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The NeoNaTal R esusciTaTioN PRogR am (NR P) was

launched in 1987 as a learning program, the primary goal of which was to ensure that at least one person trained in neonatal resuscitation tech-niques was present at every hos-pital birth.1 The program far exceeded everyone’s expecta-tions. more than 3 million health care professionals have received NRP course completion cards from about 27,000 instructors, and many hospitals now require NRP provider status as a con-dition of employment and staff credentialing.2

For experienced neonatal nurses, the NRP has become an old friend. every two years, we pick up this friendship right where we left off, catch up on what’s new, and meet our employer’s requirement to get “checked off” and “recertified.” in many hospitals, the NRP Renewal course consists of a take-home written exam fol-lowed by a five-minute megacode checkoff with an NRP

instructor. individuals whose NRP card expires are required to take the Provider course, which may include up to eight

hours of slides and lecture and a proctored examination prior to the megacode checkoff.

instructors have followed the american academy of Pediatr ics/american heart association (aaP/aha) rec-ommendations for NRP training and have made NRP convenient for their learners. however, most NRP instructors and expe-rienced course participants do not expect to be challenged by their biennial NRP experience.

That is about to change.

Why Change the nRP eduCation Methodology?

much of the success of the NRP can be attributed to the com-mitment and expertise of its instructors and Regional Trainers. since the NRP’s inception, instructors have been trained to teach learners (health care providers) in a classroom setting using lecture materials from the instructor manual, instruc-tional videos and DVDs, and PowerPoint slides. although instructors have done an excellent job teaching health care

accepted for publication November 2010.

Neonatal Resuscitation Program (NRP) 2011:

New Science, New StrategiesJeanette Zaichkin, RN, MN, NNP-BC

Gary M. Weiner, MD, FAAP

AbstrAct

in spring 2011, the american academy of Pediatrics (aaP) will release sixth edition materials for the Neonatal Resuscitation Program (NRP). This edition brings changes in resuscitation practice and a new education methodology that shifts the instructor from “teacher” to “learning facilitator” and requires the NRP course participant to assume more responsibility for learning. The change from a lecture format to simulation-based learning requires instructors to learn new skills and meet new requirements to maintain instructor status.

The sixth edition of the Textbook of Neonatal Resuscitation and the fifth edition of the Instructor’s Manual for Neonatal Resuscitation are currently in press. The aaP granted permission to use material from these forthcoming publications in this article.

Editor’s note: This article is intended to update neonatal heathcare profession-als on the upcoming NRP changes for 2011. To that end, this article has been written by authors closely involved in the NRP updating process and the article has not been peer-reviewed. It is being published simultaneously in advances in Neonatal care (11:1) to ensure that as many care providers as is possible receive this information.

DisclosureJeanette Zaichkin is a consultant for the American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee, editor of the instructor’s manual for Neonatal Resuscitation, and associate editor of the Textbook of Neonatal Resuscitation.Dr. Gary M. Weiner is a participant in the ILCOR neonatal delegation and associate editor for the Textbook of Neonatal Resuscitation.

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providers the course content, the traditional classroom model may not be the most effective method for learners to acquire the cognitive, technical, and behavioral skills essential for newborn resuscitation. The emphasis on transferring content knowledge to learners during a full day of lectures prevents instructors from using their valuable time to facilitate more productive activities.

In 2004, the Joint Commission investigated 47 cases of infant death or injury during delivery and found that ineffec-tive communication and teamwork were the most common root causes. The findings are detailed in a Sentinel Event Alert that now includes 109 cases.3 The agency recommended that health care organizations conduct the following:

team training to teach staff how to work together and com-•municate more effectivelyclinical drills to help staff prepare for uncommon but high-•risk eventsdebriefings to evaluate team performance and identify areas •for improvement The NRP Steering Committee believes that now is the

right time to update the NRP education methodology so that it supports these recommendations. They have carefully reviewed the curriculum and identified the following key issues that need revision.2

