Transcript NRP 2006 and Beyond

The 5 P’s for success in dealing
with the administration
Jay P. Goldsmith, M.D.
Tulane University
New Orleans, Louisiana
US Representative: ILCOR
Former Co-Chair, NRP
No conflicts of interest to declare
NRP Textbook: 6th Edition, 2011: New aspects
that affect hospital based programs
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Blended oxygen and pulse oximetry in all DRs
Emphasis on team approach to resuscitation
Need for IV access for epinephrine,volume
composition of resuscitation team
New paradigm: simulation education
QI: program of metrics to measure
effectiveness of resuscitation team
Profitability and liability
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How do you leverage what’s important to get
what’s important?
How do you negotiate with your hospital
administration to get the equipment, education
time and support you need?
The 5 P’s of successful program
development
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Business model
– Planning
– Preparation
– Practice
– Protection/performance
– Profitability
The golden hour: The first hour of a baby’s life is probably
the most important hour of their entire life
Planning
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Where should resuscitation take place?
– DR: often cold (60-65ᵒ F)
– Resuscitation room adjacent to DR (preferred)
Hypothermia in the Delivery Room
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Hypothermia occurs commonly in very low birth
weight infants following delivery.
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It is more severe in the smallest and most
immature infants.
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An admitting temperature < 35.0oC has been
associated with  mortality in the extremely
preterm infant.
Hypothermia incidence – VLBW
babies (<1500 gms)
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Admitting temps from DR in hospitals with
NICUs:
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40-50% < 36.5°C - Vohra, 1999 (Canada)
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Vermont-Oxford – 2007: ~ 40,000 babies in 650
centers (mostly USA):
54% < 36.5°C
Adverse effects associated with
hypothermia in VLBW infants
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Hypoglycemia
Hypoxia, metabolic acidosis
NEC, ARF
PPHN
Coagulapathy
Surfactant deficiency
IVH
Death
Heat Loss Prevention Strategies
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Preheated DR – WHO – 26.7°C (80°F)
Preheated radiant warmer
Drying
Remove wet towels
Wrap in pre-warmed blankets
Eliminate drafts
Keep away from outside windows
Polyethylene bags
Placental transfusion
Warm IV fluids
Thermal care during initial procedures
Reducing Heat Loss in VLBW Infants
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Wrap baby in transparent polyethylene
Food grade “turkey” bag will do
Use polyethylene with a high diathermancy so
that radiant heat passes through
Evaporative heat losses are virtually stopped
while heat from a radiant source can still
penetrate the polythene and warm the baby.
Polyethylene Occlusive Skin Wrap
Summary of Some Hypothermia
Studies Using Plastic Wrap
Study
Type
Subjects
Results
Vohra, 2004
RCT
<28 weeks
36.5 C vs 35.6 C
Vohra, 1999
RCT
<32 weeks
1.9 C higher <28
wk subgroup
Lyon, 2004
Retrospective
review
<29 weeks
37 C vs <36 C
Matched pair,
historical control
<33 weeks
< 35.5 C (8%) vs
> 35.5 (55%)
Retrospective
review
<28 weeks
>36.5 C (74%)
vs
< 36.5 (23%)
Lenclen, 2002
Bjorkland, 2000
Warming the Delivery Room
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Raising the temperature in the DR is not easy!!
Cubic feet of DR; BTUs of AC units
How many minutes does it take to raise room
1 degree Fahrenheit?
10-15 minute lead time is reasonable
Goal is 26.7°C (80°F)
Negotiate with Ob, Anesthesiology
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<1000 gms is < 1% of all deliveries
Knobel RB, J Perinatol, 2005
Planning
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Who should attend?
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Skills more important than degree after name
Preparing for the 1/1000 deliveries that requires
complete resuscitation (who can REALLY intubate, who
can place UVC?)
Planning
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Level 1 Hospital: who best to attend deliveries
to assure competence, especially in achieving
technical skills (intubation, UVC placement)
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Who should be team leader?
Who is best person to intubate?
IV access: best for epinephrine and volume
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Can RN place UVC? if not,
Should MD from ER, peds be in DR to achieve IV access?
Each hospital has to decide on appropriate
team
Planning
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Notification system
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List of maternal or fetal conditions which require
additional expertise in DR
Communication: “H.A.N.D.S.”
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H: hemorrhage
A: amniotic fluid
N: Number of fetuses
D: Dates
S: Strip (Category 1,2 or 3)
Attendance at Deliveries
Guidelines for Perinatal Care, 6th Edition, 2007
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Does not say MD must be present
“immediately available” defined (“It is not
sufficient to have someone ‘on call’ {either at
home or in another area of the hospital”})
Requires procedures to ensure proficiency of
personnel and procedures
Requires ability to intubate for “skilled provider”
“Pearls” of Neonatal Resuscitation
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Only 1-2 babies in 1,000 need chest compression
and/or drugs
Babies who need chest compression and/or drugs
are either very acidotic or are not being ventilated
appropriately
Hypotonia indicates acidosis until proven otherwise
IV epinephrine is more effective than ET epinephrine
(prepare the UVC tray before delivery)
Epinephrine Administration – Real Life!!!!
