Auditing resuscitation of preterm infants at birth by recording video and physiological parameters

doi:10.1016/j.resuscitation.2012.01.036

Resuscitation

Volume 83, Issue 9, September 2012, Pages 1135-1139

https://doi.org/10.1016/j.resuscitation.2012.01.036 Get rights and content

Abstract

Objective

To evaluate compliance with neonatal resuscitation guidelines during resuscitation of preterm infants by video recording of delivery room management and monitoring physiologic parameters.

Methods

The delivery room management of preterm infants at birth was recorded by an independent researcher. Physiological parameters (airway pressures, gas flow, tidal volume, heart rate and oxygen saturation) were measured, use of supplemental oxygen was noted and a video of the resuscitation was recorded. All signals were digitised and recorded using specially designed software. The delivery room management was then evaluated and compared with the local resuscitation guidelines.

Results

Thirty-four infants were included with a mean (SD) gestational age of 30.6 (3.2) weeks and birth weight of 1292 (570) g. Time from birth to initial evaluation was longer than recommended (65 (15) s). Respiratory support was started at 70 (23) s. In 7/34 infants (21%), interventions were performed according to guidelines. In 25/34 infants (74%), one or more respiratory interventions were not performed according to guidelines. In 10/34 infants (29%), one or more non-respiratory interventions (mainly related to the prevention of heat loss) were not performed according to guidelines. The presence and adequacy of spontaneous breathing was difficult to judge clinically. In almost all occasions (96%) the information from the respiratory function monitor was not used.

Conclusions

Neonatal caregivers often deviate from resuscitation guidelines. Respiratory function monitoring parameters were often not used during resuscitation. A difficult part of neonatal resuscitation is subjectively assessing spontaneous breathing.

Introduction

National and international guidelines with step-by-step flow charts on how to perform optimal resuscitation are available for caregivers to improve neonatal resuscitation and outcome. Although caregivers are recommended to follow guidelines, the stressful and sometimes unpredictable character of resuscitation can make it difficult to strictly follow guidelines. One study found a significant number of deviations from the Neonatal Resuscitation Program guidelines.¹ Video recording is considered useful for monitoring² and the detection of problems during resuscitation and it is believed to be helpful to improve resuscitation practice.³ However, video monitoring is subjective and it is difficult to judge the adequacy and effect of ventilation on video. Studies have shown that the judgment of characteristics such as colour, heart rate by auscultation and chest excursions shows large inter- and intrapersonal variability.4, 5

In Leiden, recording physiological parameters simultaneously with video during neonatal resuscitation is considered as standard of care and is performed when time is available to set up the equipment. With the parent's consent, the recordings are used for training, audit and research purposes. This approach makes it possible to evaluate resuscitation more objectively.

The aim of this study was to evaluate the delivery room management of preterm infants by the team in our unit by recording video and physiological parameters and comparing it with the local resuscitation guidelines. We hypothesise that caregivers deviate from the guidelines during neonatal resuscitation and that the subjective, clinical assessment of the condition of the infant is often inaccurate.

Section snippets

Methods

This prospective observational study was performed in the department for neonatal intensive care of the Leiden University Medical Center, a tertiary level perinatal care centre in Leiden, the Netherlands, with an average of 650 admissions per year.

During the study period our local neonatal resuscitation guidelines were based on international guidelines (ILCOR 2006, European Resuscitation Council 2005),6, 7 and national guidelines (Dutch Organisation for Paediatrics 2008 guidelines).⁸ The

Results

Recordings were made when logistics allowed us to set up our equipment. From January until July 2010, 34 resuscitations of preterm infants at the Leiden University Medical Center were observed and recorded by the researchers. Of those 34 infants, 23 infants (67.6%) were born by caesarean section. The mean (SD) gestational age was 30.6 (3.2) weeks with a mean (SD) birth weight of 1292 (570) grams. Median Apgar scores at 1 and 5 min were 5 (3–6) and 7 (6–8).

In 7/34 infants (21%), delivery room

Discussion

In this study, we found that caregivers in our centre often do not follow the neonatal resuscitation guidelines and only 21% of infants were resuscitated strictly according to the guidelines. Deviations from the guidelines mainly occurred within the first 30 s after birth (Step A of the recommended guidelines) and in the way ventilation was given.

Results from this audit emphasised that caregivers needed more time for the initial steps in the resuscitation algorithm and the evaluation of the

Conclusion

Caregivers deviate from resuscitation guidelines for many reasons. Our study suggested that more time may be needed for the initial steps in the resuscitation algorithm and the evaluation of the condition of the infant. At 1 min, caregivers are supposed to make the decision on whether to start ventilation. According to recent data, when following these guidelines approximately two thirds of infants would receive unnecessary ventilation. The recommended timing for interventions in the guidelines

Conflict of interest statement

No conflicts of interest to declare.

Acknowledgement

We would like to thank Mirjam Mulders for her help with gathering data.

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^☆: A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2012.01.036.

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Clinical PaperAuditing resuscitation of preterm infants at birth by recording video and physiological parameters☆

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Conflict of interest statement

Acknowledgement

Resuscitation

Resuscitation

Video recording as a means of evaluating neonatal resuscitation performance

Pediatrics

Ethical and legal aspects of video recording neonatal resuscitation

Arch Dis Child Fetal Neonatal Ed

Variability in the assessment of ‘adequate’ chest excursion during simulated neonatal resuscitation

Neonatology

Clinical assessment of infant colour at delivery

Arch Dis Child Fetal Neonatal Ed

The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: neonatal resuscitation

Pediatrics

Clinical Paper
Auditing resuscitation of preterm infants at birth by recording video and physiological parameters☆