Objectives Determine how consistently providers follow neonatal resuscitation programme (NRP) guidelines in the management of asystolic infants requiring intensive resuscitation in a simulated environment and determine time to first administration of intravenous adrenaline.

Design Neonatal fellows (n=10) underwent delivery room simulation involving an asystolic infant as part of their educational curriculum. Each intervention performed by the resuscitation team during the scenario was timed and compared against recommended timeline (RT) as suggested by NRP.

Results Ten simulations were conducted. Heart rate auscultation and initiation of positive pressure ventilation occurred on average within 10 s of the RT. Asystole was correctly identified by auscultation in 6 (60%) cases. Initiation of cardiopulmonary resuscitation on average was 60 s later than RT. Time to place an umbilical catheter was almost twice the RT (354±100 s) and time to first dose of intravenous adrenaline was almost 120 s later than the RT. Average time to discontinuation of resuscitation was 17 min, 43 s, which was 10 min, 42 s after initial intravenous adrenaline.

Conclusions Critical resuscitation steps during intensive resuscitation often occur later than the RT. Identifying asystole by auscultation is difficult, takes time and can delay responses. Even a trained team during a simulation code took over 7 min to administer the initial dose of intravenous adrenaline. Recommendations related to discontinuation of resuscitation should clearly delineate what constitutes effective resuscitation (minimum of early intubation, intravenous adrenaline). We recommend the ‘timer’ to discontinuation of resuscitation only starts following the first dose of intravenous adrenaline.