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Neonatal resuscitation: are your trainees performing as you think they are? A retrospective review of a structured resuscitation assessment for neonatal medical trainees over an 8-year period
  1. Jonathan Cusack,
  2. Joe Fawke
  1. Department of Neonatology, University Hospitals of Leicester NHS Trust, Leicester, UK
  1. Correspondence to Dr Jonathan Cusack, Leicester Neonatal Service, University Hospitals of Leicester NHS Trust, Infirmary Road, Leicester, LE1 5WW, UK; jonathan.cusack{at}uhl-tr.nhs.uk

Abstract

Objective To ascertain whether Newborn Life Support Course (NLS) accredited trainees could demonstrate resuscitation skills appropriate to their level of training by providing standardised assessments of both junior and senior paediatric trainees during their induction period.

Design Retrospective review of medical staff resuscitation assessments over an 8-year period from 2003 to 2010.

Setting A network-lead tertiary neonatal service with over 11 000 deliveries annually.

Participants Neonatal medical staff: junior (speciality trainee(ST) of years 1–3) and senior trainees (ST 4–8 with tier 2 on-call responsibilities).

Intervention A standardised criterion-referenced assessment was performed by two NLS instructors. Junior trainee assessment focused on the basic airway skills learnt on an NLS course. Senior trainees demonstrated resuscitation of a baby with meconium-stained liquor, focusing on advanced life support, including intubation of the mannequin.

Main outcome measures Assessment outcomes were pass/fail; fails were categorised as algorithm failure, technical skills failure or both. For trainees who failed the first assessment, the outcome of the second assessment following appropriate feedback was recorded.

Results Two hundred and sixty-two assessments were performed: 160 junior and 102 senior trainees; 98/160 (61%) of junior and 57/102 (56%) of senior trainees passed their first assessment; 69% of junior trainees who failed the first assessment had a second assessment recorded. There was a 79% pass rate at second assessment; 89% of senior trainees who failed a first assessment had a second assessment recorded. There was an 85% pass rate at second assessment. The majority of trainees who failed an assessment had problems with both the resuscitation algorithm and technical skills.

Conclusions Significant numbers of trainees who have been formally trained in neonatal resuscitation skills previously do not pass the standardised resuscitation assessment, thus require an additional input to maintain their competence in neonatal resuscitation.

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Introduction

British Association for Perinatal Medicine Staffing Standards1 recommends that a paediatric medical trainee or Advanced Nurse Practitioner (ANNP) attend deliveries that are considered moderate or high risk. About 1 in 500 babies unexpectedly need resuscitation at birth2 and the need for resuscitation is often unpredictable.

What is already known on this subject

Following formal resuscitation training, degradation in resuscitation skills is well described.

What this paper adds

Performing a standardised assessment of resuscitation skills during medical staff induction may reveal an unrecognised need for further training.

The Newborn Life Support Course (NLS) (Resuscitation Council UK) was established in the United Kingdom in 1999 in order to provide a standardised approach to resuscitation. The Newborn Resuscitation Program (American Academy of Pediatrics) was established in the late 1980s, and these two courses aim to maintain international standards in newborn resuscitation. Prior to the establishment of these formal courses, these resuscitation trainings were piecemeal and variable in both content and delivery.3

ANNPs and medical staff who work in neonatal medicine can be expected to have undertaken training in neonatal resuscitation as described in Royal College of Paediatrics and Child Health (RCPCH) competencies.4

It is well established that following completion of resuscitation training, there is ‘decay’ in psychomotor skills. There is evidence that there is a significant decay of skills as early as 3 months,5 with other studies documenting a fall off in skills between 6 and 12 months after the initial training encounter.6 ,7

There is further evidence that refresher training and assessment 6 months after a resuscitation course significantly improves retention of knowledge and psychomotor skill.8

University Hospitals of Leicester has a large tertiary neonatal service with over 11 000 deliveries per annum. Moderate- and high-risk deliveries are attended by our neonatal team, consisting of junior trainees (specialty trainees of years 1 to 3, ST1–3) and advanced nurse practitioners, with assistance from tier two staff (ST4-8) and Consultant input as required.

Junior trainees are offered a place on the Resuscitation Council UK accredited Leicester NLS course as part of their induction programme, unless they are already an NLS accredited resuscitation provider. Junior trainees who successfully completed an NLS course during their induction period were not reassessed.

Senior trainees would be expected to be an NLS provider, and further training is offered if required.

As part of the induction programme, all junior trainees who are not assessed as part of the induction NLS course and all senior trainees undertake a standardised assessment of their resuscitation skills.

Methods

We reviewed our records of resuscitation assessments from 2003 to 2010.

Two types of resuscitation assessments were performed: a junior trainee assessment which focused on the skills attained during an NLS course,9 and a senior trainee assessment, the resuscitation of a baby with meconium-stained liquor, focused on advanced life support, including intubation of the mannequin.

Standardised assessments were performed by experienced, currently accredited, NLS instructors, with two instructors present at every assessment. A number of NLS instructors were involved in the study, and in all cases a standardised criterion-referenced pro forma was used to ensure the assessments were delivered in the same way (Appendix A).

Basic and advanced life support mannequins were used (Laerdal Medical UK), and assessments were carried out on delivery suite using standard resuscitaires and equipment.