NRP instructors feed information to passive learners •through slides and lecture. Instructors report that they spend most of their face-to-face time lecturing, but also indicate that lectures are an ineffective way for learners to learn.4 Passive learners usually do not assume responsibil-ity for their own learning and are less likely to remember information. The revised NRP course must actively engage its participants.NRP learners often arrive poorly prepared for their class. •Most instructors can cite instances of learners arriving at an NRP course with the textbook still inside its packaging. Lack of learner preparation decreases the educational effi-ciency of the class and prevents instructors from using their time most effectively. Learners must be expected to arrive at the new NRP course well prepared.The current NRP course teaches content and technical skills •but lacks a component for learning the communication and teamwork skills that improve patient safety. Learner dem-onstration of skills during the predictable Megacode sce-nario, often performed in a classroom instead of a realistic delivery room setting, fails to indicate how the learner and team would behave in an actual emergency under stress and time pressure. The Megacode actually discourages teamwork and communication by demanding that assis-tants work quietly without providing critical feedback to the “lead” resuscitator. The new NRP course will develop teamwork and communication skills.The current methodology requires providers to success-•fully complete the same NRP course every two years to receive their course completion card and remain compliant with hospital requirements. This inference of competence

may give learners a false sense of security. The NRP course must gradually replace this compliance model of education, where learners are never challenged to improve their skills, with a more dynamic continuing education model that focuses on developing and maintaining competence.The current paradigm discourages instructors from chal-•lenging their learners. Learners are expected to demonstrate a “perfect” performance on their Megacode. Mistakes are often seen as a sign of failure for both the learner and the instructor. In fact, health care providers often learn the most from their mistakes (preferably, mistakes made during training, not patient care). Learners should be encouraged to test their skills in challenging scenarios, make mistakes, identify their weaknesses, and learn from them.NRP instructors are never challenged to update or improve •their own skills. Some NRP instructors have limited involvement in the program and maintain their instructor status simply to avoid taking the written examination every two years. This diminishes the quality of the NRP and has prompted a close look at requirements for becoming an NRP instructor and maintaining instructor status.A dramatic change in NRP education methodology begins

with the new sixth edition NRP materials. The instructor becomes less of a teacher and more of a facilitator, allowing par-ticipants to assume more responsibility for their own learning.5

Significant nRP PRovideR couRSe changeS

At first glance, much of the structure of the revised NRP curriculum appears unchanged. However, implementation of the new curriculum reveals significant changes. Many of these changes, such as online testing, can be implemented immediately using the fifth edition NRP materials, but the following changes are mandated by January 1, 2012.6

There are no longer separate Provider and Renewal courses. •Everyone will take a Provider course, tailored by the NRP instructor to meet each learner’s needs.The learner is required to self-study the • Textbook of Neonatal Resuscitation, sixth edition (or study the accompanying DVD) prior to attending the course.The learner must pass the online NRP examination in the •30 days before attending the in-person Provider course. After December 31, 2011, the hard copy test will no longer be available. See Table 1 for information about the online examination.The instructor will not lecture or present slides about •content that appears in the textbook. Before arriving at the course, the learner will have already mastered this material and passed the online examination.The instructor and learners will use course time to practice •technical skills as needed, to demonstrate how the cogni-tive and technical skills are integrated in accordance with current neonatal resuscitation guidelines, and to improve teamwork and communication through simulation-based learning and debriefing.

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What are the NrP Provider Course ComPoNeNts?

The revised NRP Provider course is composed of three essential components: cognitive skills (from the textbook), technical skills (hands-on practice and demonstration at skill stations), and teamwork and communication skills (simula-tion and debriefing). The Performance Skills Stations and Integrated Skills Station give the learner opportunities to integrate cognitive and technical components. The simula-tion and debriefing component focuses on teamwork and communication.6

Cognitive SkillsImplementation: Learners are expected to study the

sixth edition NRP textbook or DVD prior to attending the Provider course. Learners may choose to study independently or to study together in small discussion groups. Instructors should be available, as needed, to clarify material for new providers.

Evaluation: All providers complete the online examina-tion prior to attending the class. (See Table 1 for additional details regarding the NRP online examination.) At the beginning of the classroom component, instructors may allot a brief period to answer questions or discuss issues specific to their hospital setting.

Technical SkillsImplementation: Health care providers may choose to

learn and practice basic technical skills at home using the

Simply NRP kit. Alternatively, learners new to the program can acquire technical skills during the course at Performance Skills Stations (Table 2). For experienced health care provid-ers, Performance Skills Stations are an optional component for fine-tuning skills, reviewing rarely performed skills (e.g., emergency umbilical venous catheter placement and medica-tion administration), or acquiring new skills (e.g., laryngeal mask placement). The instructor may demonstrate the skill or use a video clip from the instructor DVD. Performance Checklists are resources provided in the textbook and the Instructor’s Manual for Neonatal Resuscitation for reference and discussion, not for scoring. Each Performance Checklist uses a scenario that places the skill in context and builds on the skills from previous lessons. This reinforces the cognitive learning that has already occurred through self-study and prepares the learner for the Integrated Skills Station.

