APPENDIX 3
Memorandum by Dr M Munro and Dr A Bowring
(MS 5)
(Dr Munro is a consultant neonatologist practising
at Aberdeen Maternity Hospital and is the Director of the Neonatal
Resuscitation Program (NRP) for Grampian.
Dr Bowring is a neonatal research fellow practising
at Aberdeen Maternity Hospital and the Assistant Director of the
NRP for Grampian).
The main term of reference for this report is
the provision of training for health professionals who advise
pregnant women and new mothers. This report will concentrate on
Grampian's experience in training its health professionals in
the skills of newborn resuscitation. This process serves as a
model, which could be used to ensure competency in any basic skill
required by NHS staff involved in providing maternity care. This
process would address inequalities in staff skills and thus ensure
that all babies requiring resuscitation are resuscitated by staff
with the necessary skills. Whilst obviously Scottish we hope that
this will be of interest to England and indeed the rest of the
UK.
Our prime interest, like the committee, is the
effect training of our staff in Grampian can have on the health
of the baby in early life, namely does improving training mean
improved outcomes of resuscitation? We have set out to answer
this. Deficiencies in resuscitation can, of course, have life
long implications for the baby. There are inequalities in the
abilities and most importantly training opportunities for our
staff in neonatal resuscitation across Grampian. We have decided
to address these problems. Our aim is to ensure that all staff
in Grampian involved in newborn resuscitation are trained to a
certified standard and regularly revalidated.
HOW HAVE
WE GONE
ABOUT THIS?
The following bulleted points summarise our
process by which we have achieved our aims (each point is explained
in more detail later on in the report):
— Scoping, by audit, existing training
for all professionals involved in neonatal resuscitation across
Grampian.
— Scoping potential external neonatal
resuscitation courses available to ascertain the best course to
apply.
— Pooling all existing resources to
start up the course in Aberdeen Maternity Hospital and ensure
that it runs as regularly as possible and fulfils all the needs
of our staff. Encourage and support peripheral units to start
up the course and sustain it.
— At the same time disseminate information
regarding the course/refine existing teaching aids to conform
with the course.
— Develop innovative teaching methods
including using new technology with particular use of IM&T.
— Perform a secondary audit to ensure
that the course meets the needs for the staff.
— Encourage other regions to begin
the same process and assist them in this.
WE HAVE
GOT THIS
FAR, WHAT
NEXT?
Ultimately perform a study to look at improved
outcomes for babies by using the course
— Show that centralisation of recording
of training is possible over two or more regions.
— Continue the process so that all
of Scotland and the rest of the UK offers opportunity to all staff
to be trained to an accredited level in neonatal resuscitation
and that they regularly are revalidated.
— Have a centralized team to aid other
regions in performing this and ensuring standards are maintained.
— Build it into all NHS staff's (involved
in resuscitation of the newborn) job plan thus ensuring uniformity
of training for staff and most importantly giving every baby equal
opportunity for optimal resuscitation regardless of who resuscitates
them. Namely that there will be no variation in the basic abilities
of NHS staff across the UK in resuscitating a baby. Unfortunately
this is not the case at present. Ultimately this basic premise
should improve the health of the nation as the consequences of
a poorly performed resuscitation can have life long consequences
to the baby in question.
These bulleted points are now explained in more
detail:
(1) Scoping existing training for all professionals
involve on neonatal resuscitation:
This involves performing an audit (see appendix
A) of 500 personnel across Grampian. (They included nurses, midwifes,
obstetricians, anaesthetists, GP's and paediatricians) The audit
looked at available training, competency levels in resuscitation
in each discipline and sought to ascertain what these professionals
are looking for in a neonatal resuscitation course. The answer
was a course that was modular, flexible and could be run in house
or externally in a day. The specifics of what it had to cover
were also made clear. All in all a tall order! In order to proceed
we set up a steering committee.
