The Neonatal Resuscitation Program NRP: An Initiative to Improve Care to Newborns at the Outset of L

1
The Neonatal Resuscitation Program (NRP)An
Initiative to Improve Care to Newborns at the
Outset of Life
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NEONATAL RESUSCITATION PROGRAM (NRP) AN OVERVIEW

• SUDHAKAR G. EZHUTHACHAN, MD, DCH, FAAP
• HEAD, DIVISION OF NEONATOLOGY
• HENRY FORD HEALTH SYSTEM
• DETROIT , MI

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WHY DO WE NEED NRP ?

• At least 10 of all newborns require some
  assistance at birth i.e. the initial steps of
  resuscitation
• And 1 require extensive resuscitation
• There are 1 million deaths per year resulting
  from Birth Asphyxia (WHO, 1995)
• A significant number will have respiratory
  problems and a large will have seizures and
  later problems such as CP which means that one
  could possibly affect the outcomes of several
  million newborn infants every year

4
NRP IN THE U.S.A.

• 1960s Mushrooming of neonatal and high risk OB
  care
• 1970s Regionalization of Perinatal Care
• Community Hospitals played pivotal role in
  neonatal resuscitation
• NIH funding of 5 educational grants to address
  neonatal resuscitation training
• American Academy of Pediatrics (AAP) forms group
  to address training

5
NRP IN THE U.S.A.

• AAP and the American Heart Association led NRP
  development
• NRP faculty approach was tiered-
• National, Regional and Hospital Based
• 1987- A Standardized National Neonatal
  Resuscitation Program built on Consensus rolled
  out in the USA

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NRP in the U.S.A. Key Factors Sustaining It

• The most critical ingredient for the success
  of NRP.the goodwill and altruism of a broad and
  diverse groupthis continues to sustain the
  program
• Need for Continuing Education and Maintenance of
  Competency
• Linked to Accreditation of Institutions
• Standard of Care and Medico-Legal concerns

7
NRP IN THE U.S.A. (contd)

• From 1987 until 2000, changes in NRP were largely
  the result of feedback from practitioners not
  necessarily based on evidence
• What is Evidence Based Medicine ?
• the conscientious, explicit, and judicious
  use of current best evidence in making
  decisions about the care of individual patients

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Definition of Evidence

• Websters - something that furnishes proof
• Definition is subjective to interpretation
• Wide latitude as to what constitutes proof
• Can be reflected in guidelines and
  recommendations
• U.S. Preventive Services Task force developed
  Classification Schema for Quality of evidence

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Evidence Based Medicine in NRP

• Ten major questions were reviewed
• Extensive literature search on each topic
• Each article was assigned a level of evidence
  based on study design and methodology

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EBM - Steps in Evaluation Level of Evidence

• Level 1 large randomized clinical trials or
  meta analyses of multiple randomized clinical
  trials
• Level 4 Historic, non-randomized, cohort or
  case control studies
• Level 8 Rational conjecture (common sense),
  common accepted practice before evidence based
  guidelines

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EBM - Next Step

• Critically evaluate the quality of each source in
  terms of research design and methods.
• Scale Excellent to unsatisfactory
• Evaluate direction of the study results and the
  statistics
• Scale Supportive, neutral, opposing proposal

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Final Step

• Determine the class of recommendation
• Class I - definitely recommended
• Class II - acceptable and useful
• Class II a - Acceptable and useful, very good
  evidence provides support
• Class II b - Acceptable and useful, fair to good
  evidence provides support
• Class III - Not acceptable, not useful, may be
  harmful

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NRP 2000 IN THE U.S.A.