Evaluation: Technical skills are evaluated at the Integrated Skills Station. This is a required component of an NRP Provider course. Using the Integrated Skills Station Checklist (Basic or Advanced), the instructor presents one or more scenarios that allow learners to demonstrate their indi-vidual resuscitation skills in proper sequence, using correct technique, without coaching or prompting. Although the Integrated Skills Station is not scored, providers should not advance to the simulation component before their skills are well established. Technical errors will occur during simula-tions and can be discussed during the debriefing, but the focus on teamwork and communication will be lost if there are frequent technical errors.

Simulation and DebriefingImplementation: Simulation and debriefing are required

components of an NRP Provider course. This experience provides a safe setting to challenge learners at all levels of expertise, integrate cognitive and technical skills, practice effective teamwork and communication, and identify areas for improvement. The instructor’s role is to develop realistic, challenging scenarios based on learning objectives. Scenarios should progress from simple to complex and provide even experienced learners with the opportunity to be challenged. Visual, auditory, and tactile cues contribute to making the setting as “real” as possible so that learners are able to “suspend disbelief” and act as they would during an actual

table 1 n About the NRP Online Examination

The fifth edition NRP online examination will be available through Exam Web until December 31, 2011. Access codes (PINs) for the fifth edition examination do not transfer for use with the sixth edition examination. Continuing education credit is offered for the NRP online examination for nurses (through the Illinois Nurses Association), physicians (through the AAP), respiratory therapists (through the American Association for Respiratory Care [AARC]), and emergency medical services personnel (through the Continuing Education Coordinating Board for Emergency Medical Services [CECBEMS]).

The sixth edition NRP online examination will be available for use in April 2011.

HealthStream is the vendor for the sixth edition NRP online examination.

If HealthStream is already your institution’s Learning Management System, contact HealthStream for purchase and delivery of the exam in the same way as you would for other online courses.

If your facility uses a different Learning Management System, HealthStream can help your facility receive the NRP online examination through your existing system.

It is possible to purchase a “batch” of examinations and take advantage of bulk-order discounts.

It is possible to purchase an individual NRP online examination by paying online with a credit card.

For more information, visit www.aap.org/nrp and click on Online Examination.

table 2 n NRP 2011 Performance Skills Stations

Lesson 1: Equipment Check

Lesson 2: Initial Steps

Lesson 3: Positive-Pressure Ventilation

Lesson 4: Chest Compressions

Lesson 5: Endotracheal Intubation and Laryngeal Mask Airway Placement

Lesson 6: Medication Administration and Emergency Umbilical Venous Catheter Placement

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emergency. Although high-fidelity simulators may be used if resources allow, effective simulation-based training can be achieved with simple, inexpensive materials.

Running a simulation is a new skill for most instructors. The instructor allows the learners to work their way through the scenario without coaching or prompting, even if they make errors. Errors are opportunities for discussion and learning during the debriefing session that follows. Filming the scenario is strongly encouraged because it enhances the debriefing experience. During the debriefing, the instructor

must avoid giving feedback or lecturing. Instead, the instruc-tor’s role is to facilitate a discussion by asking open-ended questions that enable learners to recognize their strengths, discover their weaknesses, and identify strategies for improve-ment. Watching videotape and identifying weaknesses in per-formance can be uncomfortable for health care professionals. To maintain a safe environment for learning, it is essential to assure participants that the simulation and debriefing events remain strictly confidential. The new NRP Instructor DVD is designed to help NRP instructors learn how to facilitate scenarios and conduct effective debriefings.

Evaluation: At this time, the NRP simulation and debriefing component is strictly for learning. There is no evaluation.

Changes for nrP InstruCtors NRP 2011 includes important time-sensitive requirements

for NRP Regional Trainers and hospital-based instructors who wish to maintain their instructor status.6

