“You cannot improve what you do not measure”

Collect and utilize local data to assess and improve education training, performance, and outcomes of neonatal resuscitation.

Consider participating in a multi-center registry to benchmark key metrics with other institutions and increase the pace of scientific discovery.

KEY POINTS

• The cohort of patients whom data is to be collected should be defined. Data may be captured for all newborns who are not breathing well at birth or focus only on newborns who receive neonatal resuscitation (e.g., positive pressure ventilation or more intensive interventions). These are not the same thing.
• The nature of the data collected will vary depending on facilities’ needs and resources.
• The ILCOR Neonatal Utstein-Style reporting guideline provides a framework for standardized data collection in the following domains: Setting, Antepartum, Birth, Pre resuscitation planning, Resuscitation process, Post resuscitation process, Outcomes.
• Use and build upon data collection resources currently available.
• Buy-in from those collecting data is essential.
• Registries enable comparisons both within and between institutions.
• Governance regarding collection and retention of data is critical – rules will vary between settings.
• Facility and health system (national and provincial) level data provide information about system resources and readiness.

Please provide feedback on Step 1

Make available newborn-specific resuscitation equipment available in every setting where newborns may be resuscitated.

Equipment readiness and team preparation are essential to timely, effective response.

KEY POINTS

• Newborn-specific equipment and supplies (consumables) must be available for both intrapartum care and resuscitation.
• Essential equipment for newborn care can be very different than that for pediatric or adult care in size and purpose (e.g. bag and masks, blenders for air/oxygen, flowmeters).
• Equipment that is affordable, safe and effective for the intended use, as well as the supplies (consumables – e.g. probes, filters, electrodes) should be available for each resuscitation.
• Equipment functionality and maintenance require collaboration between health care providers and biomedical technicians and engineers.
• An equipment checklist should specify essential items to perform neonatal resuscitation according to guidelines.
• The equipment should address thermoregulation, airway, breathing, circulation, and timing (e.g. timer/clock).
• Communication and preparedness extends beyond neonatal care providers to include maternal providers and the patient’s family.

Please provide feedback on Step 2

Educate providers on evidence-based practice for neonatal resuscitation; include all providers who may care for a baby at birth.

Maintain provider knowledge and skills through on-going training.

Evaluate provider performance in the clinical setting.

KEY POINTS

• Knowledgeable and skilled providers are foundational to delivering quality resuscitation.
• The ideal educational system ensures providers’ competency in resuscitation prior to independent clinical practice AND ensures on-going training with evaluation of clinical performance.
• Systems should include plans for identifying and incorporating newly hired providers into the facility’s education system.
• Education systems should focus on the providers who are primarily responsible for neonatal resuscitation, but they should also include maternal providers who may be first responders at the time of birth (e.g., obstetricians, labor and delivery nurses), as well as all individuals who may constitute the perinatal team (e.g., nurses, respiratory therapists).
• Providers’ knowledge and skill will decline without on-going training. Systematization of on-going training, including attention to strategies that will motivate providers to train, is paramount.
• On-going training should not be considered optional; it should be part of the expectations for providing clinical resuscitation care.
• Documentation of initial and on-going training should be maintained.
• Effective education systems include evaluation of performance. Performance during simulation does not necessarily predict performance in clinical care, thus proficiency should be evaluated during clinical cases.

Please provide feedback on Step 3

Establish effective and timely communication between maternal providers, newborn providers and families.

Ensure prenatal care and intrapartum monitoring of the maternal-fetal dyad.

Support regionalization of care and triage to the appropriate healthcare facility before birth.

KEY POINTS

• Preventing need for neonatal resuscitation requires effective and timely communication between maternal and newborn providers as well as communication with families about perinatal risk.
• Prenatal care beginning in the first trimester and use of ultrasound imaging supports early identification of high-risk fetal and maternal conditions.
• Intrapartum monitoring of the maternal-fetal dyad (e.g., use of a partogram, continuous electronic fetal heart rate monitoring) can support early identification of the dyad at risk.
• Provision of appropriate therapies (e.g., antenatal corticosteroids, assisted vaginal delivery, cesarean section) to support the at-risk fetus can reduce the need for resuscitation.
• Regionalization of care with risk stratification and referral to the appropriate facility and appropriate care team (preferably before birth) is a critical part of prevention.

Please provide feedback on Step 4

Every second counts.

A person capable of assessing and responding to the newborn should be present at every delivery.

Early recognition that a baby is not breathing well at birth is essential.

KEY POINTS

• Use available perinatal information to ensure the clinical team appropriate for the newborn’s anticipated needs is assembled before birth.
• First responders may include a maternal provider (e.g., midwife, obstetrician) or less experienced neonatal provider.
• First responders must be able to:
• Recognize that the newborn requires resuscitation
• Assemble the appropriate equipment, perform initial interventions to stabilize the newborn (e.g., stimulation), and start resuscitation including PPV
• Call for help and have that help available to them in a timely fashion.