• International Guidelines 2000 Conference on
  Cardiopulmonary Resuscitation and Emergency
  Cardiac Care formulated new evidence based
  recommendations for NRP
• Members included AAP NRP Steering Committee,
  AHA and the Pediatric Working Group of the
  International Liaison Committee on Resuscitation
  (ILCOR)

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NRP 2000 GUIDELINESEVIDENCE BASED RECOMMENDATIONS

• Handling of infants with amniotic stained fluid
  stained
• Prevent heat loss and avoid hyperthermia
• Use of 100 oxygen only
• Potential use of laryngeal mask and exhaled CO2
  detectors
• Change in chest compression method and simplified
  rate response

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NRP 2000 GUIDELINESEVIDENCE BASED RECOMMENDATIONS

• Early administration of epinephrine
• Albumin no longer the fluid of choice isotonic
  crystalloid solution is
• Potential for use of intraosseous route
• When resuscitation may not be initiated or may be
  discontinued in the delivery room

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• FIRST IMPRESSIONS

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Neonatal Resuscitation Program Curriculum

• Dmytro Dobrianskyi, MD, PhD
• Keti Nemsadze, MD, PhD

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Program Components

• Neonatal Resuscitation Program (NRP) developed in
  U.S. by the AHA and the AAP was used as a model
  in the NIS.
• Main features of the Program
• Implementation based on perinatal regions
• Self-study textbook
• Appropriateness for all professional levels
• Adaptability for local practice
• Formats of the NRP course
• Self-study
• Small group
• 1- or 2-day course

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Program Components

• Educational resources of the original Program
• Self-study textbook
• Educational video
• Approximately 300 slides
• Skill stations (course training equipment)
• Instructors Manual
• NRP test package
• Standardized final written evaluation and
  practical tests

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Program Components

• Didactic components of the original Program
• Student textbook provided prior to the course
  date
• Provider Course consisting of 6 separate lessons,
  each covering a specific area of a neonatal
  resuscitation
• Lectures and practical training at the skill
  stations
• Instructor Course - to prepare those providers
  who would become teachers

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Program Content

Assess babys response to birth
Always needed by newborns
Initial steps

• Establish effective ventilation
• Bag and mask
• Endotracheal intubation

Needed less frequently
Provide chest compressions
Rarely needed by newborns
Administer medications
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Program Components - NIS

• All original educational NRP material was
  translated from English and distributed in the
  NIS (Russian, Ukrainian, Georgian).
• NRP Training Centers were established.
• Provider Training Course Standards are absolutely
  the same as the requirements in the U.S.
• The first courses in the NIS were co-taught with
  U.S. partners.
• Program components and course formats used in the
  NIS were adapted to meet the needs of the Regions.

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Program Participants

• Anyone responsible for any part of a neonatal
  resuscitation is an appropriate candidate for a
  provider course.
• Historically, only physicians were considered
  participants in resuscitation
• Currently, neonatologists, obstetricians,
  midwives, nurses, anesthesiologists and
  pediatricians have been included in the provider
  courses.

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NRP Instructors

• The key person in the NRP is an instructor, who
  is responsible not only for provider training but
  for implementation of the Program in every
  institution with delivery or newborn services.
• To accomplish this the number of instructors need
  to be quite high to ensure the program will
  succeed in reaching all caregivers

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Organization of NRP Instructors in the USA

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Organization of NRP Instructors in the NIS

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NRP Instructors

• To become an NRP instructor, a person must meet
  the following eligibility requirements
• Be a physician or nurse from critical care
  nursery setting
• Have training and experience in the hospital care
  of newborns in a delivery room or critical care
  nursery setting.
• Have educational or clinical responsibilities
  within a hospital or other appropriate medical
  facility (eg, medical school, nursing school).
• Have a provider training or take an NRP
  Instructor Course that includes the provider
  component.

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NRP Instructors

• It is important to emphasize that in the NIS
  settings, not all academicians can be instructors
  and conduct the NRP course because of its
  significant practical nature.
• To achieve the objectives of the Program,
  practical clinicians must be widely involved into
  instructor activity.