All NRP instructors must view the • NRP Instructor DVD: An Interactive Tool for Facilitation of Simulation-based Learning and complete the post-DVD education compo-nent by January 1, 2012. Individuals or institutions will f ind the link for purchasing the NRP Instructor DVD online for $64.95 at http://www.aap.org/bookstoreEach instructor is required to own a personal copy of this •DVD. The DVD includes instructor information and tools explaining how to construct scenarios and prepare for simulation-based learning using both complex and simple technology. It also includes interactive media to teach instructors how to conduct an effective debriefing. A library of short video clips demonstrating key technical skills is also included. Simulation and debriefing are new skills for most instructors, and debriefing takes observa-tion and considerable practice. This DVD provides NRP instructors with a “workshop in a box” to help them master these new skills.Beginning January 1, 2013, NRP instructors must pass the •online examination (Lessons 1–9) prior to their instruc-tor status renewal date. For instructors who renew their NRP instructor or regional trainer status in fall 2012, the online examination is not required until fall 2014; however, instructors do not need to wait that long to take the online examination. Taking the online examination earlier will allow instructors to become familiar with what NRP learn-ers are expected to complete. Beginning in spring 2011, every current NRP instructor can take the NRP online examination without charge once every calendar year. Continuing education credit is offered for passing the online examination; however, credit can only be claimed by instructors once every two years and in accordance with state continuing education rules.Only registered nurses (including CNMs with RN cre-•dentials, NNPs, ARNPs, and APRNs), physicians (MD or DO), respiratory therapists, and physician’s assistants are

Figure 1 n Development Process for Neonatal Resuscitation Guidelines and NRP Materials.

Five

-yea

r pro

cess

Published Scienti�c Research (Journal Articles, Studies,

Case Reports, etc.)

International Liaison Committeeon Resuscitation (ILCOR)

International Consensus on CPRand ECC Science with Treatment

Recommendations (CoSTR)

AAP/AHA Guidelines forCardiopulmonary Resuscitation andCardiovascular Care of the Neonate

Neonatal Resuscitation Program (NRP)

From: The American Academy of Pediatrics. How neonatal resuscitation guidelines and NRP materials are developed. Retrieved from http://www.aap.org/nrp/pdf/ilcorprocess.pdf. Reprinted by permission.

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eligible to become NRP instructors. Exceptions to these requirements will no longer be granted. Health care pro-fessionals without these credentials who previously became instructors by waiver from the NRP Steering Committee will maintain their instructor status if they meet ongoing maintenance requirements.NRP instructor candidates (NRP providers who wish to •become instructors) will be required to meet eligibility pre-requisites prior to being given confirmed registration for an NRP Instructor course and additional prerequisites prior to attending the NRP Instructor course. Further details about Instructor courses are included in the Instructor’s Manual for Neonatal Resuscitation.

Where Do NrP TreaTmeNT recommeNDaTioNs come From?

The recommendations for neonatal resuscitation practice described in the Textbook of Neonatal Resuscitation, sixth edition come from the AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.7 A care-fully timed process ensures that new guidelines for resuscita-tion of adults, children, and neonates are released at the same time every five years. This process is outlined in Figure 1. These AHA Guidelines are used to create educational mate-rials for the NRP, Pediatric Advanced Life Support (PALS), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) programs.

The Guidelines document was published in October 2010 and is the result of a five-year process that begins with a review of resuscitation science by members of the International Liaison Committee on Resuscitation (ILCOR).8 ILCOR begins with a series of questions designed to evaluate the current state of resuscitation research for adults, children, and newborns. Multinational delegations of experts follow a strictly defined procedure to identify published studies, evaluate the quality of the research, and assign the studies to levels of evidence. After a series of meetings and debate, the international experts finally reach consensus and publish a document known as CoSTR, which is the international consensus on resuscitation science for adults, children, and newborns.9 The participating countries and councils interpret the scientific consensus and develop guidelines appropriate for use in their individual countries. The NRP Steering Committee works with the AHA to develop guide-lines for the U.S. and uses these guidelines to create the NRP textbook and other educational materials.

hoW Will NeoNaTal resusciTaTioN chaNge?

The Textbook of Neonatal Resuscitation, sixth edition focuses on practice recommendations to ensure adequate ventilation while avoiding lung injury, hypoxia, and hyper-oxia. The following are the most notable changes in the sixth edition.10

Begin resuscitation of the term infant with room air (21 •percent oxygen). The ideal oxygen concentration for preterm infants is not known; however, a concentration at either extreme (21 percent or 100 percent) may result in an oxygen saturation that is too low or too high.Use pulse oximetry whenever resuscitation is anticipated or •when supplemental oxygen, positive-pressure ventilation, or continuous positive airway pressure (CPAP) is used.Every delivery room should have the ability to provide •blended oxygen and pulse oximetry during resuscitation.Oxygen concentration is adjusted to achieve age-specific •preductal (right hand or wrist) oxygen saturation (SpO2) targets as determined by pulse oximetry. The 2011 NRP Flow Diagram (Figure 2) includes a table of target oxygen saturation ranges by infant age in minutes. The target ranges come from approximations of the interquartile range values reported by several investigators.11–13

The 2011 NRP Flow Diagram now includes an explicit •reminder to take ventilation corrective steps to ensure adequate ventilation before beginning chest compressions. The sixth edition textbook includes a six-step mnemonic (MR SOPA) to help learners recall the steps. The MR SOPA steps are described on page 12.