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IT epinephrine does not work at standard
doses
In order to give IV epinephrine early, you
must have person capable of placing UVC
and prepare tray BEFORE delivery
For terminal bradycardia and crash C-section,
prepare tray (and pray you don’t have to use
it!)
In order for CPR to be successful, diastolic
pressure must be >20 mmHg
Factors Associated with Need for
CPR/Medications
Perlman JM, APAM, 1995
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30,839 births
39 needed CPR and/or epinephrine
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15 term, 24 premature
Clinical events associated with need for
CPR/drugs
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Cord ph < 7.0, BE > -14
Malposition of ET tube
Ineffective ventilatory support
“Pearls” of Neonatal Resuscitation
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The three most important aspects of neonatal
resuscitation are:
– Ventilation
– Ventilation
– Ventilation
Babies born in shock need volume early
Sentinel event (i.e. near total asphyxia): for
each minute of asphyxia, the pH falls .02-.04
units
Intubation Proficiency of Pediatric
Residents: Results
70
Rates of successful
Intubation (%) by
Year of Training
(2 of 4 attempts)
60
50
40
30
20
10
0
PGY-1
Falck A et al, Pediatrics, 2003
PGY-2
PGY-3
Preparation
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Level 1 and 2 hospitals
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Drills
Both OB and Peds with auxillary personnel as
needed (ER, Anesthesia, etc.)
Level 3
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Drills
Scripting the first hour of life for VLBW infants, CDH,
gastroschisis, other
MD
Resuscitation strategy for infants < 32weeks
-5:00
•Collect and test resuscitation equipment
-Bag/mask
-2.5 ETT +/- stylet
-Suction catheter
-Pedi-cap
Birth
•Dry infant, place in warm nest
•Collect nest pack
-Nest
-Saran wrap
-Porta-warm
•Tare scale
•Set up lines:
-3.5 F single lumen UAC
-3.5 F double lumen UVC
-D10W with 1/2 unit heparin/cc via UVC
-1/2 NS with 1unit heparin/cc via UAC
•Warm nest
•Warm bed in NICU
•Quickly update parents
•Assist with CPAP, intubation
•Auscultate for HR following intubation
•Confirm ETT position
•Assist in taping ETT
•Suction prior to surfactant as needed
•Wrap infant in Saran
15:00
•Secure endotracheal tube
•Administer surfactant
To NICU
•Gown/drape, set up lines
•Place lines
•Collect and test equipment:
-Vent check: in line with Neopuff
-Neo-puff: set to PIP-16, PEEP-5
-Appropriate mask
-Infasurf (3cc/kg), tube for installation
•Set up vent with initial settings
-PIP 16, PEEP 5, Rate 30, I-Time 0.35
•Assist in OR as needed
•Position ETT: Equal to auscultation
-6 + weight in kilos at lip
•Ventilate while stabilizing ETT
Respiratory Therapist
•Assist in stabilization as needed
•Mask CPAP prior to intubation
•Intubate infant
Charge Nurse
Primary Nurse
•Weigh infant, vital signs
•Restrain infant for line placement
•Give erythro/vitamin K
•Neopuff ventilation, rate of 30-40
-Adjust PIP for TV 4-6cc/kg
-Titrate O2 for color
•Place infant on ventilator as soon as possible
•Adjust PIP for volume target of 4-6cc/kg
•Wean FiO2 for saturations 85-93%
•Send first c/s, gas, other labs
30:00
40:00
1 hour
Initial stabilization complete
•Initial CXR
•Monitor TV
•Gas results available, adjust vent
•Wean FiO2 for sats
Temp parameters
36-37.5C
•Continue to wean PIP for TV 4-6cc/kg
•Titrate FiO2 for sats 85-93%
ABG parameters
•Complete orders
•Update family
•Assist in sending off labs, running c/s
pH: 7.25-7.35
PaCO2: 50-60
Sats: 85-93
Protection/performance
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Measuring performance
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Of drills
Of actual resuscitations
Practice
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Drills
Simulation
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Cognitive skills
Procedural skills
Teamwork skills
NRP course completion: how long after course
completion do skills last?
Golden Hour Metric
0
1
2
FiO2
> 0.3
0.21 – 0.30
0.21
pCO2
< 35 or > 55
35 – 40 or
50 - 55
40 - 50
Temp
< 35.0 or > 38.0
35 – 36 or
37.5 - 38
36 – 37.5
BP
MAP < GA and
decreased
perfusion
MAP < GA or
decreased
perfusion
MAP > GA and
normal perfusion
Neuro
Flaccid,
unresponsive
and/or seizures
Decreased tone
and reactivity
and/or irritability
Normal tone,
reactivity and
activity
Profitability
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How can you convince administration it is
worth the cost and can lead to profitability?
