Post on 26-Mar-2015
transcript
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
NRPWHY 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
NRPNRP 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
NRPNRP IN THE U.S.A.
• AAP and the American Heart Association led NRP development
• NRP faculty approach was tiered-
National, Regional and Hospital Based
• 1987- A Standardized National Neonatal Resuscitation Program built on Consensus rolled out in the USA
NRPNRP 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
NRPFinal 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)
NRPNRP 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
NRPNRP 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 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 ContentAssess baby’s response to birth
Initial steps
Establish effective ventilation•Bag and mask
•Endotracheal intubation
Provide chestcompressions
Administermedications
Always needed by newborns
Needed less frequently
Rarely needed by newborns
NRP
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.
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
Providers
H ospita l Instructors Providers
R egiona l Instructors
N a tiona l Fa culty
NRP
Organization of NRP Instructors in the NIS
Providers
R egiona l Instructors
Providers
H ospita l Instructors Providers
N a tiona l Fa culty(Instructors of the N R P T ra ining C enters)
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 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 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
NRPImportance 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
NRPThe weak points of education in Former
Soviet Union Education was based only on theoretical issues. Practical skills were not
taught. No equipment and manikins were available for teaching practical skills Medical staff were unfamiliar with equipment necessary newborn
resuscitation and often could not use existing equipment despite the indications.
The first attempt at resuscitation usually was performed directly on a patient, therefore often delayed, performed incorrectly, resulting in frequent complications and resuscitation failure.
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
• Dry the newborn
• Remove wet towel
• Position the infant
• Suctioning mouth, then nose
if needed intubate and suctioning trachea
Breathing
Heart rate
Color
if necessary provide tactile stimulation and give free flow oxygen
NRPno
80-100
}}
no, <80 after 30 sec ventilation and chest comp.
No or gasping
Pink, peripheral cyanosis
Central cyanosis
yes
Breathing
> 100
Skin colour
Heart Rate
Continue newborn care protocol
Tactile stimulation
Ventilaiton
Chest compression
Medications
Free flow 100%oxygen
After stabilization
B
C
< 60, 60-80 and not increasing
NRP
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
Station 2 - Support Breathing
Importance Common practice in Former Soviet Union
Harmful methods and prolonged tactile stimulation were used
Support breathing was based on medications
Ventilation with bag and mask was rare, mostly initiating breathing was conducted mouth-to-mouth breathing
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
NRPStation 3 - Support Circulation
Importance
Provision of artificial heart rate
Restoring circulation
Ensuring adequate oxygen supply
Common Practice in Former Soviet Union
Chest compression was initiated primarily after cardiac arrest
Chest compressions were never combined with ventilation
Sometimes harmful methods of compression were used
NRP
Technique position the infant
firm support for the back,
neck slightly extended
2 finger technique
thumb technique
adequate location, depth and rate
coordination of chest compression ventilation
assessment of HR in 15-20 sec.
Station 3 - Support Circulation
NRPStation 4 - Endotracheal Intubation
Identification of indications
Ineffective bag and mask ventilation prolonged ventilation Tracheal suctioning diaphragmatic hernia
Importance Common practice in Former Soviet Union
Intubation often was not limited to 20 sec
The indications were often ignored
NRP
Technique Position the infant
Insertion of laryngoscope and
visualization of glottis
Insertion of ET tube
Checking the tube placement
Securing the tube
Selection and preparation of the equipment
Selection of the endotracheal tube sizeSelection and preparation of laryngoscope
with appropriate size of blade
Preparation of suctioning and
ventilating equipment
Station 4 - Endotracheal Intubation
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.