All positive-pressure ventilation devices, including self- �inflating bags, should be equipped with a pressure-monitoring device (manometer).Laryngeal mask airway placement has been added to �Lesson 5 as an additional performance checklist.The endotracheal intubation procedure is now allowed �30 seconds instead of the previous recommendation for 20 seconds. Administration of free-flow oxygen during intubation is no longer recommended if the baby is not breathing.Intubation is recommended before chest compressions �are performed.Oxygen concentration should be increased to 100 �percent when chest compressions are performed.

It is beyond the scope of this article to provide the evi-dence for every change in practice recommendations. For this important information, see the AHA guidelines for newborn resuscitation7 and the ILCOR document.9

comPariNg The 2006 aND 2011 NrP FloW Diagrams

Figure 2 compares the 2006 NRP Flow Diagram with the 2011 NRP Flow Diagram. Changes to previous recommen-dations are in bold print below.10

Obtain relevant perinatal history from the obstetric pro-•vider prior to the infant’s birth.

What is the gestational age? �Is the amniotic fluid clear? �How many babies are expected? �Are there other risk factors? �

When the infant is born, ask yourself these three •questions:

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Is the newborn term? �Is the newborn breathing or crying? �Does the newborn have good muscle tone? �

Note that color is not assessed at birth for the purpose of resuscitation or oxygen administration.

Clear the airway if necessary. Reserve bulb-suctioning the mouth and nose for infants whose secretions obstruct breathing and for those newborns who require positive-pressure ventilation. If the newborn is term, breathing, and has good muscle tone, the baby should stay with his mother for routine care. This includes the vigorous infant with meconium-stained amniotic fluid. Dry and place the infant skin-to-skin with his mother, and cover with a dry blanket. Provide ongoing evaluation of breathing, heart rate, and color.

If the infant has meconium-stained amniotic fluid and is not vigorous (defined by breathing, heart rate, and tone), move the infant to the radiant warmer. Do not dry or stimu-late the infant to breathe. Intubate and suction the trachea. If intubation is difficult and the infant is bradycardic, con-sider moving on to the next steps of resuscitation rather

than delaying ventilation with unsuccessful intubation attempts.

The initial steps include positioning the head to open the airway, clearing the mouth and nose with the bulb syringe if necessary, drying, and stimulating the infant to breathe. Assess breathing (apnea, gasping, or labored or unlabored breathing) and heart rate. If the heart rate is >100 beats per minute (bpm) but breathing is labored, or if there is persis-tent cyanosis, ensure a clear airway, and place a pulse oxi-meter on the infant’s right hand or wrist. Begin free-flow oxygen if the saturation is less than the minute-specific target. Consider CPAP for labored breathing. If the infant remains apneic or gasping, or the heart rate remains <100 bpm after administering the initial steps, start positive-pressure ventilation.

Resuscitation of term newborns may begin with blended oxygen titrated to achieve the target oxygen satu-ration or with room air (21 percent). If blended oxygen is not immediately available, begin resuscitation with room air. For preterm newborns, a somewhat higher oxygen concentration may achieve the target oxygen saturation more quickly. Oxygen concentration is adjusted according to

figure 2 n NRP 2006 and NRP 2011 Flow Diagrams for Comparison.

Newborn Resuscitation

Warm, clear airway if necessary, dry, stimulate

Term gestation?Breathing or crying?

Good tone?

Routine care• Provide warmth• Clear airway if necessary• Dry• Ongoing evaluation

Yes

30 sec

No

Yes, stay with mother

Postresuscitationcare

© 2010 American Heart Association

Birth

60 sec

HR below 100, gasping, or apnea?

PPV, SpO2 monitoring

HR below 100?

Take ventilation corrective steps

Clear airwaySpO2 monitoringConsider CPAP

HR below 60?

Consider intubationChest compressionsCoordinate with PPV

HR below 60?

IV epinephrine

Take ventilation corrective steps

Intubate if no chest rise!

Yes

Yes

Yes

No

No

Consider:• Hypovolemia• Pneumothorax

Yes

Labored breathing or persistent

cyanosis?

