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Am J Perinatol
DOI: 10.1055/a-1863-2312
Original Article

Identifying Gaps in Resuscitation Practices Across Level-IV Neonatal Intensive Care Units

Noorjahan Ali 
1   Division of Perinatal-Neonatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
,
Elizabeth Schierholz
2   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
,
Danielle Reed
3   Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, Missouri
,
Hannah Hightower
4   Division of Neonatology, Department of Pediatrics, Children's of Alabama, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
,
Beth A. Johnson
5   Division of Neonatology and Pulmonary Biology, Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
,
Ruby Gupta
6   Division of Neonatal/Perinatal Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
,
Megan Gray
7   Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
,
Anne Ades
8   Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
,
Elizabeth A. Wetzel
9   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
,
on behalf of the Children's Hospitals Neonatal Consortium Resuscitation Focus Group › Author Affiliations Funding None.
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Abstract

Objective This study aimed to describe resuscitation practices in level-IV neonatal intensive care units (NICUs) and identify possible areas of improvement.

Study Design This study was a cross-sectional cohort survey and conducted at the Level-IV NICUs of Children's Hospital Neonatal Consortium (CHNC). The survey was developed with consensus from resuscitation and education experts in the CHNC and pilot tested. An electronic survey was sent to individual site sponsors to determine unit demographics, resuscitation team composition, and resuscitation-related clinical practices.

Results Of the sites surveyed, 33 of 34 sites responded. Unit average daily census ranged from less than 30 to greater than 100, with the majority (72%) of the sites between 30 and 75 patients. A designated code response team was utilized in 18% of NICUs, only 30% assigned roles before or during codes. The Neonatal Resuscitation Program (NRP) was the exclusive algorithm used during codes in 61% of NICUs, and 34% used a combination of NRP and the Pediatric Advanced Life Support (PALS). Most (81%) of the sites required neonatal attendings to maintain NRP training. A third of sites (36%) lacked protocols for high-acuity events. A code review process existed in 76% of participating NICUs, but only 9% of centers enter code data into a national database.

Conclusion There is variability among units regarding designated code team presence and composition, resuscitation algorithm, protocols for high-acuity events, and event review. These inconsistencies in resuscitation teams and practices provide an opportunity for standardization and, ultimately, improved resuscitation performance. Resources, education, and efforts could be directed to these areas to potentially impact future neonatal outcomes of the complex patients cared for in level-IV NICUs.

Key Points

  • Resuscitation practice is variable in level-IV NICUs.

  • Resuscitation algorithm training is not uniform

  • Standardized protocols for high-acuity low-occurrence (HALO) events are lacking

Keywords

neonatal resuscitation - level-IV NICU - NRP - PALS - HALO - CPR

Statement of Ethics

Study was exempt by Indiana University's Institutional Review Board (IRB; IRB identifier: 1809591028).


Authors' Contributions

N.A. and E.A.W. conceptualized and designed the study, coordinated data collection, drafted the initial manuscript, and reviewed the manuscript.


D.R., H.H., B.A.J., R.G., and A.A. designed the study and critically reviewed the manuscript.


E.S. and M.G. analyzed the data and critically reviewed the manuscript.


All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.