NRPIMPACT OF NRP EDUCATION
at 10 centers in INDIA Pre training (3 m) Post training p value Total live births 5110 7198Resuscitation Bag/ Mask Ventilation 107 (2.1) 294 (4.1) <0.001 Intubations 113 (2.2) 153 (2.1) NS Apgar score <4 1 min 230 (4.5) 219 (3.0) <0.001 5 min 102 (2.0) 74 (1.0) <0.001 Outcome MAS 97 (1.9) 157 (2.1) NS Respiratory distress 362 (7.1) 412 (5.7) <0.01 Seizures 107 (2.1) 49 (0.7) <0.001 Asphyxial Brain injury 102 (2.0) 49 (0.6) <0.001 Total deaths 159 (3.1) 176 (2.4) <0.05
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
0
10
20
30
40
50
60
70
2 STAFF TRAINED 8 STAFF TRAINED 20 STAFF TRAINED
Number Trained
Ra
te p
er
10
00
NRPEvaluation 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 StaffStaff 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
NRPEquipment
• 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
HYPOTHERMIA
Cold StressAcidosis
Pulmonary VesselSpasm
Lack of Oxygen More Acid
Production
More Hypothermia
Low Glucose
ConvulsionsDeath
NRP Numbers of Neonates Transferred with Hypothermia i.e. Temperature Lower than 35° C
12.1
8.2 8.67.7
4.8
2.3
0
2
4
6
8
10
12
14
1995 1996 1997 1998 1999 2000
%
NRP
Reduction in % of Infants admitted to LOCH with Severe
Perinatal Asphyxia
38,54
22,9521,16 20,24
18,3616,46
0
5
10
15
20
25
30
35
40%
1995 1996 1997 1998 1999 2000
NRPIncidence of Severe Asphyxia in
Infants admitted to LOCH
8.6 10.1 10.097.84
5.38
14.122.33
1.92
2.613.222.99
3.15
0
5
10
15
20
1995 1996 1997 1998 1999 2000
%
% out of all infants <1500 gm % out of all infants >1500 gm
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
NRPRating of the Results of the PNR Program
by Respondents
Excellent30%
53%
17%
Good
Satisfactory
NRPChanges 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%
NRPPositive 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%
NRP Changes in Indicators of Early Neonatal Mortality in the Russian
Federation
6
7
8
9
10
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 (%)
0
2
4
6
8
10
12
14
16
1990 1993 2000
Oxygen therapy with ventilation with Apgar scores of 0-1
Drugs
Apgar scores of 1 - <7
NRP Causes of Problems in Implementing the NRP Protocol
•Inadequate equipment -25%•Inadequate training of personnel-21%•Old recommendations continue to be used -19%
•No review of NRP system quality-10%•Tolerance of minor deviations from the protocol -8%
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
72
28
68
32
60
40
Knowledge of neonatologists on the type of primary resuscitation care to be given to neonates
based on pretest results
- Passed
- Failed
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)
NRPA 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 ChildrenKey Indicators of Health of Children (1992-1995)(1992-1995)
Year№п/п
Indicators1992 1993 1994 1995
1. Newborn Mortality(per 1000 births)
13.98 14.9 14.5 14.7
2. Perinatal Mortality(per 1000 births)
14.0 12.8 12.3 12.2
3. Stillbirth(per 1000 births)
8.0 7.2 7.1 6.9
4. Early Neonatal Mortality(per 1000 births)
6.1 5.7 5.2 5.4
5. Neonatal Mortality 7.8 7.5 7.2 7.36. Newborn Morbidity
(per 1000 births)169.3 183.3 193.7 211.9
7. Morbidity of infants 0-12 mo of age(per 1000 infants 0-12 mo of age)
1474.8 1597.7 1594.7 1685.4
NRP Ratio of Stillbirth and Ratio of Stillbirth and Early Neonatal Mortality CausesEarly Neonatal Mortality Causes
75.5%
24.5%
Stillbirth
Intrauterine hypoxia and asphyxia
Other
58.5%
41.5%
Early Neonatal Mortality Rate
Respiratory Distress Syndrome
Other
NRP Primary Disability Causes Ratio Primary Disability Causes Ratio in Children 0-16in Children 0-16
20.1%
20.0%
12.8%8.4%6.7%
5.4%
4.3%
22.3%
CO NGENITAL DISO RDERS
NERVO US SYSTEM DISO RDERS
MENTAL DISO RDERS
EYES DISO RDERS
BO NES AND MUSCELS DISO RDERS
ENDO CRINE SYSTEM DISO RDERS
EAR DISO RDERS
O THER
NRP
Key Demographic IndicatorsKey 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)
13.4 14.2 14.7 15.4 15.2 14.9 15.9 14.8 15.3
Natality -2.0 -3.5 -4.7 -5.8 -6.1 -6.1 -7.2 -7.0 -7.5
NRPList of Legal and Regulatory Documents, List of Legal and Regulatory Documents,
National, State and Target Programs National, State and Target Programs in the Scope of Maternal and Child Health Care in in the Scope of Maternal and Child Health Care in
UkraineUkraine
• 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 Key Objectives of the National Program “Children of Ukraine”Program “Children of Ukraine”
• Improvement of medical care to pregnant women and newborns
• Morbidity prevention and delivery of up-to-date medical care to children
NRP
Decree of Ministry of HealthJanuary 5, 1996
“Organization of medical service for newborns in Ukraine”
NRPThree-Level System of Care of Three-Level System of Care of
Newborns in UkraineNewborns 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.
