Elsevier

Resuscitation

Volume 53, Issue 1, April 2002, Pages 47-51
Resuscitation

Neonatal resuscitation: toward improved performance

https://doi.org/10.1016/S0300-9572(01)00494-4Get rights and content

Abstract

Background: As part of a continuous quality assurance process which we instituted in 1999, we review videotapes of selected high-risk deliveries at our hospital. We utilized our reviews to evaluate the occurrence of errors, and to evaluate team and leader functions during neonatal resuscitation. Methods: We established accepted behavior for members of resuscitation teams and the team leader. The actual conduct of the resuscitation was judged against the standard of the guidelines of the Neonatal Resuscitations Program of the American Heart Association, and the American Academy of Pediatrics. The videotapes of resuscitations were reviewed, and significant deviations from accepted practices were noted, and discussed by a specifically developed quality assurance committee, including, whenever possible, the actual resuscitators. Results: We were able to detect a number of problems, which included inappropriate leader and team member activities, inappropriate preparation, communication, and coordination, and made a number of changes to our practice. Conclusions: We believe that neonatal resuscitation may be improved by the provision of teaching about team and leader functions, encouraging debriefing following complicated resuscitations, developing a minimal form to be completed for any patient requiring compressions or epinephrine within the delivery room, and providing more direct observations regarding the actual conduct of resuscitation.

Introduction

The practice of neonatal resuscitation has evolved over the past 50 years to its present form with a dearth of evidence-based data. In 1987 Bloom and Crowley and the Neonatal Resuscitation Program (NRP) Steering Committee of the AHA/AAP developed the curriculum of the NRP, which is now the accepted standard for neonatal resuscitation in USA [1], [2]. Our experience over 2 years of video recording of delivery room resuscitations is that despite an experienced staff who have been through NRP megacodes many times, errors still occur with some regularity; errors which, for the most part, are preventable, and such errors are most often not documented in the medical record.

Human error and its effect on medical care have been studied for many years, with an increased emphasis since the results of the Harvard Medical Practice Study [3] and the more recent data from Thomas et al., who evaluated adverse incidents in Colorado and Utah [4] and further emphasized the frequency of the occurrence of such errors.

In 1999 the Institute of Medicine (IOM) proposed sweeping changes to improve public safety through increased federal involvement, improved systems, and widespread involvement of educational and professional organizations [5].

As part of a continuous quality improvement process which we instituted in 1999, we review videotapes of selected high risk deliveries at our hospital [6]. In reviewing over 300 neonatal resuscitations we have identified a number of problems. In this manuscript we review our process of integrating the recommendations of the IOM report to the practice of neonatal resuscitation.

Section snippets

Materials and methods

Our methodology of the videotape review process has been previously described [6]. We developed a scoring tool which reflected the recommendations of the Neonatal Resuscitation Program, and has been changed to reflect the 4th edition recommendations [2]. We then evaluated the recommendations of the IOM report, and found that of the four broad categories of quality related errors described [7], the two most relevant and prominent in the delivery room setting were avoidable errors and variations

Results

Since the implementation of leadership training, we have reviewed leadership function during 35 video resuscitations. In this group, six resuscitations were noted to have little or no obvious leader, and five of these were led by the same individual. We have virtually eliminated four of the six major errors we recognized previously. These include: deep suctioning, excessive stimulation, not communicating the heart rate, and not re-evaluating bag valve mask ventilation. Since incorporating

Discussion

Competency in the NRP course material is demonstrated by successful completion of a written exam and a mock code. This format at least attempts to assess both the didactic and practical competencies described by Wass et al. as ‘know how’ and ‘show how’ [11]. Previous studies have used an independent observer to assess neonatal resuscitation [12], and this methodology may be easier to implement than video in many settings. More recently, Halamek et al. have devised a neonatal resuscitation

Conclusions

The videotaping of neonatal resuscitations has allowed us to begin to review the systems in place in our institution to provide consistent, error-free care. While we recognize that we have not provided improved patient outcomes, as measured by improved Apgar scores, we believe that the reduction of errors during resuscitation is a significant achievement.