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Instructor Training in the NIS

• Instructors were trained as providers by US
  faculty, Provider Course (8 hours).
• Instructor Course was used to provide physicians
  with knowledge of adult learning theory,
  principles of teaching and information on
  conducting a course (4 hours)
• To enhance the level of expertise of instructors,
  a Train the Trainer (TOT) Course was developed.
• Content of TOT includes basic physiological
  issues related to the care of high risk infants
  and is an additional resource to the original
  program.

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Importance of the Skill Stations

• The theoretical and practical knowledge of NRP
  and
• its implementation in maternity houses,
  significantly improves the quality of health care
  services contributing to desirable outcomes

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Importance of the Skill Stations

• Education on practical skills enables
  participants to establish newly acquired
  knowledge in everyday practice
• Working with small groups makes it possible to
  assess individuals, identify areas needing
  improvement and focus on these areas.
• Participants become familiar with equipment that
  is necessary for resuscitation and encounter
  simulated situations for practice.
• Improved skills, increases ones confidence in
  performing resuscitation correctly and
  efficiently

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Importance of the Skill Stations

• Participants observe each others mistakes as well
  as ways to problem solve
• Participants develop skills related to selection
  and functioning of appropriate equipment.
• Each skills station builds on the previous one,
  which gives participants the opportunity to
  master skills. This decreases the frequency of
  complications during resuscitation and enhance
  desirable outcomes.
• The performance check list gives the instructor
  an objective tool to evaluate participants
  knowledge, decision making and comfort with newly
  acquired skills

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The weak points of education in Former Soviet
Union

• Education was based only on theoretical issues.
  Practical skills were not taught.
• No equipment and manikins were available for
  teaching practical skills
• Medical staff were unfamiliar with equipment
  necessary newborn resuscitation and often could
  not use existing equipment despite the
  indications.
• The first attempt at resuscitation usually was
  performed directly on a patient, therefore often
  delayed, performed incorrectly, resulting in
  frequent complications and resuscitation
  failure.

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Station I -Initial steps of resuscitation

Common practice in Former Soviet Union

• Importance

• Important not only for a depressed infant but
  every newborn.
• Making decisions about further steps of
  resuscitation happens here
• This step requires only a few seconds, so
  mastering the sequence of the skills is very
  important.

Prevention of heat loss mostly was neglected
Suctioning was not different in cases of clear
or meconium stained amniotic fluid. Assessment of
the infant was based on Apgar score assessed at
I minute of life.
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Lesson 1Initial steps of Resuscitation

Heat loss prevention
Opening of airways
Assessment of the infant

• Position the infant
• Suctioning mouth, then nose

• Breathing
• Heart rate
• Color

• Place on warmer
• Dry the newborn
• Remove wet towel

• if needed intubate and
• suctioning trachea

• if necessary provide tactile stimulation and
  give free flow oxygen

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Station 2 - Support Breathing

• Importance Common practice in
  Former Soviet Union

• Harmful methods and prolonged tactile stimulation
  were used
• Support breathing was based on medications
• Ventilation with bag and mask was rare, mostly
  initiating breathing was conducted mouth-to-mouth
  breathing

• Supporting oxygenation,
• establishment of spontaneous
• breathing and timely prevention of hypoxia
• getting acquainted with the equipment and how
  it works
• learning how to ventilate safely
• identification of indications for chest
  compression

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Station 2 - Support Breathing
Selection of appropriate equipment and ensure it
is functioning
Performing ventilation

• Adequate rate
• Adequate pressure

• Assessment of adequate ventilation
• Assessment of HR
• Decision of next steps of resuscitation

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Station 3 - Support Circulation
Common Practice in Former Soviet Union

• Importance

• Provision of artificial heart rate
• Restoring circulation
• Ensuring adequate oxygen supply

• Chest compression was initiated primarily after
  cardiac arrest
• Chest compressions were never combined with
  ventilation
• Sometimes harmful methods of compression were
  used

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Station 3 - Support Circulation
Technique

• position the infant
• firm support for the back,
• neck slightly extended

• 2 finger technique
• thumb technique

• adequate location, depth and rate
• coordination of chest compression ventilation
• assessment of HR in 15-20 sec.

