Improving Initial Steps during Neonatal Resuscitation: A Quality Improvement Study

Abstract

Background

Neonatal resuscitation guided by the Neonatal Resuscitation Program (NRP) algorithm is a frequently performed event. However, strict adherence to the algorithm is often lacking. This quality improvement study was conducted when we identified poor compliance with the NRP algorithm in the ‘initial steps’ as a problem in our hospital.

Methods

The study was carried out over 48 weeks with an aim to improve the early steps of the NRP algorithm in the delivery room from the existing baseline score (maximum score of 22) of 5 (22%) to at least 13 (60%). Objective scoring, which included 11 domains (maximum score of 2 for each) from antenatal counselling, team briefing, equipment check and initial steps, and the time taken to begin positive pressure ventilation (PPV) were taken as process measures. Improvement of score to >90%, PPV requirement, beginning of PPV within 60 s and the use of various checklists were studied as outcome measures, along with the balancing outcome of neonatal intensive care unit admission temperature. Statistical process control charts were used for data analysis with standard rules for upper and lower control limits.

Results

A total of 480 resuscitations were scored. All domains of scoring improved from the baseline to the sustenance phase. The control limit improved from a baseline score of 5.1–21 during the sustenance phase, while the time to start PPV improved from 93.7 to 61.7 seconds. There was a significant improvement in the use of checklists for antenatal counselling, team briefing, and equipment checks. The need for PPV remained the same, and it could be started in only 36.4% of households within 60 seconds.

Conclusion

Proper implementation of the initial steps of the NRP algorithm improved along with the time of initiation of PPV after the study, though no major change was documented in the need for PPV administration.