Publication History

Accepted Manuscript online:
26 May 2022

Article published online:
23 June 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care, 2007-2012. JAMA Pediatr 2015; 169 (09) 855-862
    CrossrefPubMedGoogle Scholar
  • 2 Ali N, Lam T, Gray MM. et al. Cardiopulmonary resuscitation in quaternary neonatal intensive care units: a multicenter study. Resuscitation 2021; 159: 77-84
    CrossrefPubMedGoogle Scholar
  • 3 Foglia EE, Langeveld R, Heimall L. et al. Incidence, characteristics, and survival following cardiopulmonary resuscitation in the quaternary neonatal intensive care unit. Resuscitation 2017; 110: 32-36
    CrossrefPubMedGoogle Scholar
  • 4 Ahmad KA, Velasquez SG, Kohlleppel KL. et al. The characteristics and outcomes of cardiopulmonary resuscitation within the neonatal intensive care unit based on gestational age and unit level of care. Am J Perinatol 2020; 37 (14) 1455-1461
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Barber CA, Wyckoff MH. Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006; 118 (03) 1028-1034
    CrossrefPubMedGoogle Scholar
  • 6 Sawyer T, Clark A, Ridout R. Infant resuscitation outside the delivery room in neonatal-perinatal and pediatric critical care fellowship programs: NRP or PALS? Results of a national survey. Journal of Neonatal-Perinatal Medicine 2009; (02) 95-102
    CrossrefPubMedGoogle Scholar
  • 7 Ali N, Sawyer T, Barry J, Grover T, Ades A. Resuscitation practices for infants in the NICU, PICU and CICU: results of a national survey. J Perinatol 2017; 37 (02) 172-176
    CrossrefPubMedGoogle Scholar
  • 8 McEwan D, Ruissen GR, Eys MA, Zumbo BD, Beauchamp MR. The effectiveness of teamwork training on teamwork behaviors and team performance: a systematic review and meta-analysis of controlled interventions. PLoS One 2017; 12 (01) e0169604
    CrossrefPubMedGoogle Scholar
  • 9 Romig M, Duval-Arnould J, Winters BD, Newton H, Sapirstein A. Intensivist presence at code events is associated with high survival and increased documentation rates. Crit Care Clin 2018; 34 (02) 259-266
    CrossrefPubMedGoogle Scholar
  • 10 Crowley CP, Logiudice RE, Salciccioli JD, McCannon JB, Clardy PF. Initiation and assessment of timekeeping roles during in-hospital cardiac arrests to track rhythm checks and epinephrine dosing. Crit Care Explor 2020; 2 (01) e0069
    CrossrefPubMedGoogle Scholar
  • 11 Weiner GM, Zaichkin J. Textbook of Neonatal Resuscitation (NRP). 8th ed.. Itacasa, IL: American Academy of Pediatrics and American Heart Association; 2021
    CrossrefGoogle Scholar
  • 12 Topjian AA, Raymond TT, Atkins D. et al; Pediatric Basic and Advanced Life Support Collaborators. Part 4: pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020; 142 (16_suppl_2): S469-S523
    CrossrefPubMedGoogle Scholar
  • 13 Pfeiffer S, Lauridsen KG, Wenger J. et al; Pediatric Resuscitation Quality Collaborative Investigators. Code team structure and training in the pediatric resuscitation quality international collaborative. Pediatr Emerg Care 2021; 37 (08) e431-e435
    CrossrefPubMedGoogle Scholar
  • 14 Wiberg S, Holmberg MJ, Donnino MW. et al; American Heart Association's Get With The Guidelines-Resuscitation Investigators. Age-dependent trends in survival after adult in-hospital cardiac arrest. Resuscitation 2020; 151: 189-196
    CrossrefPubMedGoogle Scholar
  • 15 Holmberg MJ, Granfeldt A, Girotra S, Donnino MW, Andersen LW. American Heart Association's Get With The Guidelines-Resuscitation Investigators. Trends in survival and introduction of the 2010 and 2015 guidelines for adult in-hospital cardiac arrest. Resuscitation 2020; 157: 112-120
    CrossrefPubMedGoogle Scholar
  • 16 Holmberg MJ, Wiberg S, Ross CE. et al. Trends in survival after pediatric in-hospital cardiac arrest in the United States. Circulation 2019; 140 (17) 1398-1408
    CrossrefPubMedGoogle Scholar