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Station 4 - Endotracheal Intubation
Importance Common practice in Former
Soviet Union

• Identification of indications

• Intubation often was not limited to 20 sec
• The indications were often ignored

• Ineffective bag and mask ventilation
• prolonged ventilation
• Tracheal suctioning
• diaphragmatic hernia

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Station 4 - Endotracheal Intubation
Technique
Selection and preparation of the equipment

• Position the infant
• Insertion of laryngoscope and
• visualization of glottis
• Insertion of ET tube
• Checking the tube placement
• Securing the tube

• Selection of the endotracheal tube size
• Selection and preparation of laryngoscope
• with appropriate size of blade
• Preparation of suctioning and
• ventilating equipment

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Tell me and Ill forgot Show me and I may not
remember involve me, and I understand
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Quality Assessment of NRP

• Sudhakar G. Ezhuthachan, MD, DCH, FAAP

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Evaluation Strategies

• Evaluation of the course - maintaining course
  standards
• Evaluation of clinical application of knowledge
• Evaluation of patient outcomes

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Evaluation by Others

• U.S. NRP Steering Committee has just begun to
  discuss evaluation of the course
• Illinois, USA - Marked reduction in high risk
  infants with low apgars scores at 1 min. Of
  infants with low 1 min scores, more improved by 5
  mins, in the group studied after the
  implementation of the NRP course

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Evaluation by Others

• Kerala, India - Use of a standardized curriculum
  like NRP reduced perinatal asphyxia after
  delivery
• Zhuhai, China - Neonatal Mortality (perinatally)
  was reduced by 3 times after NRP curriculum was
  introduced.

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IMPACT OF NRP EDUCATION at 10 centers in INDIA

• Pre training (3 m) Post training
  p value
• Total live births 5110 7198
• Resuscitation
• Bag/ Mask Ventilation 107 (2.1)
  294 (4.1) lt0.001
• Intubations 113 (2.2) 153 (2.1)
  NS
• Apgar score lt4
• 1 min 230 (4.5) 219 (3.0) lt0.001
• 5 min 102 (2.0) 74 (1.0) lt0.001
  
• Outcome
• MAS 97 (1.9) 157 (2.1) NS
• Respiratory distress 362 (7.1) 412
  (5.7) lt0.01
• Seizures 107 (2.1) 49
  (0.7) lt0.001
• Asphyxial Brain injury 102 (2.0)
  49 (0.6) lt0.001
• Total deaths 159 (3.1)
  176 (2.4) lt0.05

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Early Attempts in Ukraine

• Data collected on every birth in maternity houses
  in western Ukraine
• Implementation sets were used as incentive
• Data sent monthly to the NRP Training Center
• Collection was tedious and not everyone
  participated

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Rater (per 1000) of CNS Abnormalities in 7
day-old newborns in 3 hospitals
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Evaluation of Courses

• First courses were co-taught with US faculty in
  most Centers
• Peer review process currently being developed and
  is to be discussed at next Steering Committee
  Meeting
• Key elements - instructor student ratio,
  ensuring students have opportunity to be
  prepared, monitoring of exams, performance at
  skills stations

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Evaluation of Clinical Application

• Site visits conducted in Ukraine in May
  1999, March 2001
• Institutions evaluated - 3 in 1999, 6 in 2001
• District as well as City sites
• Components evaluated - preparation of staff,
  equipment, performance of staff, knowledge
  base, clinical outcomes

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Preparation of Staff

• Staff Trained
• Neonatologists - 100
• Obstetricians - 56 (in 2 places, 100)
• Anesthesiologists - not active in training
• Nurses - 69 (2 places 100, many who are not
  trained have been educated by MDs)
• Midwives - 50 (most deal only with mother while
  others resuscitate infant)

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Preparation of Staff

• Most had been trained in regional center, and
  one was an outreach course
• Student to instructor ratios appropriate
• All hospitals have a process to notify the
  resuscitation team of a delivery
• All hospitals transferred high risk mothers
  appropriately as soon as possible to the City

