Helping Babies Breathe


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Helping Babies Breathe

Susan Niermeyer, University of Colorado Denver School of Medicine

CORE Group Spring Meeting, April 28, 2010

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  • As we have heard, this meeting is brimming with the latest developments in high-fidelity simulation, development of interprofessional team function, debriefing, use of simulation and standardized patients for professional evaluation – all sophisticated applications of simulation in our increasingly complex practice settings. But this morning I want to take you to a very different place – to a place where resources are limited, where health professionals are scarce, and where patients may live or die dependent upon the availability of the simplest interventions. Simulation has a role, there, too, in equally powerful, but perhaps unexpected ways.
  • The Americas shrink, as does Europe. Japan, Australia, New Zealand nearly disappear. Africa balloons and the South Asian region becomes huge.
  • Translating these images into statistics reveals the tremendous spread in rates of neonatal mortality. In the industrialized countries neonatal mortality is around 3 per 1000 live births; in eastern Europe, Latin America and the Caribbean mortality rates rise to moderate levels; but in Africa and South Asia rates rise to 10 – 15 times those of the industrialized nations. Of the nearly 4 million neonatal deaths per year, 98% occur in the developing and least developed parts of the world.
  • If now we imagine the world in proportion to the number of physicians working, we see the U.S., Europe, China grow fat; South Asia changes little – and Africa nearly disappears. So what does this tell us? The greatest burden of neonatal death remains in areas of the world where there are inadequate numbers of trained professionals and where the health systems are not strong enough to provide care to all those in need. It is necessary not only to strengthen the capability of current facilities and providers, but also to create new cadres of trained birth attendants.
  • However, the benefits to be realized are enormous. Recent estimates published in the October supplement to the International Journal of Obstetrics and Gynecology suggest that 16 million babies could be helped – saved from death or possible disability – through universal application of neonatal resuscitation.
  • From the beginning, collaborators who would play a role in implementing resuscitation training participated in the development of the global curriculum. Representatives from the WHO helped map out the target audience and the core curriculum. Senior program directors from NIH Child Health and Human Development, Save the Children – Saving Newborn Lives, and USAID reviewed and commented on educational materials.
  • It emphasizes the fundamentals of drying, warmth, clearning the airway, stimulation, and positive-pressure ventilation. The Golden Minute highlights the importance of immediate action. Supplemental oxygen, intubation, chest compressions, and medications do not enter the algorithm. Instead, Helping Babies Breathe leads into the full NRP when more advanced support is needed and available. HBB draws its evidence base from the same ILCOR consensus on science as does NRP.
  • A new low-cost infant simulator developed for the program features umbilical pulse, chest wall movement with spontaneous and ventilated breaths, and cry – although any mannequin can be used for teaching. The mannequin is shipped collapsed, but filled with warm water for use to provide realistic weight, temperature, and flexibility that mimics a lifeless baby. A low-cost ventilation bag/mask apparatus and a new boilable bulb syringe have been developed to meet the training and clinical equipment needs of the developing world.
  • HBB uses a largely pictorial format and limited text to minimize translation and make it accessible to learners with limited literacy.
  • The format is designed to promote self-learning. Though aimed at midwives, the curriculum can also be adapted for community health workers and even traditional birth attendants.
  • As with NRP, skills practice forms the foundation of the course.
  • Helping Babies Breathe

