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
,
, 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.
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ABSTRACT |
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Methods
Results
Discussion
References
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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.
The State of Illinois all-races infant mortality rate of
8.4 per 1000 live births in 1997 is 14th highest in the United
States.1 The infant mortality rate for black infants of
13.9 per 1000 live births is the 7th highest.1 Neonatal
care provided within the first few minutes of life plays a major role
in the reduction of neonatal morbidity and mortality. Successful
resuscitation requires a thorough understanding of the subject by the
health care personnel attending the neonate and prompt availability of
those with skills in neonatal resuscitation.2,3
The national Neonatal Resuscitation Program (NRP) was initiated
throughout the United States in the late 1980s, and specifically in
1987 in Illinois.3 Its purpose is to assure that the
health care personnel in the delivery room in all rural, suburban, and
urban hospitals have the necessary knowledge and skills, and that they
use these skills appropriately, to provide optimal care to newborns
immediately after birth. NRP instructors provided training to health
care personnel in almost all hospital nurseries in Illinois by 1989. Resuscitative intervention includes ventilation, direct laryngoscopy, endotracheal intubation, external cardiac massage, and administration of resuscitation medication.
It would seem that a thorough understanding of resuscitation and the
prompt availability of trained personnel would positively impact on
1-minute and 5-minute Apgar scores. The Apgar score focuses on 5 physiologic signs (heart rate, respiratory effort, reflex irritability,
muscle tone, and color) to denote the condition of an infant in the
first critical minutes of life.4,5 The purpose of this
study was to evaluate the effectiveness of the NRP in Illinois in
decreasing the incidence of low Apgar scores among high-risk newborn
infants. High-risk newborns are considered more likely to need
resuscitation and more likely to benefit from interventions by trained
personnel. The Apgar score continues to be used as the best established
index of immediate postnatal health.5,6
Design
A retrospective 3-time period cohort design was used to examine
newborn morbidity before (1985-1988), during (1989-1990), and after
(1991-1995) the implementation of the NRP in Illinois. The central
hypothesis of this study is that NRP training of health care personnel
in the delivery room initiated in 1989 and completed by the end of 1990 would result in an observable increase in 1- and 5-minute Apgar scores
between the 2 time periods, 1985 to 1988 and 1991 to 1995. There was an
increase in the incidence of higher 1- and 5-minute Apgar scores and an
increase in the incidence of infants progressing from a low 1-minute
(0-6) Apgar score to a higher (7-10) Apgar score.
However, the decrease in low 1- and 5-minute Apgar scores in Illinois
between 1985 and 1995 could be attributed to other factors such as
changing sociobehavioral risks, increasing access to technology, or
secular trends in decreasing infant morbidity. Other factors such as
regionalization into perinatal centers, changes in the quality
assurance/quality improvement programs in hospitals, and technological
innovations during the same time period have positively impacted on
newborn care.2,6,7 Three strategies were used to reduce
effects of confounding from these factors. First, more attention was
given to contrasting changes in Apgar scores by hospital level. Level I
and Level II hospitals were compared with Level II+ and Level III
hospitals. The hypothesis is that Level I and Level II hospitals are
more likely to benefit from the personnel training in standardization of newborn resuscitation. Positive changes in infant outcomes in Level
I and Level II hospitals would be more pronounced when compared with
similar changes in Level II+ and Level III hospitals. Second, we
focused on high-risk newborns in this study. High-risk newborns were
considered more likely to benefit from the NRP personnel training. And
third, logistic regression analyses were performed with multiple
maternal risk factors associated with Apgar scores. The intention was
to evaluate the independent association of NRP training with neonatal
changes between a 1- and 5-minute Apgar score.