NRPImplementing The Neonatal Implementing The Neonatal
Resuscitation Program has made it Resuscitation Program has made it possible for Ukraine to: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
NRPStandardized Approach to Standardized Approach to
TrainingTraining• 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 Standardized Approach to TrainingTraining
• First courses were co-taught with U.S. faculty
• Now, Ukrainian faculty assist with co-teaching in other new centers
• Instructor:Student ratio maintained, 1:4-5
• Certificates only issued if written exam and skill stations were independently completed
NRPNumber of Specialists Trained in Number of Specialists Trained in
Training CentersTraining Centers
Name Trained
of Center Neonatologists OB-GYNs NursesMidwives
Anesthesiologists
Total
Kiev 660 547 175 96 1478
Odessa 264 556 356 57 1487
Donetsk 223 175 114 10 522
Lvov 271 195 405 60 831
Kharkov 310 378 110 45 843
Total 1728 1851 1160 268 5007
NRPPerinatal and Newborn Mortality Perinatal and Newborn Mortality
in Ukrainein Ukraine (1997-2000) (1997-2000)
YearItem#
Item Description1997 1998 1999 2000
1. Newborn Mortality(per 1000 births)
14.0 12.8 12.8 11.91
2. Perinatal Mortality(per 1000 births)
12.2 11.3 10.9 9.7
3. Stillbirth(per 1000 births)
6.7 6.2 6.0 5.2
4. Early Neonatal Mortality(per 1000 births)
5.6 5.1 5.0 4.6
5. Neonatal Mortality 7.7 7.2 6.8 6.6
NRPNeonatal Mortality in Regions where there Neonatal Mortality in Regions where there
are Training Centersare Training Centers
Regions Early Neonatal Mortality Neonatal Mortality
1997 1998 1999 2000 1997 1998 1999 2000
Donetsk 8.2 6.5 5.8 5.9 10.5 8.3 8.2 7.4Lvov 9.0 6.2 6.7 5.3 4.6 8.0 8.9 7.7Odessa 4.9 4.1 4.8 3.9 7.2 6.5 7.0 5.2Kharkov 6.0 5.0 4.8 3.7 9.1 6.9 7.5 6.1city of Kiev 9.8 5.9 5.8 5.1 14.8 9.1 8.8 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,PhDNICU 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
NRP
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 anesthesiologistsIT WAS THE BEGINNING OF THE
REGIONALIZATION PROCESS
NRP
Present ...
Better collaboration between the unitsEBM interventions are now clearIn most severe cases still intrauterine
transport is the best ...
NRP
What are our priorities now
Better intervention in all casesIntrauterine transport to the perinatal center Decrease of NM in the whole region
especially in newborns under 1499gDelivery of high risk pregnancies in
regional center,... under 999g
NRP
Continue with ...
After 9 years of CPR projects we need to continue retraining
Updating the training modalityUse better education techniques- Real 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
0
50
100
150
200
250
1995 1996 1997 1998 1999 2000
Year
Ad
mis
sio
ns
0
5
10
15
20
25
30
Mortality in %
Addmisions
Mortality
NRP
0
10
20
30
40
50
60
70
80
1995 1996 1997 1998 1999 2000
year
Intrauterine transport to the Perinatal Center
Statistical Proof
7.5 7.47.9
6.9
5.4 5.4 5.1
0
2
4
6
8
10
12
14
16
1993 1994 1995 1996 1997 1998 1999
Year
Live birth /10000
Neonatal Mortality
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
NRP
In Closing: Issues for the Future of NRP
NRP
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
NRPSustainability 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
NRPSustainability 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
NRP
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