team approach among physicians and nurses. At the Alexandra Marine and General Hospital professionals practise as part of perinatal rounds, during informal sessions with a "buddy" and during formal review and reregistration exercises. Once a month the Maternal and Newborn Committee organizes rounds that bring together physicians and nurses involved with obstetric and newborn care. Topics of interest and case presentations generate discussion. Every 3 months, at least a portion of this time is used by the hospital-based instructor to demonstrate neonatal resuscitation and to update staff on any practice changes. Such sessions are called megacode reviews (the megacode is the algorithm that summarizes the steps of neonatal resuscitation). Providers must attend one such session yearly to qualify for reregistration. At such sessions, there is an opportunity to practise informally in pairs with the use of predesigned scenarios picked at random. Informal, nonstructured practice sessions are possible at any time with the use of a permanent, fully set-up workstation (Fig. 1). This type of session works best with two "buddies" who alternately select scenarios from the NRP-Skill Maintenance Scenarios, created by us and based on the NRP megacode and the course material dealing with medications."3"3 In the absence of a "buddy," solo practice is still beneficial. This type of learning is completely self-directed and, therefore, not stressful. Practice also occurs at structured reregistration sessions. Although they are valuable, these sessions are not a substitute for regular practice. In our hospital, providers who do not practise regularly (a minimum of one
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practice session every 6 months) are ineligible to reregister and are requested to complete the NRP training course again.

A file-card box containing the NRP-Skill Maintenance Scenarios and a Provider Practice Record card for each registered provider is kept at the workstation.

Create a workstation

Created scenarios facilitate practice and correction of errors

The creation of a workstation (Fig. 2) at which The eight NRP-Skill Maintenance Scenarios range all of the equipment is ready for use, night or day, in a readily accessible area is an essential part of this pro- from the most easy to the most difficult, and four ingram. For busy physicians, nurses and respiratory thera- volve the presence of meconium. The scenarios are classified as follows. pists, having to get out mannequins, intubation equipAl: Active and healthy newborn - stimulation ment and so on is a serious disincentive to practising. For this reason, a spacious table approximately the with or without free-flow oxygen may be indicated. A2: Active and healthy newborn - meconium height of an infant warmer was set up with all of the equipment needed to conduct all of the scenarios in a present. Bi: Bag and mask ventilation indicated. megacode. Even oxygen and suction equipment are proB2: Bag and mask ventilation indicated - mecovided to simulate the real resuscitation situation as closely as possible. The table is on wheels so that it can nium present. Cl: Chest compressions indicated. be moved conveniently to other areas for teaching and C2: Chest compressions indicated - meconium practice. The workstation must be located conveniently, present. close to the work area. In our hospital the workstation is DI: Drugs indicated. D2: Drugs indicated - meconium present. set up in the birthing area so it is readily accessible to The clinical information to be given to providers physicians for practice while awaiting a birth and to nurses who have some time on a quiet shift. being tested is highlighted (Fig. 3). They must talk about what they are doing and ask for appropriate information as they perform the scenario. The scenarios provide an easy and organized approach, facilitate informal testing and review for providers and instructors, and provide a method for correcting errors. Providers who successfully contend with all eight of these scenarios will have a sound knowledge of neonatal resuscitation. Providers have 2 years to complete all eight scenarios. Creating other scenarios with the same format adds interest and fun to the program.

Post reminders in work areas

Signs posted in work areas ("ONLY YOU CAN

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Fig. 1: Health care professionals practise neonatal resuscitation techniques informally at a permanent workstation established for this purpose.
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Fig. 2: At the workstation all equipment needed to practise neonatal resuscitation, including mannequins and equipment for suction, intubation and ventilation with oxygen, is ready for use day and night.
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SAVE A NEWBORN - visit our NRP workstation") act as a reminder. We hope that such signs nudge the conscience better than written reminders, which are generally received begrudgingly. This program has been in place for more than 1 year. Of the 30 providers registered 6 are physicians and 24 are registered nurses. During the first year of the program monthly rounds included a review of the NRP megacode and, on seven occasions, a practice session. The workstation has been used on 45 occasions to practise 130 scenarios. Of the 30 providers 18 (60%) have used all eight scenarios, 5 (17%) have used four to seven, and 7 (23%) have used fewer than four. Four (13%) have failed to maintain the minimum standard of one practice session every 6 months. Providers are given an outline of the program. The Provider Practice Record cards kept in the file-card box at the workstation furnish an easy method of evaluating the use of the workstation. They also indicate the frequency with which scenarios are used and by whom. The record cards include a column in which the provider can grade (on a scale from 0 to 5) his or her level of confidence after performing each scenario; this is intended to improve providers' perception of their skills. It is the providers' responsibility to keep their cards up to date. The date of practices, which scenarios have been performed and the date of attendance at megacode reviews are important not only for self-audit but also to indicate whether guidelines for reregistration have been met. The hospital-based instructors are responsible for the skill maintenance program. Their enthusiasm is essential and serves as a motivating force. They are also

responsible for maintaining the workstation and auditing its use. If providers do not meet the guidelines, a verbal or written reminder may be necessary.

