PEDIATRICS Vol. 107 No. 4 April 2001, pp. 648-655
Effect of a Statewide Neonatal Resuscitation Training Program on Apgar Scores Among High-Risk Neonates in Illinois
Received Jun 14, 1999; accepted Aug 14, 2000.
,
, and
From the * Catholic Health Partners-Saint Joseph Hospital,
Chicago, Illinois; Northwestern University Medical School, Chicago,
Illinois; § West Suburban Hospital Medical Center, Oak Park, Illinois;
and Illinois Department of Public Health, Springfield, Illinois.
Objective. The national Neonatal Resuscitation Program (NRP), started in 1987, provided training to hospital delivery room personnel to standardize knowledge and skills to reduce neonatal morbidity and mortality and increase successful resuscitation during the first few critical minutes after birth. The Apgar score continues to be used as the best established index of immediate postnatal health. The purpose of this study was to evaluate the impact of the NRP instruction in Illinois hospitals by examining Apgar scores among high-risk infants who are likely to benefit from the NRP.
Methods. A retrospective 3-time period cohort design was
used (before the introduction of the NRP, 1985-1988; transition when
NRP training occurred, 1989-1990; and after NRP training was completed
at least once for some delivery room personnel in each Illinois
hospital, 1991-1995). Illinois computerized birth certificate files on
a selected group of 636 429 high-risk neonates provided information on
Apgar scores and maternal characteristics. The American Academy of
Pediatrics provided instructor lists to determine when NRP training
started and when it was fully implemented in Illinois. Illinois
Department of Public Health provided data to categorize hospitals into
levels based on type and intensity of neonatal services (Level I, II,
II+, III). High-risk neonates were defined as meeting 1 of the
following criteria: maternal age <20 years old or >35 years old,
birth weight <2500 g or >4000 g, presence of a maternal medical risk
factor, and no prenatal care or prenatal care started after the first
trimester. Several exclusion criteria were applied including the following: birth
records with missing data, multiple birth or congenital anomaly, and
hospital information that indicate no birth deliveries in 1 of the 11 study years or delivery outside of a hospital. One-minute and 5-minute
Apgar scores were divided into categories for analysis (0-3, 4-6,
7-10). No change or a decrease in a low (0-6) 1-minute Apgar when
compared with the 5-minute Apgar was a primary measure to evaluate
effect of NRP resuscitation. Variables examined included the following:
race/ethnicity, maternal age, level of education, presence of maternal
medical risk factor, trimester started prenatal care, complications of
labor and delivery, and a low birth weight. Analysis consisted of
2 tests, relative risk calculations, and logistic
regression to reveal independent associations with no change in low
1-minute Apgar score or continued low (0-6) 5-minute Apgar.
Results. A total of 636 429 high-risk birth records was selected for detailed analyses out of 2 077 533 births in Illinois between 1985 and 1995 for 193 hospitals. The number of active NRP instructors in Illinois changed dramatically during the study period; for example, 1 to 6 between 1987 and 1988 to 1096 to 1242 between 1991 and 1995. The percentage of neonates reported to have low (<7) 1-minute Apgar score decreased in 1991 to 1995 overall and for each of 4 hospital levels. Overall and by hospital level, there was a statistically significant lower proportion of high-risk newborns who showed a decrease or no change in their 5-minute Apgar scores after the NRP instruction. After adjusting for several maternal characteristics, logistic regression analysis revealed that high-risk newborns with a low 1-minute Apgar were more likely to increase their 5-minute Apgar after the NRP instruction in 1991 to 1995. Additional analyses indicated that very low birth weight and low birth weight newborns benefited the most from NRP instruction.
Conclusion. Although previous research has shown that the NRP instruction improves knowledge and skill among health care personnel in the delivery room, both short-term and long-term, there has been little evidence to demonstrate NRP impact on infant morbidity. Several strategies were used in this study to control for bias and to adjust for secular trends in decreased infant morbidity during the study period. This study demonstrated sufficient support for the hypothesis that a significant improvement occurred among neonates in their Apgar score after the NRP instruction in Illinois. Empirical support is provided for the clinical effectiveness of NRP instruction. Key words: neonatal resuscitation training, Apgar scores, high-risk neonates, changes in Apgar scores.
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