Transcript Slide Title (Times New Roman, 40 pt, bold, left alignment)

NRP
The Neonatal Resuscitation
Program (NRP):
An Initiative to Improve
Care to Newborns at the
Outset of Life
NRP
NEONATAL RESUSCITATION
PROGRAM (NRP)
AN OVERVIEW
SUDHAKAR G. EZHUTHACHAN, MD, DCH, FAAP
HEAD, DIVISION OF NEONATOLOGY
HENRY FORD HEALTH SYSTEM
DETROIT , MI
NRP
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
NRP
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
NRP
NRP IN THE U.S.A.
• AAP and the American Heart
Association led NRP development
• NRP faculty approach was tieredNational, Regional and Hospital
Based
• 1987- A Standardized National
Neonatal Resuscitation Program
built on Consensus rolled out in the
USA
NRP
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
NRP
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”
NRP
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
NRP
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
NRP
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
NRP
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
NRP
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
NRP
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)
NRP
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
NRP
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
NRP
FIRST IMPRESSIONS
NRP
Neonatal Resuscitation
Program: Curriculum
Dmytro Dobrianskyi, MD, PhD
Keti Nemsadze, MD, PhD
NRP
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
NRP
Program Components

Educational resources of the original Program

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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
NRP
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”
NRP
Program Content
Always needed
by newborns
Needed less
frequently
Assess baby’s response to birth
Initial steps
Establish effective ventilation
•Bag and mask
•Endotracheal intubation
Provide chest
compressions
Rarely needed by
newborns
Administer
medications
NRP
Program Components - NIS

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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.
NRP
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.
NRP
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
NRP
Organization of NRP Instructors
in the USA
National Faculty
Regional Instructors
Hospital Instructors
Providers
Providers
NRP
Organization of NRP Instructors
in the NIS
National Faculty
(Instructors of the NRP Training Centers)
Regional Instructors
Hospital Instructors
Providers
Providers
Providers
NRP
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

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
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.
NRP
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.
NRP
Instructor Training in the NIS

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

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.
NRP
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
NRP
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
NRP
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
NRP
The weak points of education in Former
Soviet Union

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
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.
NRP
Station I -Initial steps of resuscitation
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.
Common practice in
Former Soviet Union
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.
NRP
Lesson 1:Initial steps of Resuscitation
Heat loss prevention
Opening of airways
Assessment of the infant
• Place on warmer
• Position the infant
 Breathing
• Dry the newborn
• Suctioning mouth, then

Heart rate

Color
• Remove wet towel
nose
 if needed intubate and
suctioning trachea
 if necessary
provide tactile
stimulation and give
free flow oxygen
NRP
Breathing
no
Tactile stimulation
No or gasping
yes
Ventilaiton
80-100
Heart Rate
< 60, 60-80 and not increasing
Chest compression
no, <80 after 30 sec ventilation and chest comp.
Medications
> 100
Central cyanosis
Free flow 100%
oxygen
Skin colour
Pink, peripheral cyanosis
After stabilization
Continue newborn care protocol
}
}
B
C
NRP
Station 2 - Support Breathing
Importance
 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
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
NRP
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
NRP
Station 3 - Support Circulation
Common Practice in Former
Soviet Union
Importance
Provision of artificial heart rate

Chest compression was initiated primarily
after cardiac arrest

Chest compressions were never combined with
ventilation

Sometimes harmful methods of compression
were used
Restoring circulation
Ensuring adequate oxygen supply
NRP
Station 3 - Support Circulation
Technique

position the infant
 firm support for the back,
neck slightly extended
adequate location, depth and
rate
coordination of chest compression
ventilation
assessment
of HR in 15-20 sec.
2 finger technique

thumb technique

NRP
Station 4 - Endotracheal Intubation
Importance

Common practice in Former
Soviet Union
Identification of indications
Intubation often was not limited to 20 sec





Ineffective bag and mask ventilation
prolonged ventilation
Tracheal suctioning
diaphragmatic hernia
The indications were often ignored