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Equipment

• The most crucial issue - one can educate a whole
  country, but without appropriate tools,
  clinical application is difficult
• Implementation sets distributed in 1997 were
  depleted
• Equipment is well taken care - guarded
• 8 of 9 had excellent Delivery Room set up
• Feedback from staff on equipment was obtained

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Performance

• Observation of deliveries and preparation for
  deliveries yielded positive application of
  principles
• Documentation in the medical record substantiated
  this finding
• Mock Codes may be helpful to aid in assessing and
  reinforcing knowledge

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Knowledge of Staff

• Pretests were used in Georgia -data pending
• 90 of institutions yielded good understanding of
  most principles
• Management of infants with meconium stained
  amniotic fluid needed reinforcement
• Thermal management issues uncovered in 2
  institutions -water baths

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Clinical Outcomes

• Mortality is multifactorial and takes time to
  impact
• Morbidities related to temperature and low apgar
  scores show improvement

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Low Temperature and the Newborn

• A wet newborn loses heat very rapidly
• Hypothermia reduces the ability of the infant to
  respond to resuscitation efforts
• Hypothermia uses up energy (glucose) and oxygen,
  both needed by the brain.
• Effective temperature maintenance is critical for
  both survival and reducing morbidity

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THE EFFECTS OF LOW TEMPERATURE ON AN INFANT
Cold Stress
Acidosis
Convulsions
Death
HYPOTHERMIA
Pulmonary Vessel Spasm
Low Glucose
More Hypothermia
Lack of Oxygen
More Acid Production
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Numbers of Neonates Transferred with Hypothermia
i.e. Temperature Lower than 35 C
62
Reduction in of Infants admitted to LOCH with
Severe Perinatal Asphyxia
63
Incidence of Severe Asphyxia in Infants admitted
to LOCH
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Implementation Phases and Effectiveness of the
Neonatal Resuscitation Program in RussiaO. N.
Belova
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The NRP Program has been operating as part of the
Russian-American Partnership in Russia since 1989
- 11 years
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Order of Ministry of Health of the Russian
Federation No. 372 Improvement of Primary
and Resuscitation Care for Neonates in the
Delivery Room became effective on 12/28/95. More
than 5 years have passed
67
The results of the implementation of the NRP
protocol were summarized at the conference on
Primary and Resuscitation Care for Neonates in
the Delivery Room.Results of the Implementation
of the Order of the Russian Ministry of Health
No. 372.Problems. Outlook for Growth.

• Samara, October 2000

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Rating of the Results of the PNR Programby
Respondents
Excellent
17
30
Good
Satisfactory
53
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Changes in Statistical Indicators as a Result of
the Implementation of the NRP Protocol

• Find it difficult to respond - 25
• See positive changes in statistical indicators -
  62
• Do not associate the positive changeswith the
  effect of the order - 2
• Do not see an association between indicators and
  negative changes - 2
• Did not respond - 9

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Positive Changes in Statistical Indicators

• Perinatal mortality - 22
• Early neonatal mortality - 43
• Infant mortality - 18
• Death due to asphyxia, RDS, including low birth
  weight infants - 10
• Neonatal mortality - 6

71
Changes in Indicators of Early Neonatal Mortality
in the Russian Federation
72
Change in the type of primary resuscitation and
state of neonates during 1990-2000 in Maternity
Hospital No. 27 in the city of Moscow ()
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Causes of Problems in Implementing the PNR
Protocol

• Health care organizers regard level of knowledge
  of Order No. 372 as adequate - 6
• Lack of understanding by local organization - 5
• Disagreement with requirements of protocol -
  2.5
• Other - 2.5

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The results of a questionnaire showed that only
63 of neonatologists have mastered neonatal
resuscitation procedures

• The order of the Ministry of Health of the
  Russian Federation No. 372
  Improvement of Primary and
  Resuscitation Care for Neonates in the Delivery
  Room became effective almost five years ago.