(2) Scoping potential external neonatal
resuscitation courses available to ascertain the best course to
apply:
The only existing training course was the neonatal
advanced life support course. Whilst an excellent course it is
only being run four times a year at present in Scotland. Thus
we could not use this to train all our staff unless we set up
the course ourselves in Grampian. Unfortunately due to strict
regulations (Indeed one might argue excessive regulation) we would
have taken a minimum of two years and a cost of £10,000 to
get to a point where we could offer the course in Aberdeen. We
therefore, looked for other solutions. The oldest and largest
of its kind (1.4 million providers trained worldwide to date)
is the neonatal resuscitation program (NRP). We approached the
American Academy of Paediatrics and found that the course was
being run in Leicester. We analysed the requirements and realised
that we could get the NRP course up and running (and conforming
to all their guidelines) in a matter of one month. Most importantly
the NRP is evidence based and has been shown to improve babies
outcomes when adopted1.
To keep costs to a minimum we hired a self-drive
minibus and 10 of us drove down to Leicester. The 10 were carefully
chosen (They comprised of medics covering all grades, midwives
from Aberdeen and Elgin, clinical educators and resuscitation
training officers in tertiary and primary care.
(3) Pooling all existing resources to start
up the course and ensure that it runs as regularly as possible
and fulfils all the needs of our staff. Encourage and support
peripheral units to start up the course and sustain it:
Once trained on the Leicester course we had
a core of instructors. Equipment was purchased at minimal cost
(using charity, endowment and training funds from the Scottish
Executive) and we made sure that each course whilst general also
covered the units own equipment in particular. This has been an
education in itself as it is clear that across Grampian there
are numerous different types /makes of resuscitation equipment
and it became clear that a committee is required to review and
monitor this equipment. Our steering group is currently trying
to collate data on this and ultimately get some uniformity in
equipment usage across Grampian. Lessons learnt from this process
could be applied at a national level.
Not including staff time we can run the course
giving each provider a copy of the manual and interactive CD-Rom
for £35. Of course some of the staff time is NHS time and
therefore incurs cost but the majority has been done to date on
goodwill in staff's spare time. With the ability to run the course
cheaply we have secured small amounts of funding and therefore
been able to run the course monthly in Aberdeen and Elgin. This
is allowing us to quickly train the majority of our staff and
will ensure a basis for the validation and revalidation process
of competency in neonatal resuscitation for all our staff. The
high turn over also allows us to create instructors as required
and thus keep a pool large enough to sustain the large number
of courses. We have managed to run in four months more NRP courses
than NALS courses are collectively going to run across Scotland
this year.
The NRP courses have been met with universal
enthusiasm (We have maintained course evaluation forms at all
our courses and these have been universally positive and complimentary
of the course. We would be happy to share copies of these or any
other records with the committee) All our future courses are fully
subscribed. Anecdotally we have noticed improvement already in
our resuscitations. What the course produces is uniformity in
resuscitation technique, which produces much better teamwork.
(4) At the same time disseminate information
regarding the course/refine existing teaching aids to conform
with the course:
In order to do this we have as well as advertising
the course in the usual fashion (posters/fliers etc.) designed
and run a website on the Grampian University Hospital Trust intranet.
This gives updates to providers and instructors plus numerous
teaching tools for the providers and instructors. It also supplies
details and forms for anyone wishing to register for the course.
We plan to eventually take it onto the internet and in particular
increase the interactivity of it. We have made sure that our charts/posters
etc on resuscitation all conform to our teaching and this has
meant using much of the ready made NRP material. This has been
met with universal praise from the staff using it as the materials
are of an extremely high standard reflecting the course in general.
It is clear that there is a strong desire for uniformity across
the NHS in terms of training and equipment that we use.
(5) Develop innovative teaching methods
including using new technology:
We have been fortunate to have been promised
a mannequin by Fischer-Paykel (A manufacturer of resuscitation
equipment) that is unique in its properties. Namely it can give
computer analysis of candidates technique when they resuscitate
a baby. We have trialled the mannequin and await delivery. Once
received this will give us useful information when judging the
abilities of the providers. It is an example of how new technology
can be adapted for use in the training process. Allied to this
is the use of web technology to allow us to videoconference to
remote areas in Grampian for revalidation of the providers. We
plan to revalidate all providers every two years. Using videoconferencing
has been shown to be possible for this2 purpose and we plan to
use our in house videoconferencing facility to do this. We are
currently exploring uses for state of the art IT hardware particularly
in an education role. We are particularly interested in personal
digital assistants (PDA's) and wireless technology. One could
see how this could be used to allow access via portable devices
to central teaching resources allowing users access to educational
resources at any time and also giving them the ability to monitor
their progress. We continue discussion with Graeme Buckley (NHS
chief executive education) regarding some support for this and
the two projects will be integrated as they would both benefit
from each other. One hopes that we might benefit form all the
investment in IT promised by the NHS in the next few years.