Measurement
Three different sources of data were obtained to examine
effectiveness of NRP training: newborn morbidity, NRP training, and hospital level indicating level of perinatal services. Newborn information was obtained from birth certificate computerized files of
all live births in Illinois from 1985 to 1995 from the Illinois Department of Public Health. The information regarding the number of
NRP educators in Illinois from 1985 to 1995 was obtained from the
American Academy of Pediatrics. By tracking the number of NRP
instructors and courses taught in Illinois, an estimate indicated the
time periods when there was very little instruction (Before), when
instruction was introduced and implemented in Illinois hospitals (Transition), and when instruction was already completed for Illinois hospitals (After). Data regarding the Illinois State-designated hospital status with respect to perinatal/neonatal level of care (I,
II, III) was obtained from the director of the Perinatal Advisory Board
of Illinois State. Level of care designation is assigned to a hospital
based on the availability of maternity, infant, and resuscitative
services. Nationally and in Illinois, regionalization and designation
of hospital level as either Level I, II, or III resulted in a network
of hospitals and the formation of regional university-based or other
Level III-based perinatal centers. For this study, Level II+
designation was applied to further distinguish those Level II hospitals
with the greater availability and intensity of maternity, infant, and
resuscitative services. Level I and Level II hospitals, relative to
Level II+ and Level III hospitals in Illinois, are less likely to have
high technology and specially-trained physicians; for example,
neonatologists readily available during infant delivery. Levels of
capabilities including Level II+ was assigned by the Perinatal Advisory
Board of Illinois Department of Public Health.
Several exclusion criteria were applied to birth data and hospital
data. Hospitals were excluded if a hospital changed from one level to
another level or if a hospital did not have any births in 1 year
between 1985 and 1995. Birth certificates were excluded for the
following reasons: missing data for Apgar scores or other maternal data
examined in logistic regression; missing code for hospital identity;
Illinois mothers who delivered out of state, delivery occurred outside
of the hospital or there was no medical personnel attendant during the
delivery. Multiple births and newborns with a congenital anomaly were
also excluded.
A high-risk group of newborns thought to benefit from the NRP training
was selected for study. The high-risk newborn group was selected based
on having any 1 of the following characteristics: no prenatal care or
prenatal care started after the first trimester, age <20 or >35
years, presence of 1 more maternal risk factors; and birth weight
<2500 g or >4000 g.
The 1-minute and 5-minute Apgar scores were used because they predict
newborn mortality and morbidity.5 We used Apgar score
ranges and focused on low 1-minute Apgar scores (0-6) after Hegyi et
al5, who demonstrated associations between Apgar scores in
the 0-3, 4-6, 7-10 intervals and other infant morbidity outcomes (4, 5, 6, and 8). In this study, a positive change in a low 1-minute (0-6)
Apgar can indicate successful effects of resuscitation.
To control for confounding between 1985 to 1988 and 1991 to 1995, several independent variables were examined for each birth: maternal
age (<20 and >35 years old compared with 20 to 35 years old), race
and ethnicity (black, Hispanic, white), level of education (less than
high school, high school), presence or absence of a maternal medical
risk factor (eg, hypertension, diabetes), complications during labor
and delivery, trimester started prenatal care (first trimester, after
first trimester, or no prenatal care), and low birth weight (<1500 g,
1500-2499 g, and 2500 g and higher). Each birth was assigned to 1 of 4 hospital levels (I, II, II+, III).
Statistical Analysis
SAS (Version 6.12) personal computer software (SAS Institute,
Inc, Cary, NC) was used for descriptive and inferential statistical analyses. The analysis focused on comparing percents: each 1- and
5-minute Apgar category and change between 1- and 5-minute Apgar
categories; by 4 hospital levels; and between time periods (before
1985-1988; and after 1991-1995). Between 1985 and 1995 there was a total of 2 077 533 live
births. Of this number, 389 249 were eliminated because they were born
during the transition training period of 1989 to 1990. In addition,
105 437 live births were eliminated because a hospital place of birth
was not identified (33 358) or there was 1 or more years between 1985 and 1995 where there were no live births at the hospital. Applying
missing data and other exclusion criteria removed an additional
182 318 births. Of the remaining 1 400 529 births, a total of
636 429 newborn birth records were selected as high-risk newborns for
detailed analyses. From the 193 hospitals that participated in the NRP
in Illinois, 147 had births in each year of the study period. Frequency
by hospital and births was as follows: Level I, 31, 25 839; Level II,
86, 324 269; Level II+, 12, 76 585; and Level III, 18, 209 736. The
number of active NRP instructors in Illinois changed dramatically
during the 11-year study period: 1 in 1987 and 6 in 1988; 504 to 935 in
1989 to 1990; and 1096 to 1242 between 1991 and 1995. A total of
10 084 NRP training courses were taught in the State of Illinois
during the study period. By the end of 1989, virtually all hospitals
had some nursery health care personnel that received the NRP sponsored instruction.
