Reprinted with permission of AAP News, February 2005

NRP among Academy's notable accomplishments

As the Academy reflects on its accomplishments over the last 75 years, the development and implementation of the Neonatal Resuscitation Program (NRP) serves as one of its most ambitious grassroots endeavors.

From modest beginnings in 1987, the program has seen unprecedented growth, reaching 1.7 million providers through a network of 25,000 instructors. Additionally, NRP materials are the most widely used AAP publication in the world, in use in more than 70 countries.

This article provides a glimpse at the program's early development and significant milestones.

History

With the emerging prominence of neonatal intensive care units (NICUs) in the mid-1970s, it became increasingly important that community hospitals recognize and provide initial management of infants requiring transfer to a NICU. At the time, the National Institutes of Health (NIH) funded five projects to provide education regarding the fundamentals of neonatal care to level 1 hospitals. The Drew Postgraduate Medical School in Los Angeles received one of these contracts, which resulted in the Neonatal Educational Program (NEP) developed under the leadership of Ronald Bloom, M.D., FAAP, and Catherine Cropley, R.N., M.N.

Soon after the development of the NEP, the Academy assembled a group led by George Peckham, M.D., FAAP, to address the adequacy of training for neonatal resuscitation. The group decided to use six NEP modules to form the basis of a new standardized national program called the Neonatal Resuscitation Program (NRP).

When the prototype was nearly complete, Errol R. Alden, M.D., FAAP, joined the Academy as the director of education. Dr. Alden, who is now AAP executive director, worked with Leon Chameides, M.D., FAAP, to develop a collaborative relationship with the American Heart Association (AHA); this resulted in development of a joint task force to review the material and lay the groundwork for dissemination. The goal was to have at least one person trained in NRP present at each delivery in the United States.

Utilizing the Academy's district structure and the concept of perinatal regionalization, dissemination of the NRP moved from national rollouts with faculty from tertiary care centers, through instructors at level 2 hospitals, to providers at all levels of perinatal service across the country.

Principles of success

The instructional design and dissemination of the NRP differed significantly from other AHA resuscitation programs. The principles critical to early acceptance of the program remain the pillars of its continued success.

The program is designed to: 1) encourage self-directed learning, 2) allow various levels of personnel working in delivery rooms and nurseries to complete the program at a level equivalent to their responsibilities, 3) foster the development of a team approach to resuscitation and 4) incorporate hands-on training, under the guidance of an instructor, to help integrate cognitive knowledge into skill performance.

Scientific evolution

One of the most dramatic evolutions of the program has been the strengthening of the scientific principles on which it is built.

The original AHA neonatal resuscitation guidelines emerged from the consensus of expert opinion, rather than through the rigors of scientific method.

"We were constantly aware of the paucity of data to support recommendations on critical issues (in the first text)," said William Keenan, M.D., FAAP, one of the first NRP Steering Committee co-chairs. "… Often the recommendations had to be formulated along the lines of accepted practice rather than supported from the medical literature."

The committee recognized the critical role it must play in forwarding science. The Neonatal Resuscitation Research Grant Program, initiated in 1994, was the first step in this initiative. To date, the program has funded 27 studies that have had a significant impact on the program's scientific basis and educational foundation.

The other significant factor in the evaluation of the science was the development and evolution of the International Liaison Committee on Resuscitation (ILCOR) and the evidence-based worksheet review process. ILCOR, which was formed in the mid-1990s, provides a forum among principal resuscitation organizations worldwide and fosters scientific research in areas of resuscitation where there is controversy or a lack of data.

Organization members collaborate to provide a mechanism for collecting, reviewing and sharing international scientific data on resuscitation, participate in the evidence-based worksheet process and develop a consensus of opinion on the literature. ILCOR's consensus has led to the development of evidence-based guidelines that are linked to specific rated and weighted scientific findings.

International impact

Participation in ILCOR represents only a fraction of the program's international activity. Since the late-1980s, AAP volunteers have traveled to numerous countries, including Argentina, Brazil, the Dominican Republic, Laos, Romania, South Africa, Thailand and most recently China, to implement the program. Their efforts have helped to build strong relationships between the Academy and the World Health Organization, international pediatric societies and ministries of health.

Enthusiasm for taking the program beyond borders is not limited to the committee. Hundreds of health care professionals motivated by goodwill have brought the program to dozens of other countries, including Australia, Ireland, Peru and Zimbabwe.

Educational enhancements

As the NRP audience has grown more proficient with technology, so too have the instruction modalities. The original program used a paper-based text and evaluation. Program materials now include an award-winning CD-ROM, video and other multimedia learning tools.

The 5th edition materials, which will be available in spring 2006, will further integrate performance improvement and technology through an interactive DVD with multiple decision-point learning scenarios, an optional online cognitive skills examination and a validated performance assessment instrument.

Future initiatives

The NRP Steering Committee recognizes that for sustained impact, it must continually refine its goals and directions. The committee is in its second year of implementing a comprehensive long-term outcomes initiative. As part of this initiative, the committee is exploring enhanced training possibilities. These include simulation-based learning and the development of patient simulators that display realistic anatomic features and physiologic parameters that change in response to actions of professionals undergoing training.

Another goal of the committee, "is to see whether we can take the science we collect and implement it in the developing world," said NRP Steering Committee Co-chair Jeffrey Perlman, M.D., Ch.B., FAAP. Committee members are planning such initiatives with the NIH.

The NRP has made significant strides over the years, but much work remains, noted John Kattwinkel, M.D., FAAP, former NRP Steering Committee co-chair and current NRP editor.

"While it appears that the original goal of having NRP touch each of the more than 5,000 delivery rooms in the U.S. is close to realization," Dr. Kattwinkel said, "there are still many activities that need to occur before (the committee) can be comfortable that our future citizens are entering the world as safely as possible and that unpredictable perinatal emergencies are being responded to promptly and with optimum expertise."

October excerpt

November excerpt

December excerpt

January excerpt

March excerpt