Evaluation of Effectiveness of Neonatal Resuscitation Programme (NRP) Course Among Paediatric Residents of BPKIHS

Address for correspondence: Dr. Sunil Kumar Yadav, MBBS, MD DM (Neonatology) Resident Department of Paediatrics and Adolescent Health Division of Neonatology BPKIHS, Dharan E-mail: dr.sunil_yadav@yahoo.com Tel No: +9779817930222 1Dr. Sunil Kumar Yadav, DM Neonatology Resident, 2Dr. Nisha Keshary Bhatta, Professor, 3Dr. Shankar Prasad Yadav, Senior Resident, 4Dr. Piush Kanodia, DM Neonatology Resident, 5Dr. Deepak Moktan, Junior Resident. All from the Department of Paediatrics and Adolescent Health, BP Koirala Institute of Health Sciences, Dharan, Nepal. Abstract


Introduction
T he life of a foetus in utero and the independent existence of a newborn are two vastly varied condi ons requiring complex transi ons.Birth asphyxia contributes to 23% of the 4 million neonatal deaths worldwide every year.In addi on to its contribu on to mortality, birth asphyxia can result in cogni ve impairment, epilepsy, cerebral palsy, and chronic diseases in later life 1 .These numbers assume signifi cance in Indian se ngs where neonatal mortality rate of 33 contributes to about 75% of the infant mortality rate of 47 as fi gures from 2010 reveal.There is similar scenario in Nepal where neonatal mortality is 24.2 and infant mortality rate is 33.6 2 .This contribu on of neonatal mortality to infant mortality rate has been increasing over the past decade as measures to reduce infant mortality are becoming eff ec ve 3 .Approximately 10% of newborns (4-7 million per year) require some form of assistance at birth.This makes neonatal resuscita on a frequently performed medical interven on 4,5,6 .As per the updated (October 2010) recommenda ons of Interna onal Liaison Commi ee on Resuscita on (ILCOR), Neonatal Resuscita on Program (NRP) of American Heart Associa on (AHA) and American Academy of Paediatrics (AAP), at least one trained person is required to be present during delivery 5 .This requires that the healthcare personnel involved need to be abreast with the latest recommenda ons and should follow them in their clinical prac ce.The Indian Academy of Paediatrics (IAP) and Na onal Neonatology Forum (NNF) of India currently follow NRP guidelines.IAP in collabora on with Na onal Rural Health Mission of Government of India developed Basic Newborn Care and Resuscita on Programme (BNCRP) of Navjaat Shishu Suraksha Karyakram (NSSK) adopted from NRP guidelines for grass root workers as well as paediatricians 7 .
Neonatal resuscita on is an essen al skill for neonatal care providers, especially for junior doctors who are o en the fi rst persons to a end to a newborn in need of resuscita on.The Neonatal Resuscita on Provider (NRP) training course, jointly developed by the American Academy of Paediatrics (AAP) and the American Heart Associa on, off ers a comprehensive and systema c training programme that has been adopted in 130 countries worldwide 8 .Reports from diff erent countries a ributed the improvements in neonatal mortality and morbidity over the past two decades partly to the implementa on of a systema c neonatal resuscita on training programme 9,10,11, .Neonatal resuscita on program guidelines (NRPG) is indeed a very eff ec ve and feasible technique during the delivery process in the reduc on of neonatal mortality.It is important to disseminate widely the knowledge and technique of NRPG in places where tradi onal resuscita on is s ll being widely prac ced especially in developing countries 12,13 .However, reports also showed that many involved in the care of newborn infants felt unprepared to perform neonatal resuscita on 14,15,16, .Three-quarters of all births in New South Wales (NSW) and Australian Capital Territory (ACT) take place in rural or urban non-ter ary hospitals where one-third of health personnel are inadequately trained in neonatal resuscita on and many do not feel confi dent in their skills.Eff ec ve neonatal resuscita on training for these areas is urgently required 17,18,19 .
The Neonatal Resuscita on Program (NRP), a widely adopted training program endorsed by the American Heart Associa on (AHA) and the American Academy of Paediatrics (AAP) 20 , has shown to provide good reten on of knowledge in the par cipants 21,22 , but informa on regarding its effi cacy in rela on to the specialty training of the a endants is lacking.We evaluated the eff ec veness of the NRP course in improving the knowledge of paediatric resident doctors in BPKIHS.

Material and Methods
This was a cross-sec onal interven onal study involving a cohort of 18 paediatric residents (fi rst, second and third year) of B.P. Koirala Ins tute of Health Sciences (BPKIHS) which is a ter ary care centre and medical college located in eastern Nepal.It is running a seven bedded level II neonatal intensive care unit (NICU) with two neonatal ven lators.BPKIHS enrols fi ve to eight students per year for post gradua on study in department of paediatrics.

Educa onal
Interven on: The neonatal resuscita on classes were adapted from the American Academy of Paediatrics (AAP) Neonatal Resuscita on Programme (NRP) 6 th edi on.The course consisted of eight classes of one hour dura on every day.The eight lessons of NRP 6 th edi on were systema cally taught: The classes included the following components: a. Overview lectures: using the slides from the standard NRP course, the major concepts in neonatal resuscita on were highlighted, including cardiopulmonary adapta ons, apnoeas, important equipments and an overview of the NRP algorithm focusing on the ini al steps in resuscita on.
b. Demonstra on of key skills such as bag and mask ven la on and cardiac compression, followed by hands-on prac ce on the manikins.