Table 1 shows the before and after NRP
training time periods number and percent of 1- and 5-minute Apgar
scores grouped into 3 categories. There were 259 153 high-risk live
births in 1985 to 1988 and 377 276 in 1991 to 1995. The percentage of
high-risk neonates was <5% in the 0 to 3 category and substantially
higher in the 4 to 6 category (6.9% and 8.0%). Comparisons between
the 2 time periods of before and after NRP training indicated that the
percentage of neonates in the 0 to 3 and 4 to 6 categories decreased
whereas the percentage of neonates in the 7 to 10 category increased
for 1- and 5-minute Apgar scores (each at P < .001). Table 2 shows the before and after NRP
training distribution of 1- and 5-minute Apgar scores by category
(0-3, 4-6, and 7-10). These are presented for each of the 4 hospital
levels. The percentage of neonates with low (0-3, 4-6) 1-minute Apgar
scores was significantly lower after the NRP training for each hospital
level (P < .001). The largest differences before and
after NRP training were for Level II (1.88%) and Level III hospitals
(1.55%). The smallest differences were for Level I (1.25%) and II+
hospitals (1.30%).
TABLE 1 TABLE 2
METHODS
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Discussion
References
2 tests
using a probability of .05 for statistical significance were computed.
Relative risks with 2-sided 95% confidence intervals were computed.
Logistic regression was used to examine the independent association of
change in low 1-minute Apgars and NRP training. Differences between
before NRP Apgar category scores and after NRP Apgar category scores in
Level I and II hospitals, which are more likely to benefit from
resuscitation training by NRP instructors, were compared with similar
differences in Level II+ and Level III hospitals. Changes between 1985 and 1995 in Level II+ and Level III hospitals are less likely a result
of the NRP intervention because of the fact that these perinatal
centers had extensive resuscitation programs in place, often within a
university medical school environment. The 2-year period between 1989 and 1990 was considered a transition time period when training was
initiated and essentially fully implemented. For ease in
interpretation, interim data were excluded from the tables.
RESULTS
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Abstract
Methods
Results
Discussion
References
Number and Percent of High-Risk Births by Three Categories of One- and
Five-Minute Apgar Scores Before and After the Introduction of the NRP
Instruction in Illinois
Number and Percentage of High-Risk Births by Three Categories of One-
and Five-Minute Apgar Scores Before and After the Introduction of NRP
Instruction By Hospital Level in Illinois
The percentage of neonates with low (0-3, 4-6) 5-minute Apgar scores was significantly different before and after the NRP training for each hospital level (P < .001). Overall, the before and after NRP training differences were less pronounced with 5-minute Apgar scores, primarily because of the smaller number of neonates in the 0 to 6 category.
Another way to examine possible effects of NRP instruction in 1991 to 1995 is to examine the change between 1-minute and 5-minute Apgar scores among high-risk newborns who had a low (0-6) 1-minute Apgar. The assumption is that after standardized resuscitation training among the hospital health care providers, the proportion of neonates with a low 1-minute Apgar score (0-6) may be higher than the similar proportion during the time period before the NRP instruction. In addition, after the NRP instruction, there would be a smaller proportion of newborns who evidence no change or a decrease in their 5-minute Apgar scores. Table 3 presents data on 63 093 high-risk infants with a 0 to 6 one-minute Apgar score and changes (decrease or no change vs increase) in 5-minute Apgar scores before and after NRP instruction. For the total group of high-risk neonates with a low 1-minute Apgar, there was a statistically significant lower proportion of neonates who evidenced no change or a decrease in their 1-minute Apgar after the NRP instruction (P < .003). The differences were statistically significant for each hospital level, ranging from 1.9% for Level II to 2.4% for Level I hospitals.