NRP
Station 4 - Endotracheal Intubation
Selection and preparation
of the equipment
Selection of the endotracheal tube size
Selection and preparation of laryngoscope
with appropriate size of blade
Preparation of suctioning and
ventilating equipment
Technique
Position the infant

Insertion of laryngoscope and

visualization of glottis
Insertion of ET tube

Checking the tube placement

Securing the tube

NRP
Tell me and I’ll forgot
Show me and I may not
remember
involve me, and I
understand
NRP
Quality Assessment of NRP
Sudhakar G. Ezhuthachan, MD, DCH,
FAAP
NRP
Evaluation Strategies
• Evaluation of the course - maintaining
course standards
• Evaluation of clinical application of
knowledge
• Evaluation of patient outcomes
NRP
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
NRP
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.
NRP
IMPACT OF NRP EDUCATION
at 10 centers in INDIA
Pre training (3 m)
Total live births
Resuscitation
Bag/ Mask Ventilation
Intubations
Apgar score <4
1 min
5 min
Outcome
MAS
Respiratory distress
Seizures
Asphyxial Brain injury
Total deaths
Post training
p value
5110
7198
107 (2.1)
113 (2.2)
294 (4.1)
153 (2.1)
<0.001
NS
230 (4.5)
102 (2.0)
219 (3.0)
74 (1.0)
<0.001
<0.001
157 (2.1)
412 (5.7)
49 (0.7)
49 (0.6)
176 (2.4)
NS
<0.01
<0.001
<0.001
<0.05
97 (1.9)
362 (7.1)
107 (2.1)
102 (2.0)
159 (3.1)
NRP
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
NRP
Rater (per 1000) of CNS Abnormalities
in 7 day-old newborns in 3 hospitals
70
60
Rate per 1000
50
40
30
20
10
0
2 STAFF TRAINED
8 STAFF TRAINED
Number Trained
20 STAFF TRAINED
NRP
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
NRP
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
NRP
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)
NRP
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
NRP
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
NRP
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
NRP
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
NRP
Clinical Outcomes
• Mortality is multifactorial and takes time
to impact
• Morbidities related to temperature and
low apgar scores show improvement
NRP
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
NRP
THE EFFECTS OF LOW
TEMPERATURE ON AN INFANT
Acidosis
Pulmonary Vessel
Spasm
Lack of
Oxygen
Cold Stress
Death
HYPOTHERMIA
More Acid
Production
Convulsions
Low Glucose
More
Hypothermia
NRP
Numbers of Neonates Transferred
with Hypothermia i.e.
Temperature Lower than 35° C
% 14
12
12.1
10
8.2
8
8.6
7.7
6
4.8
4
2.3
2
0
1995
1996
1997
1998
1999
2000
NRP
Reduction in % of Infants
admitted to LOCH with Severe
Perinatal Asphyxia
%
38,54
40
35
30
22,95
21,16
20,24
25
20
15
18,36
16,46
10
5
0
1995
1996
1997
1998
1999
2000
NRP
Incidence of Severe Asphyxia in
Infants admitted to LOCH
20 %
3.15
15
3.22
2.99
2.61
1.92
10
2.33
14.12
5
0
1995
8.6
10.1
1996
1997
% out of all infants <1500 gm
10.09
1998
7.84
1999
% out of all infants >1500 gm
5.38
2000
NRP
Implementation Phases and
Effectiveness of the Neonatal
Resuscitation Program in Russia
O. N. Belova
NRP
The NRP Program
has been operating
as part of the
Russian-American
Partnership in
Russia since 1989 11 years
NRP
Order of Ministry of Health of the Russian
Federation No. 372
Improvement of Primary and Resuscitation
Care for Neonates in the Delivery Room
became effective on 12/28/95.
More than 5 years have passed
NRP
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. 372.
Problems. Outlook for Growth.
Samara, October 2000
NRP
Rating of the Results of the PNR Program
by Respondents
Excellent
17%
30%
Good
53%
Satisfactory
NRP
Changes in Statistical Indicators as a Result of
the Implementation of the NRP Protocol
• Find it difficult to respond