Discussion
The establishment of active training programs for neonatal resuscitation based on national guidelines has been recommended for all Ontario hospitals with obstetric units. At our hospital the NRP is widely known, and neonatal resuscitation techniques are frequently practised as a result of the practical reinforcement program. There are no published reports of similar programs. The strengths of this program are its simplicity and convenience. The scenarios are easy to use, and the program is simple to monitor. The main limitation of this program is that its success depends primarily on the motivation of the provider because it is largely self-directed. This program provides a basis for skill maintenance for the NRP. We plan to evaluate the program in two regions of Ontario through a controlled study, endorsed by the Neonatal Resuscitation Program Advisory Group of the Heart and Stroke Foundation of Ontario. The knowledge and skills of NRP providers in level I, II and III hospitals will be tested before and after training. Similarly matched neonatal resuscitation providers will be assigned to study and control groups; the study group will follow the practical program for skill maintenance, and the control group will have no structured program. The two groups will be retested 1 year later. If previous obI

SCENARIO BI
Healthy full term pregnancy. No anticipated concerns. Cord tightly around the neck once at birth. Amniotic fluid Is clear
Note time of birth Place infant on preheated radiant warmer Dry amniotic fluid from body and head Remove wet linen from contact with infant Position infant on flat surface with neck slightly extended Suction mouth, then nose Evaluate respirations (GASPING) Slap foot, flick heel, or rub back briefly (optional) Evaluate respirations (APNEIC) Indicate need for bag and mask ventilation Select bag, connect to 02 source capable of delivering 90-100% 02 Select correct size mask Test bag Check infant's position Ventilate 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 BACK
C N.R.P. - S.M.S., 1994

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

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servations hold true and if this program is successful, there should be a significant observed difference in skill levels between the two groups." This practical program provides a model for future studies that seek to improve the retention of skills in those trained in resuscitation.
Material support was received from Alexandra Marine and General Hospital, Goderich, Ont. We thank Dr. Graham W. Chance, chairman, Division of Neonatal-Perinatal Medicine, St. Joseph's Health Centre, London, Ont., for his review and suggestions.

Conferences continuedfrom page 296

Sept. 16-18, 1994: 6th National Conference on Outreach Education: the Changing Colours of Outreach Education (presented by the Four Corners Coalition on Continuing Education) Durango, Colo. Study credits available. Joann Bauer, conference coordinator, Office of Continuing Medical Education, University of Colorado Health Sciences Center, PO Box C-295, 4200 E 9th Ave., Denver, CO 80262; tel (303) 372-9050 or 1-800-882-9153, fax (303) 372-9065

References
1. Guidelines for cardiopulmonary resuscitation a.id emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part VII. Neonatal resuscitation. JAMA 1992; 268: 2276-2281 2. National Guidelines for Neonatal Resuscitation, Canadian Institute of Child Health, Ottawa, 1989

Sept. 16-19, 1994: Quality of Life: Women and Breast

Cancer Toronto Registration coordinator, Community Resources and Initiatives, 106-344 Dupont St., Toronto, ON M5R lV9; tel (416) 924-8998, fax (416) 924-8352

3. Bloom RJ, Cropley C: Textbook of Neonatal Resuscitation, American Heart Association and American Academy of Pediatrics, Dallas, 1990
4. Special Committee on Obstetrical Care, Canadian Medical Association: Obstetrics 1987: a report of the Canadian Medical Association on obstetrical care in Canada. Can Med Assoc J 1987; 136

(6, suppl)
5. Chance GW: The national neonatal resuscitation program. Ont Med 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 Ministry of Health, 1991: 91-93 7. Bailey C, Kattwinkel J: Establishing a neonatal resuscitation team in community hospitals. Am J Perinatol 1993; 10: 294-298

Du 17 au 21 sept. 1994: tOe Congres international sur les soins aux malades en phase terminale (presente par la Division des soins palliatifs, Departement d'oncologie, Universite McGill, et co-commandite par l'Organisation mondiale de la sante) Montreal Les Services de congres GEMS, 10e Congres international, 710-759, Square Victoria, Montreal, QC H2Y 2J7; t6l (514) 485-0855, fax (514) 487-6725

Sept. 17-21, 1994: 10th International Congress on Care of the Terminally Ill (presented by the Palliative Care Division, Department of Oncology, McGill University, and cosponsored by the World Health Organization)
Montreal GEMS Conference Services, 10th International Congress, 701-759 Victoria Square, Montreal, PQ H2Y 2J7; tel (514) 485-0855, fax (514) 487-6725

8. Byrd FH: Early experience with the neonatal resuscitation program. Neonatal Netw 1990; 9 (3): 35-39
9. Singhal N, McMillan DD, Lockyer JM et al: Attitudinal and resource changes after a neonatal resuscitation training program. Neonatal Netw 1992; 11 (4): 37-40
10. McCulloch KM, Vidyasagar D: Assessing adherence to standards for neonatal resuscitation taught throughout the perinatal referral area. Pediatr Clin North Am 1993; 40: 431-438 11. Dunn S, Niday P, Watters NE et al: The provision and evaluation of a neonatal resuscitation program. J Contin Educ Nurs 1992; 23:

Sept. 18-23, 1994: 12th International Congress of Neuropathology (in conjunction with the annual meetings of the Canadian Association of Neuropathologists and the American Association of Neuropathologists)
Toronto Dr. J.J. Gilbert, Department of Pathology, Victoria Hospital, PO Box 5375, London, ON N6A 4G5; tel (519) 667-6649, fax (519) 667-6749

Sept. 19-20, 1994: Rationalizing Health Care in Canada: the

New Realities (presented by Insight Conferences and The Globe and Mail) Toronto Insight Information Inc., 1700-55 University Ave., Toronto, ON MSJ 2V6; tel (416) 777-1242, fax (416) 777-1292

118-126
12. Moser DK, Coleman S: Recommendations for improving cardiopulmonary skills retention. Heart Lung 1992; 21: 372-380

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