    1. 1. Helping Babies Breathe Susan Niermeyer, MD, MPH, FAAP University of Colorado Denver School of Medicine Aurora, Colorado, USA
    2. 2. The world 2002
    3. 3. The world of early neonatal deaths 2002
    4. 4. Regional rates of neonatal mortality UNICEF, State of the World’s Children 2009
    5. 5. The world of physicians working 2002
    6. 6. Inverted pyramid of neonatal resuscitation Medications Chest Compressions Positive-Pressure Ventilation Initial Steps: Drying, Warmth, Clearing the Airway, Stimulation Assessment at Birth and Simple Newborn Care All infants Some infants Few infants Wall, Lee, Niermeyer et al. IJGO 2009 136 million babies born Approx 10 million babies Approx 6 million babies < 1.4 million babies
    7. 7. Global Implementation Task Force Collaborators <ul><li>World Health Organization (WHO) </li></ul><ul><li>Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) </li></ul><ul><li>United States Agency for International Development (USAID, MCHIP) </li></ul><ul><li>Save the Children U.S. - Saving Newborn Lives (SNL) </li></ul>
    8. 8. Helping Babies Breathe evidence base <ul><li>International Liaison Committee on Resuscitation (ILCOR) </li></ul><ul><ul><li>Neonatal Resuscitation: Consensus on Science and Treatment Recommendations </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>112/22_suppl/III-91 </li></ul></ul><ul><li>World Health Organization </li></ul><ul><ul><li>Basic resuscitation guidelines (in revision) </li></ul></ul><ul><ul><li>Post-partum hemorrhage </li></ul></ul><ul><ul><li>Handwashing </li></ul></ul><ul><ul><li>Breast feeding </li></ul></ul>
    9. 9. Action Plan
    10. 10. Helping Babies Breathe flipchart/simulator/learner workbook
    11. 11. Helping Babies Breathe facilitator flipchart
    12. 12. Flipchart image for learner and instructional guide for facilitator
    13. 13. Helping Babies Breathe learner workbook
    14. 14. Helping Babies Breathe learner workbook - exercises
    15. 15. Peer learning/teaching
    16. 16. Extension to the clinical setting <ul><li>Clinical supervision </li></ul><ul><li>Case audit </li></ul><ul><li>Perinatal quality improvement </li></ul>Bookman L et al. PAS 2009 2505.7 Singhal N, McMillan DD, Cristobal FL, et al. Health Care for Women Intl 2001; 22:569
    17. 17. Educational field trials <ul><li>Learner evaluation </li></ul><ul><ul><li>Written/verbal knowledge check (MCQs) </li></ul></ul><ul><ul><li>Bag and mask ventilation skill check </li></ul></ul><ul><ul><li>Case scenarios (OSCEs) – The Golden Minute </li></ul></ul><ul><li>Educational evaluation </li></ul><ul><ul><li>Learner and facilitator questionnaires </li></ul></ul><ul><ul><ul><li>Materials – content, presentation, function </li></ul></ul></ul><ul><ul><ul><li>Satisfaction, self-efficacy </li></ul></ul></ul><ul><ul><li>Focus group discussions </li></ul></ul>
    18. 18. Educational field trials - results <ul><li>Learner evaluation </li></ul><ul><ul><li>Gains in knowledge, skills, performance </li></ul></ul><ul><ul><li>Significant revisions of evaluation tools </li></ul></ul><ul><li>Educational evaluation </li></ul><ul><ul><li>High satisfaction, feasibility, self-efficacy </li></ul></ul><ul><ul><li>Strengths: Neonatal simulator </li></ul></ul><ul><ul><ul><li> The Golden Minute </li></ul></ul></ul><ul><ul><li> Pictorial Action Plan and Flip Chart </li></ul></ul><ul><ul><li> Check yourself questions </li></ul></ul><ul><ul><li>Suggestions: </li></ul></ul><ul><ul><li> More time for practice </li></ul></ul><ul><ul><li> Simultaneous distribution of equipment/training </li></ul></ul><ul><ul><li> Involvement of men in advocacy activities </li></ul></ul>
    19. 19. Implementation field trials educational outcomes <ul><li>Master trainer/facilitator/provider cascade followed by scale-up </li></ul><ul><li>Learner evaluations of knowledge, skills, performance, competence (delivery room observation) </li></ul><ul><li>Learner questionnaires and focus group discussions </li></ul><ul><ul><li>Satisfaction, self-efficacy among different cadres of providers </li></ul></ul><ul><li>Retention of knowledge, skills </li></ul>
    20. 20. Implementation field trials clinical outcomes <ul><li>Time to spontaneous breathing </li></ul><ul><li>Intervention (routine, initial steps, PPV) </li></ul><ul><li>Apgar score </li></ul><ul><li>Provider </li></ul><ul><li>Skin-to-skin positioning </li></ul><ul><li>Breastfeeding in first 30 minutes </li></ul><ul><li>Need for special care/length of stay </li></ul><ul><li>Outcome: stillborn, neonatal death, seizures, normal </li></ul>
    21. 21. Helping Babies Breathe