(6) Perform a secondary audit to ensure
that the course meets the needs for the staff:
Our secondary audit to ensure the course meets
staff requirements will be underway towards the end of the year
by which time 150+ providers will have been created in Grampian
as well as providers in other regions.
(7) Encourage other regions to begin the
same process and assist them in this:
We have begun this process by entering into
dialogue with Inverness. Their consultant neonatologist is shortly
to take the provider course in Aberdeen then we plan to take a
team to Inverness to help them establish the course. We would
anticipate them being able to run the course after this in house
and all we have asked for in return is a regular updated record
of all the providers they produce. This will show the feasibility
of one center holding the records for all providers regardless
of region. We plan to use web based secure technology to assist
us in this process. This will allow us to keep accurate records
of when staff need to revalidate and how many staff in each area
are trained. This information could be used for audit and research
purpose to further evaluate the course
RECOMMENDATIONS FOR
ACTION:
The main recommendation is a simple one: that
the NHS ensures all staff are trained to a certified level in
the skills required for their job. Whilst this may seem obvious
and is recommended by numerous important bodies (Royal College
of Paediatrics and child Health3, Royal College of Obstetricians
and Gynaecologists4, British Association of Perinatal medicine5,
CESDI 20006 and The report of the expert maternity group7), in
practice, it doesn't necessarily happen in the NHS. Any training
is generally done voluntarily by the provider. This is usually
limited by availability of courses and associated cost. Grampian
is leading the way in developing a course in neonatal resuscitation
which gives a base for the provider to build skills on and can
be certified and , most importantly, which we expect every member
of staff involved in newborn resuscitation to undertake. We have
been careful to make sure that the core modules are relevant to
any staff involved in resuscitation of the newborn. With a lot
of effort (much of which has been unrecognized and unpaid) we
are running it regularly enough to ensure all our staff have the
opportunity to go on it. Indeed we expect within two years to
be able to say that all our staff have been on our course and
are certified providers. At that stage we will be recertifying
those initial providers and we will be able to offer a place on
the course to any new staff either before or immediately when
they begin work. We have shown that this type of course does not
necessarily have to be expensive and we would request that funding
is built into their job plan allowing and indeed insisting staff
take courses such as the NRP.
We would ask the committee to formally recognise
Grampian as an official pilot site to prove the concept: namely
by providing specific training to all staff we ensure that all
staff meet a specific competency in their clinical skills (in
this case newborn resuscitation) and thus promote equality in
provision of service. Also we would expect to prove that the outcome
for babies requiring resuscitation improves when the staff are
trained in this fashion. We thus improve the nation's health.
Grampian's experience could be used it to look at the feasibility
of introducing this to other regions and ultimately the whole
of Scotland and the rest of the UK. Again we could prove concept
and allow measurement of benefit but of course now at a national
level. Also Grampian's experience with the NRP could show the
feasibility of applying the same principles to other vital competencies
required by staff involved in the maternity service.
In recognising Grampian as a pilot site we would
ask for the following:
(1) Creation of a new post (suggest initially
four sessions per week with secretarial support) whose remit is
as follows:
— To ensure continuing development
and implementation of the training programme (presently the NRP).
— To audit the success of implementation
and benefits of the course for the patient.
— To suggest new developments particularly
relating to IT and technology in general (we in Aberdeen are currently
exploring uses for state of the art IT hardware particularly in
an educational role. To ensure complete record collection on providers
given support to develop a web base data collection.
— To assist with advice and support
for other regional units should they wish to set up their own
training programme.
— To ensure integration with other
training programmes.
(Ideally this person would already be working
on the programme in Aberdeen thus having maximum experience and
insight into the development required.)
(2) Create an associated team to work on
developments for the course eg new CD-Roms/manuals for different
target groups. (These would be designed to keep the core training
as it is with the NRP but develop add on modules that are of the
same standard allowing all professionals to have a core training
programme but also have add ons tailored specifically to their
needs).
(3) Provide on going funding to allow all
staff to undertake training in newborn resuscitation.
(4) Integrate the course with other ongoing
developments eg The new neonatal transport service for Scotland.