Targeted Preductal SpO2 After Birth

1 min 60%-65%

2 min 65%-70%

3 min 70%-75%

4 min 75%-80%

5 min 80%-85%

10 min 85%-95%

No

No

Newborn Resuscitation

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age in minutes and oxygen saturation (see target box on 2011 NRP Flow Diagram in Figure 2). A system for blending air and oxygen and pulse oximetry should be available when-ever newborn resuscitation is required. This means every delivery area should have access to an air/oxygen blender and a pulse oximeter.

Pulse oximetry is used whenever:• Resuscitation can be anticipated �Positive-pressure ventilation is administered for more �than a few breathsCyanosis is persistent �Supplemental oxygen is administered �

To achieve a reliable oximeter signal as quickly as pos-sible, the pulse oximeter probe is placed on the infant’s right hand or wrist first, and then connected to the pulse oximeter.

Positive-pressure ventilation may begin with a self-inflat-ing bag, flow-inflating bag, or T-piece resuscitator. Each of these devices has advantages and disadvantages. Whichever device is used, it is essential that operators fully understand its safety features and how to troubleshoot problems. The pop-off valves provided on some self-inflating bags have been shown to be inaccurate and to allow generation of higher than intended pressures. All positive-pressure devices, including self-inflating bags, should have a pressure gauge (manometer) in place.

A rising heart rate is the best indication of improvement during positive-pressure ventilation. An assistant assesses for rising heart rate and oxygen saturation. If this is not immediately evident, the assistant assesses for bilateral breath sounds and chest movement. If these indicators are not evident in the first 5–10 attempted breaths, the team proceeds to ventilation corrective steps. A useful mnemonic for ensuring the proper sequence of corrective steps is MR SOPA. During corrective steps, the assistant con-tinuously monitors the infant for rising heart rate and increasing oxygen saturation.

M Reapply the mask to ensure a good face-to-mask seal.R Reposition the head to ensure an open airway.

Reattempt ventilation. If no bilateral breath sounds and no chest movement:S Suction the mouth and nose with the bulb syringe to

ensure a clear airway.O Open the infant’s mouth with your finger to improve

ventilation.Reattempt ventilation. If no bilateral breath sounds and no

chest movement:P Increase pressure every few breaths until bilateral breath

sounds and chest rise are evident. Exceeding an inspira-tory pressure >40 cm H2O is not recommended.

A If still unsuccessful, use an alternative airway (endotra-cheal tube or laryngeal mask airway).

Once positive-pressure ventilation has achieved breath sounds and chest movement for 30 seconds, recheck the

heart rate. If the heart rate still remains <60 bpm, consider intubation and begin chest compressions.

The oxygen concentration should be increased to 100 percent during chest compressions. The ratio for compres-sions to breaths remains 3:1. The two-thumb method of chest compressions is preferred over the two-finger method. Coordinate chest compressions with ventilations for at least 45–60 seconds before interrupting chest com-pressions to assess heart rate. If, after 45–60 seconds of chest compressions, the heart rate is >60 bpm, discontinue chest compressions and continue ventilation, with heart rate assessment every 30 seconds. Continue positive-pressure ventilation until spontaneous breathing supports a heart rate >100 bpm.

Intubation is recommended when chest compres-sions are required. Attempt to complete the intubation procedure within 30 seconds. Administering free-flow oxygen to an infant who is not breathing during an intubation attempt offers no benefit and is no longer recommended.

Epinephrine (1:10,000 concentration) is indicated when the heart rate remains <60 bpm after at least 45–60 seconds of chest compressions and coordinated, effective positive-pressure ventilation. Administration of epinephrine via an emergency umbilical venous catheter (UVC) is the preferred route. The dose for intravenous epinephrine is 0.1–0.3 mL/kg in a 1 mL syringe. Current evidence sug-gests that intratracheal (IT) epinephrine is likely to be less effective than intravenous epinephrine.14 IT administration is acceptable while placement of the emergency UVC is in progress. The dose for IT epinephrine is 0.5–1 mL/kg (higher than the IV epinephrine dose) and should be drawn in a clearly labeled 3–6 mL syringe. Do not use this larger IT dose intravenously.

If the heart rate does not respond to effective positive-pressure ventilation, coordinated chest compressions, and epinephrine, call for additional expertise, and consider other complications such as pneumothorax or hypovolemia. If the heart rate rises to >60 bpm but remains <100 bpm, reevaluate the effectiveness of positive-pressure ventilation and consider other complications.

The sixth edition NRP textbook also includes10

Recommendations for management of the premature •infant:

Pre-warm the delivery room to 26°C (80°F). �Place the infant under radiant heat (and cover in plastic �wrap if <29 weeks’ gestation).Consider using an exothermic mattress. �Monitor for hyperthermia if using all the above methods �in combination.