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Logistic regression analyses (Table 4) were performed to identify if the previously noted 1985 to 1988 versus 1991 to 1995 differences among high-risk neonates with low (0-6) 1-minute Apgar scores were independently associated with the introduction of NRP. Unadjusted and adjusted odds ratios were computed. The variables tested were maternal race (black, Hispanic vs white), maternal education (less than high school vs high school plus), maternal age (<20 years old, 36 years old and above vs 20-35 years old), prenatal care (begin the first trimester vs later or none), maternal medical risk factor (none vs 1 or more), complication(s) during labor and delivery (none vs 1 or more) and low birth weight (<1500 g, 1500-2499 g versus 2500 or higher). NRP (before [1985-1988] vs after [1991-1995]) was included in the model to assess if risk of no change or a decrease in a low (0-6) 1-minute Apgar were associated with no resuscitation training in 1985 to 1988. From the adjusted logistic regression analyses, newborns with a low (0-6) 1-minute Apgar score were more likely to have a lower or the same 5-minute score if the mother was black or Hispanic, started prenatal in the first trimester, had no medical risk factor, had no complications during labor and delivery, and was low birth weight. Protective effects decreasing likelihood of a continuing low 5-minute Apgar were as follows: white race, prenatal care after the first trimester, maternal medical risk factor, presence of a complication during labor, and birth weight >2499 g. In the unadjusted and adjusted (logistic regression) analyses, the time periods, 1985 to 1988 versus 1991 to 1995, were significantly associated with a change in the 1-minute Apgar score. Neonates born after the introduction of NRP instruction were more likely to have a higher 5-minute Apgar score (P < .0001).
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Similar logistic regression analysis was performed to examine change from a 0 to 6 1-minute Apgar category to a 7 to 10 5-minute Apgar category. (Not presented here.) From the logistic regression analysis, the estimated relative risk of an increased 5-minute Apgar score (from the 0-6 1-minute range to 7-10 5-minute range) in 1991 to 1995 was 1.29 (confidence interval: 1.24-1.34). Resuscitation after the NRP instruction resulted in a greater proportion of high-risk neonates with higher7-10 5-minute Apgar scores after NRP instruction (77.23% in 1985-1988 and 81.36% in 1991-1995, P < .001).
Additional analyses were performed to explore the strong association between changes between 1-minute and 5-minute Apgars and birth weight (Table 5). Overall (combined 1985-1988 with 1991-1995) results indicated that low birth weight newborns were less likely to show positive changes between the 1-minute and the 5-minute Apgar scores; 26.22% demonstrated no increase from a low (0-6) 1-minute Apgar among newborns <1500 g; 3.1% demonstrated no increase from a low (0-6) 1-minute Apgar among newborns 1500 to 2499 g; and 1.48% demonstrated no increase from a low (0-6) 1-minute Apgar for newborns 2500 g or more). Table 5 presents birth weight stratified analyses of no increase in 1-minute Apgar scores among high-risk newborns for the study group (n = 636 429) and for the subgroup (63 093) with a low 1-minute Apgar (0-6) before and after the NRP instruction. Not surprisingly, and similar to the United States as the whole,1 the incidence of low birth weight and very low birth weight newborns in Illinois decreased between 1985 to 1988 and 1991 to 1995. In the selected subgroup (n = 63 093 with 1-minute Apgar between 0-6) similar decrease in percent low birth weight were noted that may have accounted for some of the reported changes in Apgar scores before and after NRP instruction. A stratified analysis was performed to examine any differential effect on Apgar scores by birth weight.
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The stratified analyses with 2 different ways to examine change between 1-minute and 5-minute Apgar scores indicated that there were before and after NRP training differences within each birth weight level. The proportion of newborns who evidence no increase in 1-minute Apgars is statistically significantly (P < .001)and substantially lower in 1991 to 1995 for very low birth weight newborns and for low birth weight newborns. Although the incidence of no increase in 1-minute Apgar scores was substantially higher for very low birth weight newborns than low birth weight newborns, both groups benefited from the introduction of the NRP instruction in Illinois. It seems that the greatest benefit of NRP instruction was with low birth weight newborns as compared with newborns at or above 2500 g.
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DISCUSSION |
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This study has examined the effectiveness of the NRP in Illinois on immediate neonatal outcomes such as Apgar scores by comparing the pretraining period (1985-1988) with the posttraining period (1991-1995), according to the Illinois State designated hospital nursery levels of care. The results of this study indicate that the introduction of the American Academy of Pediatrics- and the American Heart Association-sponsored neonatal resuscitation program in Illinois in 1987 resulted in improved Apgar scores and reduced the incidence of low (0-6) 5-minute Apgar scores. This study also demonstrated the use of the Apgar scores to evaluate the positive outcomes of NRP as an educational and administrative intervention.