Patient consent was not required, as resuscitation was carried out on mannequins. Prospective recording of resuscitation assessment data forms part of our neonatal services routine data collection. Consent was not taken from staff as this was a retrospective review of standard data collected from our routine medical staff induction. Individuals are not identifiable from the data.

Trainees who failed the first assessment were provided with individualised feedback along with a brief review of resuscitation algorithms. A further assessment was rescheduled after a few days, and an opportunity to practice skills and ask questions was provided.

Trainees, who failed the second assessment, were offered more formal re-training with subsequent reassessment.

Assessment records were retrospectively reviewed by both authors independently and for those who failed, and the reason for failure was recorded as either:

  1. Algorithm (failure to follow the standardised neonatal resuscitation algorithm).

  2. Technical (eg, failure to perform technical psychomotor skills such as intubation or two-person jaw thrust).

  3. Both (algorithm and technical).

Results

Two hundred and sixty-two assessments were performed between 2003 and 2010.

Of these, 160 were junior assessments and 102 were senior assessments.

Ninety-eight of the 160 (61%) of junior trainees and 57 of the 102 (56%) senior trainees passed their first assessment.

The pass rate remained fairly constant over the time period studied (table 1).

Table 1

First assessment outcomes for all trainees expressed as a percentage

69% of junior trainees who failed a first assessment had a second assessment recorded.

Of those who received a second assessment 79% passed.

89% of senior trainees who failed a first assessment had a second assessment recorded.

Of those who received a second assessment 85% passed.

The majority of trainees who failed an assessment had problems with both the resuscitation algorithm and technical skills. Reasons for failure are shown in table 2.

Table 2

Reasons for first assessment failure

All trainees who failed a second assessment received individualised training followed by a successful assessment.

Discussion

Our trainees were assessed using standardised resuscitation assessments, by accredited NLS instructors, covering skills within the RCPCH curriculum. We have shown that during assessment around half of trainees do not demonstrate adequate resuscitation skills.

All of our senior trainees are accredited NLS providers and most have previous experience as a tier 2 doctor at least in a level 2 neonatal unit. It is reasonable to expect a trainee at this level to be able to initiate resuscitation in a compromised baby with meconium-stained liquor.

We accept that performance in a real resuscitation may be different from performance during a structured assessment, but we remain concerned that significant numbers of trainees perform worse than expected when formally assessed.

Decay of resuscitation skills has been well documented, and the optimal timing of resuscitation courses is difficult to quantify.10

Current NLS providers need to recertify every 4 years. More frequent recertification carries logistical problems, and even with 2-yearly paediatric basic life support (PBLS) training one study found 75% deviated from AHA PBLS protocols.11 Our study is limited in that we did not have access to details of when all trainees attended their last formal resuscitation course.

Uncertainty over rate of resuscitation skill decay, combined with the practical problems of increasing NLS recertification frequency leads us to suggest that routine assessment of resuscitation skills should be carried out locally at the start of a post. Other options to reinforce resuscitation skills include simulation training which has been reported to lead to an improved paediatric survival following cardiopulmonary arrest.12 Such training would ideally occur regularly and allow teams that work together to train together. High fidelity in situ simulation is one way of providing this training.13

Assessment itself is a powerful extrinsic motivating factor. The presence of an assessment reinforces students' learning,14 and we were reassured by the high pass rate at the second assessment.

In our group 69% of junior trainees and 85% of senior trainees who failed their first assessment had a second assessment recorded. Our retrospective data maybe incomplete, but we are concerned that small numbers of trainees who fail their first assessment might have missed their second assessment although all received appropriate retraining. This can be difficult to arrange repeat assessments after the induction period due to the complexities of a full shift rota. It is potentially unhelpful to ‘fail’ a trainee and then not give them the opportunity to pass a subsequent assessment.

Our data may provide some reassurance to those concerned that reduced junior doctors' hours has lead to less clinical experience. Despite marked changes in medical training since 2003 the percentage pass rate at the first assessment did not change significantly.

It is very difficult to design studies that demonstrate an improvement in clinical practice following resuscitation training,15 and we accept that performance in a resuscitation assessment may not always reflect clinical practice.

As experienced course directors, we strongly support the Resuscitation Council Newborn Life Support Courses, and have personally seen an improvement in the standards and consistency of neonatal resuscitation training. Despite this, we have demonstrated that nearly half of the trainees were below the expected standard when assessed.

Our findings are likely to be applicable in paediatric and adult resuscitation practice due to a similar decay in resuscitation skills after formal training.

Although we think that attendance at nationally accredited resuscitation courses should be encouraged, we suggest that units with a responsibility for acute resuscitation carry out their own staff assessments rather than relying on prior completion of a national course.

Conclusions

Significant numbers of trainees who have been previously trained formally in neonatal resuscitation skills do not pass a standardised resuscitation assessment and require an additional input to maintain their competence in neonatal resuscitation.

Neonatal units should consider performing their own assessments of neonatal resuscitation skills during induction rather than relying on the previous performance on a national resuscitation course.

References

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Footnotes

  • JC and JF contributed equally to this paper.

  • Competing interests Both authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that both JC and JF are Course Directors for the Newborn Life Support Course (Resuscitation Council UK).JC has received conference funding once from Laerdal, both authors run Neonatal High Fidelity Simulation Courses with all money received going to their institution. They have no other financial relationships with companies that might have an interest in the submitted work in the previous 3 years; no spouses, partners, or children have financial relationships that may be relevant to the submitted work and neither author has non-financial interests that may be relevant to the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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