Evalua on of eff ect of course on cogni ve knowledge:
The NRP evalua on mul ple choice and fi llin ques ons were administered for each lesson taught.The results of the 30-item ques onnaire pre-and postclasses which cover all aspects of the resuscita on were used to assess change in cogni ve knowledge.The pre-test was administered before the class and the post-test immediately a er the class.The NRP passing criterion was followed for this paper and considered a score of 25.5 or above.
The test script: The standard teaching materials, including the test script, from the NRP programme were used.The mul ple-choice and fi ll-in ques ons were taken from AAP/NRP 6 th edi on.In the test script, there were 30 ques ons which were distributed as shown in Table 1.Ethics and care at the end of life Data were analyzed with SPSS 20.The results were analyzed by descrip ve sta s cs and we used paired t-test to compare the diff erence between preand post-test scores for resident doctors.
This study was approved by the Ins tu onal Ethics Review Board (IERB) of BPKIHS.

Results
The en re cohort of resident doctors (n = 18) par cipated in the course, sat for the tests, and agreed to have their scores included in the research.All 18 resident doctors completed the pre-test and post-test; among them four were females and 14 were males (eight from fi rst year, seven from second year and three from third year).Table : 2 display the mark distribu on among resident doctors before and a er the course.Out of 18 resident doctors, 17 (94.4%)scored between 10-20 and one resident doctor scored less than 10 in pre-course test whereas 16 resident doctors (88.9%) scored between 10-20 and two (11.1%)

Discussion
This study shows that our one-hour simula onbased neonatal resuscita on course for eight days produced a substan al learning gain immediately a er the course.The overall degree of learning gain was below our expecta on.
The degree of learning gain from pre-to post-tests in our study was consistent with previous studies on medical students 23,24 although neither of these studies followed up the par cipants and assessed knowledge reten on.
Ques ons on infant evalua on received the lowest scores compared with prac cal ac ons and theory.Possible reasons for this included the diffi cul es in remembering algorithms and specifi c clinical signs or numbers, such as the cri cal heart rate and the size and length of the endotracheal tube in rela on to the infant's weight, and these areas deserved more emphasis in our future training classes.
The following were the strengths of this study: First, we assessed knowledge acquisi on as well as short-term knowledge reten on, using a test script from a well-established training programme, with ques ons covering three major domains in neonatal resuscita on.The format, educa onal resources and the delivery of our classes followed that of the NRP programme.The majority of the ques ons in our test scripts were related to prac cal aspects of neonatal resuscita on (i.e.evalua on and ac on), and all items in the assessment were covered in the course.Besides, iden cal test scripts were used for pre-and post-tests, and this minimized the issue of non-equivalence in terms of contents across diff erent assessments.
Several limita ons were noted in our study.First, we assessed only knowledge and not skills performance in the form of simulated scenarios.It was therefore unclear to what extent the knowledge demonstrated by the resident doctors was translated into actual competence.It has been shown that wri en test evalua on is a poor predictor of skills performance in resuscita on 25 .Secondly, we used a single test script with a limited number of ques ons for assessment.We haven't assessed the knowledge reten on a er months or year of comple on of the course.It was unclear how much of the improvement in performances in between the tests were due to an actual gain in knowledge and how much to increased familiarity with the format of the mul ple-choice ques ons and an improved ability to guess a correct response.Further, the test script appeared not to have been formally validated in any published report, despite that fact that it was from a well-established programme that is widely used around the world.We were also unable to perform a meaningful sample size or power es ma on because there has not been a commonly accepted defi ni on on what cons tutes an educa onally important learning gain in terms of neonatal resuscita on skills.Next, the resident doctors' awareness that they were part of a research project might have infl uenced their learning and performance.Our small sample size represented further limita ons.

Conclusion
This study demonstrates that neonatal resuscita on training classes conducted at the postgraduate level was feasible and produced a modest gain in resident doctors' knowledge on neonatal resuscita on at the end of their course, although it was unclear whether such knowledge gain would translate into a sustained and important gain in the doctors' future prac ce.The resident doctors' overall gain in knowledge was below our expecta on.NRP training has the poten al to substan ally improve knowledge of neonatal resuscita on.
i. Overview and principles of resuscita on ii.Ini al steps of resuscita on iii.Posi ve pressure ven la on iv.Chest compressions v. Endotracheal intuba on vi.Medica ons vii.Special considera ons viii.Ethics and care at the end of life.

Fig 1 :
Fig 1: Mean mark before and a er course

Fig 2 :
Fig 2: Mean mark before and a er course in each topic assessed

Table 2 :
scored between 21-30 in post-course test.Their mean scores (out of 30) were 13.84 (SD 2.57) [(pre-course) and 16.68 (SD 3.15) (post-course)] which is depicted in Table 3.The increment in mean score from 13.84 (pre-course) to 16.68 (post-course) was signifi cant (p=0.001) which is shown in Fig 1.Though there was improvement in mean score in post-course test, no resident a ained the NRP criteria for passing by scoring 25.5 or above.Marks distribu on before and a er the course

Table 3 :
Mean mark before and a er the course