NRP The Neonatal Resuscitation Program (NRP): An Initiative to Improve Care to Newborns at the Outset of Life.

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