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Knowledge of neonatologists on the type of
primary resuscitation care to be given to
neonatesbased on pretest results
1996
1997
- Passed
- Failed
2000
77
In the opinion of 44 of the respondents, the
primary reason for this is the absence of NRP
training

• NRP resource training centers operate only in 5
  regions within Russia

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Excerpt from the decree of the Board of the
Ministry of Health of Russia of January 9, 2001
Infant Mortality and Ways to Reduce It

• 9.6. To organize ongoing seminars for
  neonatologists on topics in primary neonatal
  resuscitation care

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Measures to Improve Neonatal Care

• Development/improvement of perinatal networks
• Creation of departments specializing in care of
  children who had problems at birth
• Increasing the role of mid-level medical
  personnel in providing NR

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Measures to Improve Neonatal Care

• Analysis of legal and ethical aspects of this
  issue
• Research (asphyxia, meconium aspiration, NR in
  children with ELBW, infection control during NR,
  oxygen therapy)

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A tree has grown from the seed planted by AIHA,
USAID, and the Russian and American partners.
And then...
82
Neonatal Resuscitation Program in Ukraine
Results of Implementation

• Goyda N. M.D., Ph.D.
• Head, Medical Services Department
• Ministry of Health of Ukraine

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Key Indicators of Health of Children (1992-1995)
84
Ratio of Stillbirth and Early Neonatal
Mortality Causes
85
Primary Disability Causes Ratio in Children 0-16
86
Key Demographic Indicators
87
List of Legal and Regulatory Documents,
National, State and Target Programs in the
Scope of Maternal and Child Health Care in Ukraine

• Long-term Program to improve status of women,
  family, Maternal and Child Care
• Complex Program to resolve disability problem
• National Program Children of Ukraine
• Additional activities to support implementation
  of the National Program Children of Ukraine up
  until CY 2005
• National Program on Reproductive Health

88
Key Objectives of the National Program Children
of Ukraine

• Improvement of medical care to pregnant women and
  newborns
• Morbidity prevention and delivery of up-to-date
  medical care to children

89
Decree of Ministry of HealthJanuary 5, 1996

• Organization of medical service for newborns in
  Ukraine

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Three-Level System of Care of Newborns in Ukraine

• Level I - Resuscitation of newborns in a delivery
  room right after the delivery, which is primary
  resuscitation aimed at developing an adequate
  postnatal adaptation of a baby from the very
  first second of his life.
• Level II - Resuscitating in Newborn Departments
  at Maternity Hospitals and delivering intensive
  care.
• Level III - Delivering medical care to newborns
  in ICUs at Pediatric Regional and Multi-Specialty
  Pediatric City Hospitals.

91
Implementing The Neonatal Resuscitation Program
has made it possible for Ukraine to

• Study the experience of U.S. leading
  neonatologists
• Teach Ukrainian Instructors
• Develop and equip Training Centers
• Start mass dissemination of neonatal
  resuscitation principles among medical staff
• Apply new medical techniques in neonatology
• Create a distinctively new system of health care
  delivery to newborns

92
Standardized Approach to Training

• First Training Center was created through an AIHA
  partnership
• Replication of this model was used to open 5
  additional centers
• Instructor training program was developed to help
  standardize the course format and prepare
  instructors
• Instructor training model has been used to train
  instructors from many countries.