Information about induced therapeutic hypothermia•Infants of � ≥36 weeks gestational age with evidence of moderate to severe hypoxic-ischemic encephalopathy (HIE) should be considered eligible for therapeutic hypothermia.

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Therapeutic hypothermia should begin within six hours �of birth.Therapeutic hypothermia should be administered with �clearly defined protocols in facilities capable of multi-disciplinary care and longitudinal follow-up.

Questions and answersCommon questions about the content of the sixth edition

NRP appear below, with answers.6 Readers who continue to have questions about the sixth edition NRP materials and requirements, even after publication of the Textbook of Neonatal Resuscitation, sixth edition, and the Instructor’s Manual for Neonatal Resuscitation, f ifth edition, should direct their questions to lifesupport@aap.orgQ. A lot of things have changed with NRP 2011. What

basics of the NRP curriculum have stayed the same?A. These facts about the NRP Provider course have not

changed:The minimum course requirement is Lessons 1–4 and �Lesson 9.Any person who works with newborns is eligible to take �an NRP Provider course; however, the course has little relevance for someone who has never seen a healthy term newborn at birth.All learners may study, practice, and demonstrate all �NRP skills if desired, including intubation and emer-gency line placement. NRP does not certify or ensure competence in performing these skills in an actual resuscitation.The recommended NRP instructor-to-learner ratio at a �Provider course is one instructor for each three to four learners.

Q: Do we need a sophisticated electronic simulator to implement simulation-based learning?

A: No, you do not need an electronic simulator for the sixth edition NRP. The methodology is more important than the technology. An electronic simulator cannot make up for a poor curriculum or an instructor who does not know how to create a scenario, prepare the setting, orient learners, and conduct an effective debriefing. The NRP Instructor DVD covers the “how-to” of simulation and debriefing using simple technology and traditional mannequins.

Q: How important is filming the scenario and viewing it during debriefing?

A: Filming enhances learning and is highly recommended. Filming the scenario for use during the debriefing saves a lot of time because learners need not spend time reciting what happened next or arguing about what they remem-ber. Video provides an objective record of what actually happened during the scenario. A camcorder with flash memory and cables can be purchased for between $140 and $200. A tripod is handy and costs less than $20. A device for viewing the film is needed, such as a laptop computer, an LCD projector, or a DVD player; prices begin at about $80, depending on the device selected.

Q: How long does it take to conduct a Provider course in this new format?

A: Course length depends on the needs of the learners. A group of experienced physicians and nurses who work with the NRP instructor and have demonstrated exem-plary skills during actual resuscitations may not need to go through every Performance Skills Station. The Integrated Skills Station would ensure that learners understand new practice recommendations; most of the course time would then be spent conducting scenarios and debriefing. On the other hand, staff who resuscitate newborns infrequently benefit from reviewing and discussing resuscitation skills. This group will require more time at the Performance Skills Stations. The Instructor’s Manual includes a few sample agendas and examples of how to tailor Provider courses to meet the needs of learners. In most situations, 3 instructors can facilitate a comprehensive course for 12 learners in approximately four hours.

Q: Our NRP instructors are accustomed to checking off individuals whenever they need to renew their pro-vider status. We rarely schedule a “course” of learners. How can we do simulation and debriefing with one learner?

A: An NRP Provider course with one or two learners is dif-ficult for the learner and an inefficient use of the instruc-tor’s time. It also precludes simulation and debriefing unless the learner assembles two or three volunteers who are willing to actively participate in simulation and debriefing. Instructors should consider using this NRP curriculum change to reorganize the way they conduct NRP training. Multidisciplinary groups are most useful for simulation and debriefing. Consider rearranging staff renewal schedules and putting groups together in courses that allow 1 instructor to lead a team of 3–4 learners through a course. The number of teams in a course is guided by the number of mannequins your program can access for a course. To create these groups, you may con-sider making individuals’ renewal dates earlier than now scheduled and establishing a course schedule that makes the best use of instructor time and facility resources.

Q: Some of our instructors are great at teaching skills one-on-one; however, I cannot imagine them having the confidence to lead a group through simulation and debriefing. What will happen to these instructors?