• See positive changes in statistical
indicators
• Do not associate the positive changes
with the effect of the order
• Do not see an association between
indicators and negative changes
• Did not respond
- 25%
- 62%
- 2%
- 2%
- 9%
NRP
Positive Changes in Statistical
Indicators
Perinatal mortality
Early neonatal mortality
Infant mortality
Death due to asphyxia, RDS,
including low birth weight infants
Neonatal mortality
- 22%
- 43%
- 18%
- 10%
- 6%
NRP
Changes in Indicators of Early
Neonatal Mortality in the Russian
Federation
10
9
8
7
6
1995
1996
1997
1998
1999
Change in the type of primary resuscitation and
state of neonates during 1990-2000 in Maternity
Hospital No. 27 in the city of Moscow (%)
16
14
12
10
8
6
4
2
0
1990
1993
2000
Oxygen therapy with ventilation with Apgar scores of 01
Drugs
Apgar scores of 1 - <7
NRP
NRP
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
- 2.5%
• Other
- 2.5%
NRP
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. 372
Improvement of Primary and Resuscitation
Care for Neonates in the Delivery Room became
effective almost five years ago.
NRP
Knowledge of neonatologists on the type of primary
resuscitation care to be given to neonates
based on pretest results
28
72
32
68
- Passed
- Failed
40
60
NRP
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
NRP
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
NRP
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
NRP
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)
NRP
A tree has grown
from the seed
planted by AIHA,
USAID, and the
Russian and
American partners.
And then...
NRP
Neonatal Resuscitation
Program in Ukraine: Results of
Implementation
Goyda N. M.D., Ph.D.
Head, Medical Services Department
Ministry of Health of Ukraine
NRP
Key Indicators of Health of Children
(1992-1995)
№
Year
Indicators
п/п
1992
1993
1994
1. Newborn Mortality
13.98
14.9
14.5
(per 1000 births)
2. Perinatal Mortality
14.0
12.8
12.3
(per 1000 births)
3. Stillbirth
8.0
7.2
7.1
(per 1000 births)
4. Early Neonatal Mortality
6.1
5.7
5.2
(per 1000 births)
5. Neonatal Mortality
7.8
7.5
7.2
6. Newborn Morbidity
169.3 183.3 193.7
(per 1000 births)
7. Morbidity of infants 0-12 mo of age 1474.8 1597.7 1594.7
(per 1000 infants 0-12 mo of age)
1995
14.7
12.2
6.9
5.4
7.3
211.9
1685.4
NRP
Ratio of Stillbirth and
Early Neonatal Mortality Causes
24.5%
41.5%
58.5%
75.5%
Intrauterine hypoxia and asphyxia
Respiratory Distress Syndrom e
Other
Other
Stillbirth
Early Neonatal Mortality Rate
NRP
Primary Disability Causes Ratio
in Children 0-16
20.1%
22.3%
4.3%
5.4%
20.0%
6.7%
8.4%
12.8%
C O NGENITAL DISO RDERS
BO NES AND MUSC ELS DISO RDERS
NERVO US SYSTEM DISO RDERS
ENDO C RINE SYSTEM DISO RDERS
MENTAL DISO RDERS
EAR DISO RDERS
EYES DISO RDERS
O THER
NRP
Key Demographic Indicators
Description of
Year
an indicator
1992
1993
1994
1995
1996
1997
1998
1999
2000
Birth Rate
(per 1000 people)
11.4
10.7
10.0
9.6
9.1
8.8
8.7
7.8
7.8
Total Mortality
(per 1000 people)
Natality
13.4
14.2
14.7
15.4
15.2
14.9
15.9
14.8
15.3
-2.0
-3.5
-4.7
-5.8
-6.1
-6.1
-7.2
-7.0
-7.5
NRP
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”
NRP
Key Objectives of the National
Program “Children of Ukraine”
• Improvement of medical care to pregnant
women and newborns
• Morbidity prevention and delivery of up-todate medical care to children
NRP
Decree of Ministry of Health
January 5, 1996
“Organization of medical service
for newborns in Ukraine”
NRP
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.
NRP
•
•
•
•
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
NRP
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.
NRP
Standardized Approach to
Training
• First courses were co-taught with U.S.
faculty