Neonatal resuscitation based on accepted guidelines should be commenced promptly.

Please provide feedback on Step 5

Ensure appropriately trained teams provide effective care consistent with local guidelines.

Maintain individual skills, particularly those related to performing effective PPV and team performance (communication and leadership).

KEY POINTS

• Team composition will be determined by the clinical context and available resources.
• Team roles and responsibilities (including team leader) should be clearly identified before the newborn is born.
• Closed loop communication is vital throughout resuscitation.
• Patient monitoring should be undertaken using context-specific tools and should include assessment of breathing, heart rate and oxygenation.
• Guideline based cord management, thermal management and stimulation should be undertaken.
• Effective PPV is the key to successful resuscitation

Please provide feedback on Step 6

Use data collected during routine care and specific quality-oriented activities to compare performance to best practices as defined by guidelines and quality standards.

Identify gaps and then use the data to drive change.

Expand positive change through collaborative networks and research.

KEY POINTS

• Global guidelines exist for neonatal resuscitation; quality standards for routine newborn care define standards at the level of the patient (mother and baby), health care providers, facilities, and the health system.
• National guidelines and performance standards may specify adaptations to the local context. Activities that assess performance compared to these standards and guidelines should be part of everyday practice in the health facility.
• Periodic, regular review of data should not only reveal gaps in quality of care but also serve as a basis for driving change.
• The momentum for positive change can be amplified through quality collaboratives and through research aimed at innovation in systems and implementation as well as technology.

Please provide feedback on Step 7

Commit to every baby surviving and thriving.

Promote teamwork with psychological safety to reflect and improve.

Support provider well-being.

Respect the dignity of the fetus and newborn.

KEY POINTS

• An intentional approach to developing a culture of excellence is key; culture is modifiable.
• Success should be defined by reducing both preventable mortality and morbidity.
• A culture of excellence is one that is accountable to newborns and families and always in pursuit of improvement.
• Excellence includes a commitment to safe care that does not harm newborns.
• Getting to excellence requires reflecting on the care provided. Effective reflection requires transparency, which cannot be accomplished without psychological safety.
• Empower all team members to speak up if mistakes are noted, regardless of their role on the team.
• Respecting fetuses and newborns includes recognizing the value of human life and treating death accordingly with appropriate classification and registration of stillbirths and early neonatal deaths.
• Respect for the newborn includes how the neonate is physically handled during a resuscitation (i.e., not picking up by the feet, not aggressively stimulating).
• Providers are often deeply affected by challenging resuscitations and should feel safe to debrief with colleagues regarding these cases.
• Identifying ways to psychologically support the provider will contribute to their well-being.

Please provide feedback on Step 8

KEY POINTS

• The emotional and physical demands of the birthing process and resuscitation, coupled with the uncertainty of favorable outcomes, result in significant psychological stress and anxiety.
• The appropriate methods to support, engage, and empower of parents, birth companions and family members varies widely across cultures and facilities.
• Parents and family members might be present during resuscitation and critical phases of care, and their involvement is often integral to newborn, parent, and family well-being.
• Practice family-centered care during and following resuscitation and avoid parent/family separation whenever possible.
• Engage, monitor, support, and empower family and community as team members.
• Routinely assess the emotional state of parents and families and communicate this to the care team.
• Offer psychological and spiritual support, when appropriate.
• Support diversity of beliefs, traditions, and culture throughout and beyond facility care.

Please provide feedback on Step 9

Provide guideline-based post-resuscitation care throughout and beyond care in the birth facility.

Post-resuscitation care should include those patients who do not ultimately survive and support birthing companion/parents and family.

KEY POINTS

• The specific moment of transition from “resuscitation” to “post-resuscitation” phase is difficult to define (e.g. location vs time vs intervention-based definitions); this should generally follow ILCOR and WHO guidance.
• Team members should have ready access to and a clear understanding of contemporary guidelines and their institution’s specific protocols for post-resuscitative care, risk assessment, and prognosis.
• Team composition and interventions may be determined by the clinical context and available resources.
• Provide consultation and safe intra-facility/interfacility transport to appropriate location after resuscitation, coupled with structured and forward planning communication at transitions of care.
• Avoid parent/family separation and engage, monitor, document, support, and empower family and community as team members.
• Goals of care (e.g. aggressive resuscitation, comfort/palliative care, organ donation) should be collaboratively assessed and considered, in the appropriate clinical and cultural context.
• Guideline-based care continues beyond the delivery area and birth facility into the home, and community. Thus, post-resuscitative care should include appropriate referral, early developmental support, and follow-up.

Please provide feedback on Step 10