  • 17 Alten JA, Klugman D, Raymond TT. et al. Epidemiology and outcomes of cardiac arrest in pediatric cardiac ICUs. Pediatr Crit Care Med 2017; 18 (10) 935-943
    CrossrefPubMedGoogle Scholar
  • 18 American Academy of Pediatrics Committee on Fetus And Newborn. Levels of neonatal care. Pediatrics 2012; Sep; 130 (03) 587-97
    PubMedGoogle Scholar
  • 19 Cheng A, Duff JP, Kessler D. et al; International Network for Simulation-based Pediatric Innovation Research and Education (INSPIRE) CPR. Optimizing CPR performance with CPR coaching for pediatric cardiac arrest: a randomized simulation-based clinical trial. Resuscitation 2018; 132: 33-40
    CrossrefPubMedGoogle Scholar
  • 20 Hunt EA, Jeffers J, McNamara L. et al. Improved cardiopulmonary resuscitation performance with CODE ACES2: a resuscitation quality bundle. J Am Heart Assoc 2018; 7 (24) e009860
    CrossrefPubMedGoogle Scholar
  • 21 Girotra S, Nallamothu BK, Tang Y, Chan PS. American Heart Association Get With The Guidelines–Resuscitation Investigators. Association of hospital-level acute resuscitation and postresuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest. JAMA Netw Open 2020; 3 (07) e2010403
    CrossrefPubMedGoogle Scholar
  • 22 Holmberg MJ, Ross CE, Yankama T, Roberts JS, Andersen LW. American Heart Association's Get With The Guidelines-Resuscitation Investigators. Epinephrine in children receiving cardiopulmonary resuscitation for bradycardia with poor perfusion. Resuscitation 2020; 149: 180-190
    CrossrefPubMedGoogle Scholar
  • 23 Jayaram N, Spertus JA, Nadkarni V. et al; American Heart Association's Get with the Guidelines-Resuscitation Investigators. Hospital variation in survival after pediatric in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes 2014; 7 (04) 517-523
    CrossrefPubMedGoogle Scholar
  • 24 Bradley SM, Huszti E, Warren SA, Merchant RM, Sayre MR, Nichol G. Duration of hospital participation in Get With the Guidelines-Resuscitation and survival of in-hospital cardiac arrest. Resuscitation 2012; 83 (11) 1349-1357
    CrossrefPubMedGoogle Scholar
  • 25 Foglia EE, Jensen EA, Wyckoff MH, Sawyer T, Topjian A, Ratcliffe SJ. American Heart Association's Get With The Guidelines-Resuscitation Investigators. Survival after delivery room cardiopulmonary resuscitation: a national registry study. Resuscitation 2020; 152: 177-183
    CrossrefPubMedGoogle Scholar
  • 26 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46 (Suppl. 01) 10-67
    CrossrefPubMedGoogle Scholar
  • 27 Rhodes A, Phillips G, Beale R. et al. The surviving sepsis campaign bundles and outcome: results from the international multicentre prevalence study on sepsis (the IMPreSS study). Intensive Care Med 2015; 41 (09) 1620-1628
    CrossrefPubMedGoogle Scholar
  • 28 Workman JK, Ames SG, Reeder RW. et al. Treatment of pediatric septic shock with the surviving sepsis campaign guidelines and PICU patient outcomes. Pediatr Crit Care Med 2016; 17 (10) e451-e458
    CrossrefPubMedGoogle Scholar
  • 29 Samransamruajkit R, Uppala R, Pongsanon K, Deelodejanawong J, Sritippayawan S, Prapphal N. Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP. Indian J Crit Care Med 2014; 18 (02) 70-76
    CrossrefPubMedGoogle Scholar
  • 30 Grover TR, Pallotto EK, Brozanski B. et al. Interdisciplinary teamwork and the power of a quality improvement collaborative in tertiary neonatal intensive care units. J Perinat Neonatal Nurs 2015; 29 (02) 179-186
    CrossrefPubMedGoogle Scholar
  • 31 Piazza AJ, Brozanski B, Provost L. et al. SLUG bug: quality improvement with orchestrated testing leads to NICU CLABSI reduction. Pediatrics 2016; 137 (01) DOI: 10.1542/peds.2014-3642.
    CrossrefPubMedGoogle Scholar
  • 32 Brozanski BS, Piazza AJ, Chuo J. et al. STEPP IN: working together to keep infants warm in the perioperative period. Pediatrics 2020; 145 (04) e20191121
    CrossrefPubMedGoogle Scholar