• Now, Ukrainian faculty assist with coteaching in other new centers
• Instructor:Student ratio maintained, 1:4-5
• Certificates only issued if written exam and
skill stations were independently completed
NRP
Number of Specialists Trained in
Training Centers
Name
of Center
Kiev
Odessa
Donetsk
Lvov
Kharkov
Total
Neonatologists
660
264
223
271
310
1728
Trained
OB-GYNs
Nurses
Midwives
547
175
556
356
175
114
195
405
378
110
1851
1160
Anesthesio
logists
96
57
10
60
45
268
Total
1478
1487
522
831
843
5007
NRP
Perinatal and Newborn Mortality
in Ukraine (1997-2000)
Item
Item Description
#
1. Newborn Mortality
(per 1000 births)
2. Perinatal Mortality
(per 1000 births)
3. Stillbirth
(per 1000 births)
4. Early Neonatal Mortality
(per 1000 births)
5. Neonatal Mortality
1997
Year
1998 1999
2000
14.0
12.8
12.8
11.91
12.2
11.3
10.9
9.7
6.7
6.2
6.0
5.2
5.6
5.1
5.0
4.6
7.7
7.2
6.8
6.6
NRP
Neonatal Mortality in Regions where there
are Training Centers
Regions
Donetsk
Lvov
Odessa
Kharkov
city of Kiev
Early Neonatal Mortality
1997 1998 1999 2000
Neonatal Mortality
1997 1998 1999 2000
8.2
9.0
4.9
6.0
9.8
10.5
4.6
7.2
9.1
14.8
6.5
6.2
4.1
5.0
5.9
5.8
6.7
4.8
4.8
5.8
5.9
5.3
3.9
3.7
5.1
8.3
8.0
6.5
6.9
9.1
8.2
8.9
7.0
7.5
8.8
7.4
7.7
5.2
6.1
7.4
NRP
The following issues remain
unresolved:
• Legalizing the work of the centers
• Certification - national issues
• Standardization of program throughout Ukraine
NRP
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
Neonatal Resuscitation in
Slovakia 1992..2001
Peter Krcho MD,PhD
NICU Perinatal Center Kosice Slovakia
NRP
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
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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
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Present ...
Better collaboration between the units
EBM interventions are now clear
In most severe cases still intrauterine
transport is the best ...
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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
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Continue with ...
After 9 years of CPR projects we need to
continue retraining
Updating the training modality
Use better education techniquesReal time video , www based education,
better selection of the NICU team ...
...skills, skills, skills...
NRP
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
Admissions/Mortality
Mortality in %
250
Addmisions
30
Mortality
25
200
Admissions
20
150
15
100
10
50
5
0
0
1995
1996
1997
1998
Year
1999
2000
NRP
Intrauterine transport to
the Perinatal Center
80
70
60
50
40
30
20
10
0
1995
1996
1997
1998
year
1999
2000
Statistical Proof
16
14
Live birth /10000
Neonatal Mortality
12
10
8
7.5
7.4
7.9
6.9
6
5.4
5.4
5.1
1997
1998
1999
4
2
0
1993
1994
1995
1996
Year
NRP
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...
Case Р ULBWN 540g
Sustainability / Dissemination / Teaching
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In Closing: Issues for the
Future of NRP
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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
NRP
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
NRP
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
NRP
NRP TC - Start Up Costs
• Medical equipment for skills
stations plus shipping
$7,000.00
• Office Equipment, furniture $9.200.00
• Educational materials
$2,000.00
• Training by US Trainers
One 2 person trip
$10,000.00
TOTAL $28,200.00
NRP
NRP TC Maintenance Costs
• Telephone and email 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
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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
NRP
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
NRP