A: If you are one of a very small number of instructors in a small hospital, it seems probable that at least 2 instructors will need to work on simulation and debriefing skills. A hospital-based NRP with a larger group of instructors has the advantage of allowing instructors to use their strengths where they are most comfortable—and that may not be conducting simulation and debriefing. Instead, use these instructors to facilitate learning for small groups at Performance Skills Stations and to evaluate learning at the Integrated Skills Station. They may also have talent for writing scenarios, creating “props,” or being in charge

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of providing the mannequin’s vital signs (e.g., using a metronome for heart rate). Some NRP instructors may decide that this new methodology does not relate to any of their interests or abilities. These instructors may decide to retire their instructor status and participate as learners in future Provider courses.

RefeRences 1. Halamek, L. P. (2008). Educational perspectives: The genesis, adaptation, and

evolution of the Neonatal Resuscitation Program. Neoreviews, 9, e142–e149. 2. Zaichkin, J., & McGowan, J. E. (2008). The “new” NRP instructor:

2011 and beyond. NRP Instructor Update, 17(2), 1, 2, 7. 3. The Joint Commission. (2004). Preventing infant death and injury

during delivery. Retrieved from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_30.htm

4. Weiner, G. (2007). NRP 2007: What it is and isn’t, what works and doesn’t. Presented at American Academy of Pediatrics National Conference and Exhibition. San Francisco, California. Retrieved from http://www.aap.org/nrp/pdf/NRPToday.pdf

5. American Academy of Pediatrics. (2007). Instructor development. NRP Instructor Update, 16(1), 1, 4.

6. Zaichkin, J. (Ed.). (in press). Instructor’s manual for neonatal resuscitation (5th ed.). Elk Grove Village, IL: American Academy of Pediatrics, American Heart Association.

7. Kattwinkel, J., Perlman, J. M., Aziz, K., Colby, C., Fairchild, K., Gallagher, J., . . . Zaichkin, J. (2010). Part 15: Neonatal resuscitation—2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122, S909–S919. doi:10.1161/CIRCULATIONAHA.110.971119

8. Kattwinkel, J. (2008). Neonatal resuscitation guidelines for ILCOR and NRP: Evaluating the evidence and developing a consensus. Journal of Perinatology, 28, 27–29.

9. Perlman, J. M., Wyllie, J., Kattwinkel, J., Atkins, D. L., Chameides, L., Goldsmith, J. P., . . . Velaphi, S. (2010). Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Retrieved from http://pediatrics.aappublications.org/cgi/reprint/peds.2010-2972Bv1

10. Kattwinkel, J. (Ed.) (in press). Textbook of neonatal resuscitation (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics, American Heart Association.

11. Kamlin, C. O., O’Donnell C. P., Davis, P. G., & Morley, C. J. (2006). Oxygen saturation in healthy infants immediately after birth. The Journal of Pediatrics, 148, 585–589.

12. Mariani, G., Dik, P. B., Ezquer, A., Aguirre, A., Esteban, M. L., Perez, C., . . . Fustiñana, C. (2007). Pre-ductal and post-ductal O2 saturation in healthy term neonates after birth. The Journal of Pediatrics, 150, 418–421.

13. Rabi, Y., Yee, W., Chen, S. Y., & Singhal, N. (2006). Oxygen saturation trends immediately after birth. The Journal of Pediatrics, 148, 590–594.

14. Barber C. A., & Wyckoff, M. H. (2006). Use and efficacy of endotracheal versus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics, 118, 1028–1034.

About the AuthorsJeanette Zaichkin has been a neonatal nurse for more than 30 years.

She is a consultant for the American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee, editor of the Instructor’s Manual for Neonatal Resuscitation, and associate editor of the Textbook of Neonatal Resuscitation. Jeanette is the neonatal outreach coordinator at Seattle Children’s Hospital.

Dr. Gary M. Weiner is a neonatologist at St. Joseph Mercy Hospital, Ann Arbor, Michigan, and associate clinical professor at Wayne State University School of Medicine, Detroit, Michigan. He is a former member of the American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee, a participant in the ILCOR neona-tal delegation, and associate editor for the Textbook of Neonatal Resuscitation. You can contact him at weinerg@trinity-health.org.

The authors wish to acknowledge Rachel Poulin, MPH, manager, Neonatal Resuscitation Program, American Academy of Pediatrics, for her assistance with the preparation of this manuscript.

For further information, please contact: Jeanette Zaichkin, RN, MN, NNP-BC E-mail: jeanette.zaichkin@seattlechildrens.org.

Copyright © 2011 Springer Publishing Company, LLC, and the National Association of Neonatal Nurses.

11th National Neonatal Nurses

ConferenceSeptember 7–10, 2011

Marriott Wardman Park Washington, DC

Provided By The Academy Of Neonatal Nursing™

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