Carbine D N, Finer N N, Knodel E, Rich W
Department of Pediatrics, Division of Neonatology, University of California, San Diego, San Diego, California, USA.
Pediatrics. 2000 Oct;106(4):654-8. doi: 10.1542/peds.106.4.654.
To determine the compliance to Neonatal Resuscitation Program (NRP) guidelines in our institution, by the use of videotaped newborn resuscitations.
NRP is the standard of care for newborn resuscitation. The application of NRP guidelines and resuscitation skills in actual clinical settings is undocumented.
DESIGN/METHODS: A video recorder, mounted to the radiant warmer in the main obstetrical operating room, was used to record all high-risk resuscitations. All members of the resuscitation team were NRP-certified. The videotapes were reviewed within 14 days of the resuscitation and then erased. This ongoing review was approved as a quality assurance (QA) project ensuring confidentiality under California law. The first 100 resuscitations were evaluated to assess NRP compliance. Each step in the resuscitation (positioning, oxygen delivery, ventilation, chest compressions, intubation, and medication) was graded. A score was devised, with 2 points being awarded for every correct decision and proper procedure, 1 point for delayed interventions or inadequate technique, and zero points for indicated procedures that were omitted or for interventions that were not indicated. The total points were divided by the total possible points for that patient. The scores for the first 25 resuscitations (group 1) and the last 25 resuscitations (group 2) were compared.
Fifty-four percent of the 100 resuscitations had deviations from the NRP guidelines. Ten percent received overly aggressive stimulation and 22% had poor suction technique. Of the 78 infants given oxygen, this decision was considered incorrect in 15% and the delivery technique was poor in 10% of the infants given oxygen. Of those requiring mask ventilation (n = 18), 24% had poor chest expansion, 11% used an incorrect rate, and 17% had inadequate reevaluation. Twelve infants were intubated; only 7 were successfully intubated on the first attempt and only 4 were intubated in <20 seconds. The longest intubation attempt was 50 seconds. Naloxone was given to 2 patients. One was breathing spontaneously with a heart rate >100. Resuscitations receiving a perfect evaluation score were more likely to occur in infants needing less intervention. The level of resuscitation required for groups 1 and 2 were statistically similar. There was no difference in resuscitation scores between the 2 groups. Only the inappropriate use of deep suctioning improved, with 8 of 25 events in group 1, and 0 of 25 in group 2.
We have found a significant number of deviations from the NRP guidelines. Video recording of actual clinical practice is a useful QA tool for monitoring the conduct of newborn resuscitation. We are now conducting repeat video assessments of individual NRP providers to determine whether there is improved performance.
通过对新生儿复苏录像的分析，确定我院对新生儿复苏项目（NRP）指南的遵循情况。
NRP是新生儿复苏的护理标准。在实际临床环境中，NRP指南和复苏技能的应用情况尚无记录。
设计/方法：在产科主手术室的辐射保暖台上安装一台录像机，用于记录所有高危复苏情况。复苏团队的所有成员均获得NRP认证。在复苏后14天内对录像带进行审查，然后删除。根据加利福尼亚州法律，这项持续审查被批准为一项确保保密性的质量保证（QA）项目。对前100例复苏进行评估以评估NRP的遵循情况。对复苏过程中的每一步（体位、给氧、通气、胸外按压、插管和用药）进行评分。设计了一个评分系统，每做出一个正确决策并采用正确程序得2分，干预延迟或技术不充分得1分，遗漏规定程序或进行未指明的干预得0分。总得分除以该患者的总可能得分。比较前25例复苏（第1组）和最后25例复苏（第2组）的得分。
100例复苏中有54%偏离了NRP指南。10%的患儿受到过度积极的刺激，22%的患儿吸痰技术不佳。在78例接受吸氧的婴儿中，15%的吸氧决策被认为不正确，10%接受吸氧的婴儿给氧技术不佳。在需要面罩通气的18例婴儿中，24%的患儿胸廓扩张不佳，11%的患儿通气频率不正确，17%的患儿重新评估不充分。12例婴儿接受了插管；只有7例首次插管成功，只有4例在20秒内完成插管。最长的插管尝试时间为50秒。2例患者使用了纳洛酮。其中1例心率>100且自主呼吸。需要较少干预的婴儿更有可能获得完美评估得分。第1组和第2组所需的复苏水平在统计学上相似。两组之间的复苏得分没有差异。只有深部吸痰的不当使用情况有所改善，第1组25例中有8例，第2组25例中无。
我们发现大量偏离NRP指南的情况。实际临床实践的录像记录是监测新生儿复苏操作的有用QA工具。我们现在正在对个体NRP提供者进行重复视频评估，以确定其表现是否有所改善。