One could use either the NRP as the core training for those staff
who wish to transfer a baby to a tertiary unit but are required
to stabilise the baby until the transport team arrives. Perhaps
some of the resources for transport could be shared for this purpose.
(5) After the pilot period use the above
team to take the concept of "neonatal resuscitation training
for all" across Scotland and the rest of the UK. Provide
funding to ensure they can travel the land encouraging and assisting
units to set up training programmes so that wherever you work
there will be a training programme running close to your base
and running as often as necessary to allow everyone virtually
immediate training.
Once a large number are trained there is potential
to perform a study to actually demonstrate the improvement in
outcome for babies who require resuscitation across regions such
as Scotland and even the UK if all were trained in this manner.
As mentioned above this has already been shown to be the case
in North America. To demonstrate this at a national level would
be quite an achievement.
(6) Finally it would seem logical that if
we are aiming to standardise training of our NHS staff across
regions and hopefully the nation it is time to standardise the
equipment they use. We have begun in Grampian in conjunction with
running the NRP auditing the equipment used in resuscitation of
the Newborn. It is clear there is a wide range of equipment in
use some of which is not appropriate for the local requirements.
Also needlessly expensive equipment has been purchased eg resuscitaires
which are capable of measuring pressure generated but have been
adapted to use older technology which does not measure breaths.
This has happened because the operators do not understand or are
familiar with newer operation techniques. Again emphasising the
need for a training course. One of the most important audit findings
was that staff desire any course they attend to teach with the
equipment and facilities they will actually use. We have achieved
this in our course but obviously the more types of equipment there
are the more difficult it is to use a generic course and thus
the current equipment situation makes any attempt at expanding
any course across regions more difficult. It is time that the
NHS standardises its equipment for basic life support. A precedent
for this has recently been made in two situations. The new Neonatal
Transport Service for Scotland has standardised the equipment
and all the three regional centers have purchased the same equipment.
Also the the Scottish NHS supplies agency have recently negotiated
with INO therapeutics a national price for Nitric Oxide (NO) which
includes equipment and training. Ultimately all users of NO will
use the same equipment in Scotland. We believe this to be an advantage
to the patient. Basic life support equipment committees should
be formed which cover hospital and primary care services ensuring
uniformity in equipment and allowing training to be performed
more easily. We have begun the process in Grampian by setting
up an equipment committee to look at and standardise equipment
for newborn life support across the region. The expectation would
be that this would decrease equipment expenditure in the long
term as the expert group could advise purchase of the best equipment
to meet requirements of the operator in their location. At present
the equipment purchased is often more sophisticated than actually
required and thus more expensive.
If these recommendations are carried forward
this will be the beginning of a system where by the training of
NHS staff is standardised across the nation. All staff would be
shown to have undergone basic training in neonatal resuscitation
and shown to retain these competencies on a regular basis. If
the NRP was the main training programme adopted, research has
shown that this will improve the outcomes of resuscitated babies.
Thus we start a programme that begins with the baby's birth and
ensures that the baby is given the best chance for having a healthy
life free of disability. What could be more important?
Dr Bowring and myself would be happy to meet
with the committee to discuss this document in more detail. We
look forward to your comments.
February 2003
References:
1. Patel D et al. Effect of a statewide
neonaatl resusciataion training program on Apgar scores among
high-risk neonates in Illinois. Pediatrics 2001 Apr; 107(4):
648-55.
2. Cronon C. et al. Videocoferencing can
be used to assess neonatal resuscitation skills, Med Educ 2001
Nov; 35(11); 1013-23
3. British Paediatric Association. Neonatal
Resuscitation (1993). London. Available from the Royal College
of Paediatrics and Child Health, 50 Hallam St, London W1N 6DE.
4. Royal College of Paediatrics and Child
Health and Royal College of Obstetricians and Gynaecologists.
Resuscitation of Babies at Birth (1997). London. BMJ Publishing
Group.
5. Royal College of Paediatrics and Child
Health and Royal College of Obstetricians and Gynaecologists The
training needs of professionals responsible for resuscitation
of babies at birth.
6. Fourth Annual Report of CESDI, 1 January—31
December 1995 (1997). Maternal and Child Health Research Consortium,
188 Baker Street, London NW1 5SD.
7. Changing Childbirth. Report of the Expert
Maternity Group (1993). HMSO.
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