Neonatal resuscitation in Australia and New Zealand

It is estimated that 4–7 million newly born infants are resuscitated annually, making neonatal resuscitation among the most commonly performed medical interventions.1 Clinical practice in the delivery room is guided by consensus statements issued by a panel of international experts in the field.2, 3 These ‘best-practice’ guidelines, which are updated every 5 years, recommend that personnel trained in the basic skills of neonatal resuscitation should attend every delivery with at least one person solely responsible for the care of the infant. It is further recommended that a person trained in advanced life support of the newborn should be immediately available for normal low-risk deliveries and that more than one experienced person should attend an anticipated high-risk delivery. Training in neonatal resuscitation is a requirement for doctors training in paediatrics in many countries, including Australia and New Zealand.4-7 Moreover, competence in aspects of neonatal resuscitation, including mask ventilation and endotracheal intubation, is mandatory for paediatricians in training in many countries.4, 6 In order to fill this need for training, several life support courses have been developed which teach resuscitation of newly born infants.8, 9 Sounds reasonable – but what do these courses teach? What is ‘competence’ and may it be assessed? Is training available? Does it work? See related paper by Foster K et al. Neonatal resuscitation educational experience of staff in NSW and ACT hospitals. pp. 16–19. The answers to these questions are complex. Although recommendations exist, the evidence on which they are based is scant; thus practice is based largely on precedent and opinion.10 This undesirable situation has arisen because neonatal resuscitation is difficult to study. It is an emotive, often unanticipated, event, where infants may be critically ill. These factors conspire to make prospective informed consent difficult to obtain. However, where randomized or quasirandomized trials have been conducted, their findings have contradicted the conventional wisdom and practice that preceded it.11-14 We therefore do not know how ‘correct’ the subject matter we teach is. Although concerns about the ethics of conducting research in infants are rightfully often voiced,15 concerns about not doing research are less often raised. Discouraging research in ill infants implies that it is acceptable to use unproven therapies on this most vulnerable group and that a lesser standard of proof is acceptable for babies than for other age groups. Such an approach is misguided at best, morally bankrupt at worst and, arguably, infringes the human rights of infants. Although research on neonatal resuscitation may be difficult, it is imperative that it continues. It is difficult to say whether patients benefit from health care professionals attending life support courses. Systematic reviews have concluded that there is insufficient evidence to determine whether adult trauma victims benefit.16 The impact of neonatal life support courses on infant mortality has not been studied and has been identified as a research priority by the American Academy of Pediatrics.17 It is not clear how competence should be defined or how it may be assessed. Traditionally, life support courses test knowledge using a mix of written and scenario testing. Whether passing such a test means a candidate is ‘competent’ is debatable; indeed, the authors of these programmes explicitly state that this is not the case.8, 9 US studies of neonatal intubation found that clinicians who had attended the Neonatal Resuscitation Program8 were not successful within the set time limit (<20 s)18 and were not ‘competent’ as defined by the authors (i.e. successful on first or second attempt 80% of the time).19 These difficulties are not restricted to the USA, a study at the Royal Women's Hospital showing similar delays.20 It appears that training programmes do, however, increase clinicians' belief in their own ability to function effectively in an emergency situation.21 In this issue of the Journal, Foster et al. report the results of their 2002/2003 survey which asked about the level and availability of neonatal resuscitation training in NSW and the ACT and the respondents perception of their own competence. This survey achieved excellent representation both geographically and across the varying care setting (level 1–level 3) where infants are delivered. Worryingly, it identifies a level of training inferior to that recommended by NSW Health in 2002 and a lack of confidence on the part of these professionals in their own skills. Since this survey was conducted, attempts have been made to standardize and coordinate neonatal resuscitation training in Australia and New Zealand with varying degrees of success. In October 2003, the somewhat ambitiously named ‘Australian Neonatal Resuscitation Project’ convened a workshop to gauge the level of support for a national approach to neonatal resuscitation. Sixty-five people attended, with broad geographic and professional representation. All medical and nursing colleges and organizations were represented as well as individuals and groups with a specific interest in resuscitation. There was unanimous support for a national approach and most favoured working towards a single programme. If, however, this project is to continue, it may need resuscitation itself. Although a steering group has been formed, it has met only once in 18 months. Despite a strong support for the concept, lack of resources – the time of those concerned, in particular – threaten its viability. Realization of the importance of training has increased over recent years and formalized teaching is in either the planning or roll-out phase in each state. Thus, one would hope that the quality of care available to babies in Australia who require delivery room resuscitation is at least being partially addressed. The challenge lies in developing a structure that ensures all staff who may be called upon to resuscitate a newborn are trained to do so. Unlike Australia, a large proportion of pregnancies and deliveries in New Zealand are managed by independent midwife practitioners. In 2002, the New Zealand Resuscitation Council (NZRC) proposed to the NZ Paediatric Society that a working party be set up to formulate a national guideline that would eventually lead to a standardized national newborn resuscitation course. The NZRC was particularly concerned that the NZ College of Midwives, which represents 3000 practitioners, would be closely involved in this process. At present there is no nationwide programme; instead, either the UK or US programmes have been adopted at individual centres and modified according to local requirements. At time of writing, however, a standardized Neonatal Resuscitation guideline, which is evidence-based where possible and acknowledges International Liason Committee on Resuscitation (ILCOR) recommendations, has been formulated. Great emphasis has been placed on the minimum requirements a practitioner needs for infant resuscitation. It is also recognized that more advanced interventions are outside the scope of practice of many and that ‘call for help early’ is an important part of any algorithm. The formulation of a national course stemming from this guideline has been more difficult. Course content, costs to practitioners, instructor training and credentialing issues have all complicated what initially seemed a relatively straightforward process. Planning a course with a committee of practitioners with different needs and agendas has also proved a tricky diplomatic exercise; despite that, we are on the cusp of success. Within 6 months a course approved by all the relevant parties should be delivered to the NZRC. The educational infrastructure that the NZRC already has in place will then administer the implementation of this course around New Zealand. The working party will then reconvene periodically to review the course with respect to changing evidence and the requirements of the parties involved.