The 5 P’s for success in dealing The 5 P’s for success in dealing with the administrationwith 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

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

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

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

Where should resuscitation take place?– DR: often cold (60-65ᵒ F)– Resuscitation room adjacent to DR (preferred)

Hypothermia in the Delivery Room

Hypothermia occurs commonly in very low birth weight infants following delivery.

It is more severe in the smallest and most immature infants.

An admitting temperature < 35.0oC has been associated with mortality in the extremely preterm infant.

Hypothermia incidence – VLBW babies (<1500 gms)

Admitting temps from DR in hospitals with NICUs:

– 40-50% < 36.5°C - Vohra, 1999 (Canada)

– Vermont-Oxford – 2007: ~ 40,000 babies in 650 centers (mostly USA):

54% < 36.5°C

Adverse effects associated with hypothermia in VLBW infants

Hypoglycemia Hypoxia, metabolic acidosis NEC, ARF PPHN Coagulapathy Surfactant deficiency IVH Death

Heat Loss Prevention Strategies

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

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 ResultsVohra, 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

Lenclen, 2002 Matched pair, historical control

<33 weeks < 35.5 C (8%) vs

> 35.5 (55%)

Bjorkland, 2000 Retrospective review

<28 weeks >36.5 C (74%) vs

< 36.5 (23%)

Warming the Delivery Room

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

– <1000 gms is < 1% of all deliveries

Knobel RB, J Perinatol, 2005

Planning

Who should attend?– 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

Level 1 Hospital: who best to attend deliveries to assure competence, especially in achieving technical skills (intubation, UVC placement)– Who should be team leader?– Who is best person to intubate?– IV access: best for epinephrine and volume

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

Notification system– List of maternal or fetal conditions which require

additional expertise in DR– Communication: “H.A.N.D.S.”

H: hemorrhage A: amniotic fluid N: Number of fetuses D: Dates S: Strip (Category 1,2 or 3)

Attendance at DeliveriesGuidelines for Perinatal Care, 6th Edition, 2007

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

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!!!!

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

30,839 births 39 needed CPR and/or epinephrine

– 15 term, 24 premature Clinical events associated with need for

CPR/drugs– Cord ph < 7.0, BE > -14– Malposition of ET tube– Ineffective ventilatory support

“Pearls” of Neonatal Resuscitation

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

Rates of successful

Intubation (%) by

Year of Training

(2 of 4 attempts)

0

10

20

30

40

50

60

70

PGY-1 PGY-2 PGY-3

Falck A et al, Pediatrics, 2003

Preparation

Level 1 and 2 hospitals– Drills– Both OB and Peds with auxillary personnel as

needed (ER, Anesthesia, etc.)

Level 3– Drills– Scripting the first hour of life for VLBW infants, CDH,

gastroschisis, other

MD Primary Nurse Charge Nurse Respiratory Therapist

•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

•Collect and test resuscitation equipment -Bag/mask -2.5 ETT +/- stylet -Suction catheter -Pedi-cap

•Collect nest pack -Nest -Saran wrap -Porta-warm•Tare scale

•Warm nest

•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 bed in NICU

Resuscitation strategy for infants < 32weeks

-5:00

Birth•Dry infant, place in warm nest

•Mask CPAP prior to intubation

•Intubate infant

•Position ETT: Equal to auscultation -6 + weight in kilos at lip

•Ventilate while stabilizing ETT

•Quickly update parents

•Assist with CPAP, intubation

•Confirm ETT position

•Secure endotracheal tube

•Administer surfactant

•Neopuff ventilation, rate of 30-40 -Adjust PIP for TV 4-6cc/kg -Titrate O2 for color

•Assist in stabilization as needed

•Auscultate for HR following intubation

•Assist in taping ETT•Suction prior to surfactant as needed•Wrap infant in Saran

•Assist in OR as needed

To NICU•Weigh infant, vital signs

•Give erythro/vitamin K

•Send first c/s, gas, other labs

•Restrain infant for line placement

•Assist in sending off labs, running c/s

•Place infant on ventilator as soon as possible

•Adjust PIP for volume target of 4-6cc/kg

•Wean FiO2 for saturations 85-93%

•Gown/drape, set up lines

•Place lines

•Initial CXR

•Gas results available, adjust vent

•Complete orders

•Update family

15:00

30:00

40:00

1 hour

Initial stabilization complete•Continue to wean PIP for TV 4-6cc/kg

•Titrate FiO2 for sats 85-93%

ABG parameters

pH: 7.25-7.35

PaCO2: 50-60

Sats: 85-93

•Monitor TV

•Wean FiO2 for sats

Temp parameters 36-37.5C

Protection/performance

Measuring performance– Of drills– Of actual resuscitations

Practice

Drills Simulation

– 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

How can you convince administration it is worth the cost and can lead to profitability?– Actual need for full CPR is rare (1/1000 deliveries)– Paradigm:

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

Reduced number of asphyxiated babies Decreased LOS Reduced medical-legal exposure

Resuscitation as part of HIE case: Claimed breaches

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

Increased focus on ventilation– 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

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

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.

“Effect of a statewide neonatal resuscitation training program on Apgar scores among high risk neonates in Illinois”

Patel, Piotrowski, Nelson and Sabich Pediatrics 2001

“Certification”

From Wikipedia, the free encyclopedia 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.

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?

How do you benchmark competence?

How do you evaluate clinicians using the 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?

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

Why?– Intense, focused, complex activities– Multiple participants– Time constraint

Says who?– The Joint Commission: “Preventing infant death and

injury during delivery”. Sentinel event alert #30. July 24, 2004

Joint Commission: SEA #30

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

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)