93
Standardized Approach to Training

• First courses were co-taught with U.S. faculty
• Now, Ukrainian faculty assist with co-teaching in
  other new centers
• InstructorStudent ratio maintained, 14-5
• Certificates only issued if written exam and
  skill stations were independently completed

94
Number of Specialists Trained in Training Centers
95
Perinatal and Newborn Mortality in Ukraine
(1997-2000)
96
Neonatal Mortality in Regions where there are
Training Centers
97
The following issues remain unresolved

• Legalizing the work of the centers
• Certification - national issues
• Standardization of program throughout Ukraine

98
Suggestions with respect to further cooperation

• Support the creation of 8-10 additional Training
  Centers due to the vast area of Ukraine
• Regular scientific forums on issues of primary
  newborn resuscitation
• Involvement of international experts in the
  development of national neonatology standards

99
Neonatal Resuscitation in Slovakia 1992..2001

• Peter Krcho MD,PhD
• NICU Perinatal Center Kosice Slovakia

100
Situation before

• The newborns were not resuscitated by neonatal
  team
• Airway management ? not adequate and late
• The majority of cases did not receive adequate
  care... High neonatal mortality

101
Our Priorities in 1992

• Early detection of the problems after delivery in
  newborns
• Early resuscitation with bag and mask
• Better selection of the kind of follow up
  intervention that is necessary
• START with better CPR especially in perinatal
  centers
• CPR managed by neonatal physicians and nurses not
  by anesthesiologists
• IT WAS THE BEGINNING OF THE REGIONALIZATION
  PROCESS

102
Present ...

• Better collaboration between the units
• EBM interventions are now clear
• In most severe cases still intrauterine transport
  is the best ...

103
What are our priorities now

• Better intervention in all cases
• Intrauterine transport to the perinatal center
• Decrease of NM in the whole region especially in
  newborns under 1499g
• Delivery of high risk pregnancies in regional
  center,... under 999g

104
Continue with ...

• After 9 years of CPR projects we need to continue
  retraining
• Updating the training modality
• Use better education techniques-
• Real time video , www based education, better
  selection of the NICU team ...
• ...skills, skills, skills...

105
How did we make it ...

• AAP/AHA training guidelines from 1992
• Direct personal teaching
• Every neonatal physicians and nurses in contact
  with newborns
• resuscitation dolls, photodocumentation and
  direct participation in transport, or
  resuscitation in delivery room
• It has impacted networking, better confidence for
  the center

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Intrauterine transport to the Perinatal Center
108
Statistical Proof
109
Still some severe problems...

• Can we provide the best skills over 24 hours?
• Can we build the best team in region?
• Can we maintain the same level with the same
  equipment?
• Can we follow the progress of the world...

110
Case ? ULBWN 540g
111
Sustainability / Dissemination / Teaching
112
In Closing Issues for the Future of NRP
113
Sustainability Issues

• Ministry level support to legalizecenter
  activities and training
• Affiliation of centers with academic institutions
  
• Incorporation of NRP into CME to ensure
  standardization
• Development of a recertification process to
  ensure skills are maintained

114
Sustainability Issues

• Quality monitoring of courses to ensure the
  certification process is legitimate
• Development of an outreach plan to ensure
  widespread dissemination
• Development of additional centers in large
  countries
• Obtaining basic resuscitation equipment for all
  institutions

115
Sustainability Issues

• Technical support for centers to encourage
  continued networking and communication between
  hospitals, health departments and the Ministry
• Development of Perinatal Networks
  (regionalization) to support those infants who
  need continued care

116
NRP TC - Start Up Costs

• Medical equipment for skills
• stations plus shipping 7,000.00
• Office Equipment, furniture 9.200.00
• Educational materials 2,000.00
• Training by US Trainers
• One 2 person trip 10,000.00
• TOTAL 28,200.00

117
NRP TC Maintenance Costs

• Telephone and email connections 1,680.00
• Equipment resupply, manuals, office supplies,
  printing 5,100.00
• Outreach courses and quality assessment
  visits 5,260.00
• Yearly total per center 12,040.00

118
The Future of NRP in the Former Soviet Union

• NRP Steering Committee formed in 2000
• Encourage collaboration between centers
• Establish standards for NRP Courses in these
  countries
• Learn from each other

119
The Future of NRP in the Former Soviet Union

• Collectively address problems of sustainability
• Quality assessment plan implemented
• Implementation of new evidence based medicine
  guidelines, beginning with faculty training, Fall
  2001

120
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