We make the following recommendations for improving the conduct of neonatal resuscitation: provide teaching about team and leader functions,

Portuguese Abstract and Keywords
Fundamento: Integrado no âmbito de um processo de avaliação contı́nua de qualidade instituı́do em 1999, revimos videos de partos de alto risco seleccionados no nosso hospital. Utilizámos as nossas revisões para avaliar a ocorrência de erros, e para avaliar o funcionamento da equipa e do seu lı́der durante a reanimação neonatal. Método: Estabelecemos comportamentos aceitáveis para membros da equipa de reanimação e para o lı́der. A forma como a reanimação foi

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Portuguese Abstract and Keywords
Fundamento: Integrado no âmbito de um processo de avaliação contı́nua de qualidade instituı́do em 1999, revimos videos de partos de alto risco seleccionados no nosso hospital. Utilizámos as nossas revisões para avaliar a ocorrência de erros, e para avaliar o funcionamento da equipa e do seu lı́der durante a reanimação neonatal. Método: Estabelecemos comportamentos aceitáveis para membros da equipa de reanimação e para o lı́der. A forma como a reanimação foi conduzida foi comparada com o standard das Guidelines do Programa de Reanimação Neonatal da American Heart Association e da Academia Americana de Pediatras. Os vı́deos da reanimação foram revistos, sendo registados e discutidos desvios significativos das práticas aceitáveis por um comité especificamente desenvolvido na avaliação contı́nua de qualidade, incluindo sempre que possı́vel os reanimadores envolvidos. Resultados: Detectou-se um número de problemas que incluiram a actividade de liderança e da equipa bem como a preparação, a comunicação e a coordenação inapropriadas que levaram a mudanças na nossa prática. Conclusão: Acreditamos que a reanimação neonatal pode ser melhorada através do treino do trabalho em equipa e das funções de liderança, encorajando a discussão após reanimações complicadas, criando um registo a preencher em todas as situações de doentes que necessitem de compressão cardı́aca externa ou epinefrina na sala de partos e fazendo observação mais directa da conduta efectiva durante a reanimação.
Palavras chave: Erros, Neonatal; Reanimação

Spanish Abstract and Keywords
Antecedentes: Como parte del proceso de control de calidad continuo instituido en 1999, revisamos los videos seleccionados de partos de alto riesgo en nuestro hospital. Utilizamos nuestras revisiones para evaluar la ocurrencia de errores, y para evaluar las funciones del equipo y de los lı́deres durante la resucitación neonatal. Métodos: Establecimos los comportamientos aceptables para miembros de equipos de resucitación y su lı́der. Se juzgó la conducta real en relación con los estándares de las Guı́as del Programa de Resucitación Neonatal de la Asociación Americana de Corazón, y la Academia Americana de Pediatrı́a. Se revisaron los videos de las resucitaciones, y se encontraron desviaciones significativas respecto a las prácticas aceptadas. Estas desviaciones fueron discutidos por el comité de control de calidad, especı́ficamente desarrollado, incluyendo—cada vez que fue posible—los resucitadores que participaron. Resultados: Fuimos capaces de detectar una cantidad de problemas, que incluyeron actividades inapropiadas del lı́der y de miembros del equipo, preparación inadecuada, comunicación, y coordinación, e hicimos una serie de cambios a nuestra práctica. Conclusiones: Creemos que la resucitación neonatal puede ser mejorada si proveemos enseñanza acerca de funciones de equipo y de lı́der, estimulando revisión de procedimientos después de resucitaciones complicadas, desarrollando un formulario mı́nimo para ser completado para cualquier paciente que requiera compresiones o epinefrina en el pabellón de partos, y proporcionando más observación directa en relación con las conductas de resucitación actuales.
Palabras clave: Errores; Neonatal; Resucitación

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