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Actual need for full CPR is rare (1/1000 deliveries)
Paradigm:
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Train everyone
Train a very skilled team that can intubate and gain IV
access
Costs of training, simulation mannekin, time away
from patient care
Potential Savings
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Reduced number of asphyxiated babies
Decreased LOS
Reduced medical-legal exposure
Resuscitation as part of HIE case:
Claimed breaches
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Failure to have appropriate or competent people at
delivery
Failure to properly or timely intubate baby
Failure to administer epinephrine in right dose or by
IV route
Failure to recognize hypovolemia and administer
blood or volume in a timely manner
Failure to place in appropriate nursery after resuscitation
Failure to recognize and treat seizures
Failure to resuscitate baby at limits of viability or
resuscitate against parental wishes
Trends in Jury Awards
PIAA Claims data, 2007
Medical-Legal Implications of ILCOR
(NRP) Changes
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Increased focus on ventilation
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Documentation of adequate ventilation, correct ET
tube placement
CO2 detector can be used with BVM ventilation
pCO2 in first neonatal blood gas
Pressure manomometer on bag; pneumothoraces
The Deposition
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Lawyer to Deponent in a case in which the
neonatal resuscitation is an issue:
“Dr. (or Nurse) Jones, are you NRP certified?
What is wrong with this question?
What happened?
NRP became a hospital credentialing requirement
in the US to have people trained in resuscitation
available for all deliveries
At least a few studies provided some evidence of
the assumption that it would improve
outcomes
Illinois study, 2001
“Effect of a statewide neonatal resuscitation training program on Apgar
scores among high risk neonates in Illinois”
Patel, Piotrowski, Nelson and Sabich
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Pediatrics 2001
Study of change in Apgar scores between 1 and 5
minutes comparing state wide data from before the
implementation of NRP training to after its
accomplishment
Examined data from 636,429 high risk patients out of
total of over 2 million births over a 10 year period
Results showed a statistically significant decrease in the
portion of infants that showed no change or lower Apgar
scores at 5 minutes after NRP training. Furthermore,
VLBW and LBW infants benefited most.
“Certification”
From Wikipedia, the free encyclopedia
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A professional certification….. is a designation
earned by a person to certify that he is qualified
to perform a job. Certification indicates that the
individual has a specific set of knowledge,
skills, or abilities in the view of the certifying
body.
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People become certified through training and/or
passing an exam. Individuals often advertise their
status…..
Does knowledge = performance?
Study of the Observed Structured
Clinical Exam (OSCE)
Only 4% of Senior residents in good
academic standing passed the
minimum threshold set by the
faculty for a passing score
“Evaluation of Clinical Competence: the gap between expectation and
performance” Joorabchi, Pediatrics 1996
Competency based education
How do you define competence?
benchmark competence?
How do you evaluate clinicians using the
How do you
benchmark definition?
What defines the competency?
• The use of criterion-referenced assessment as
opposed to norm-referenced assessment.
• The learner’s performance is compared with a
predetermined threshold, standard or benchmark
rather than compared to peers
• This means that competencies must be defined
with appropriate benchmarks and performance
standard set in terms of thresholds.
What is competence in neontatal
intubation?
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What defines competence? e.g.To be able to
successfully place the ETT in the trachea
What is the benchmark which defines competence? e.g
The ability to successfully intubate within 3 attempts >
90% of the time
How do you evaluate using the benchmark definition?
e.g. The sequential opportunities for the individual to
intubate are recorded with regard to time, number of
attempts, and success or failure of placement.
Measuring competence is
difficult
“Until we can make a mental shift … we
will continue to struggle to measure the
immeasurable and may end up measuring
the irrelevant because it is easier”
(Snadden, Med Edu 1999)
 Measure attendance or contact hours rather
than actual competencies in knowledge, skills
and teamwork (What does your NRP card
mean?)
Delivery Work Teamwork
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Why?
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Intense, focused, complex activities
Multiple participants
Time constraint
Says who?
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The Joint Commission: “Preventing infant death and
injury during delivery”. Sentinel event alert #30.
July 24, 2004
Joint Commission: SEA #30
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Conduct TEAM training….to work together and
communicate more effectively
Conduct clinical drills to help staff prepare
Conduct debriefings to evaluate team
performance
C.A.P.E.
(Stanford)
Stanford’s Center for Advanced
Pediatric Education is one of the
leaders in creating realistic
simulation for resuscitation
training— One of their flyers
says ”Suspend your disbelief”
Resuscitation Simulation
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Achieve “suspension of disbelief”
Same physiologic responses as in actual code
More effective than traditional training
Cognitive, technical and behavioral skills
acquired and refined
High fidelity better than low fidelity (Thomas,
Pediatrics, 2010)