The Apgar scoring tool has been developed for discrimination, prediction, and evaluation. In a review of Virginia Apgar's research, Jepson and colleagues9 describe that the Apgar scores were developed: 1) to establish clear, concise guidelines for the classification of newborn physical status, which would serve as a "basis for discussion and comparison of results of obstetric practice, types of maternal pain relief and effects of resuscitation"; 2) to provide indication for resuscitation of the newborn; 3) to predict long-term neurologic outcome of the infant; and 4) to increase awareness among clinicians of the neonate's status during the early minutes of adaptation to extrauterine life. Although there continues to be concern about the reliability (interrater and independent rater reliability) and predictive validity of the 1- and 5-minute Apgar values,10 the scores remain the best tool for the identification of newly-born infants in need of cardiopulmonary resuscitation. For predicting infant mortality or later developmental difficulty, the scores are less sensitive but fairly specific. This study demonstrated that the Apgar scores can be used in an evaluation outcomes analysis.9
Donabedian's classic framework11 delineated 3 dimensions to quality assessment that apply to neonatal care in the delivery room: 1) structure, or the characteristics of the setting, which includes credentialling procedures and staffing patterns; 2) process, or what is done to the neonate in the first few minutes after birth; and 3) outcomes, or how neonates do after the NRP instruction. The introduction of NRP provided for a structure for training and credentialling of health care personnel in the delivery room in Illinois hospitals in the late 1980s. Health care personnel in the delivery room were taught to have the necessary knowledge and skill to apply successful procedures in a prescribed and timely sequence that includes suctioning, warming, drying, positioning, suctioning again, stimulating, and checking vital signs, as well as determining if oxygen or cardiac compression and endotracheal insertion are necessary within the first 30 seconds. If resuscitative intervention is deemed necessary, NRP training enhances timely interventions such as ventilation, direct laryngoscopy, endotracheal intubation, external cardiac massage, and administration of resuscitation medication. Training was not provided on how to compute and enter a 1-minute and 5-minute Apgar score. There is no evidence that the 1985 to 1988 and 1991 to 1995 changes observed in this study are a result of a positive shift toward higher rater scoring and recording of the 1-minute and the 5-minute Apgar.
Although a number of studies have examined improving the process of providing timely and appropriate care to the newborn2,10-16 few studies have examined the clinical outcome of the NRP instruction on the neonate. How neonates do after NRP training has been studied infrequently. As Lohr17 points out for hospital-based studies, there are few links between processes and outcomes that are backed by solid evidence from well-controlled studies. In addition, uncontrolled studies comparing outcomes across groups frequently require adjustment for patient risk and the recognition that some patients are sicker than others.18 The purpose of our study was to examine neonatal outcomes as indicated in Apgar scores immediately after birth that may have resulted from the implementation of NRP in Illinois. The amount of change in the incidence in low 1-minute Apgar scores seemed to support the maximum benefit of the NRP training program among Level I and II hospitals. The a priori hypothesis of greater change among neonates from Level I and Level II hospitals was supported in this study.
Although improvement in the 1-minute Apgar score may occur because of better obstetric care during antenatal and intranatal periods in neonates showing prenatal, antenatal, and intranatal complications of pregnancy, it seems unlikely that these improvements account for the observed positive changes among high-risk neonates in this study. Altered ability to evaluate a high-risk neonate at birth, better estimate Apgar scores, and good record keeping after the NRP training are less likely explanations compared with the improved technique of resuscitation for the observed improvement in Apgar scores.
NRP training emphasizes systematic and prompt care consisting of thoroughly drying the neonate, removing the wet linen, suctioning of the pharynx followed by suctioning of the nose, providing tactile stimulation, assessing the color, respiration, and heart rate, delivering oxygen for cyanosis, and providing bag and mask ventilation for nonbreathing before 1-minute Apgar score is estimated. Adhering to those first steps before 60 seconds elapse after birth not only improves 1-minute Apgar score but increases 5-minute Apgar score and thereby reduces morbidity. Furthermore, preventing heat loss can become especially important with a preterm or an infant who is asphyxiated and hypoxic. A hypoxic infant will undergo a greater than a normal drop in core temperature if not thermally protected. Recovery from acidosis also is delayed by hypothermia. Clearing the airway by suctioning the mouth first to prevent aspiration and suction of a trachea before drying and tactile stimulation of neonates presenting with meconium stained amniotic fluid prevents morbidity and improves outcomes. At time of delivery, the neonate may aspirate clear or purulent amniotic fluid or even blood. Pneumonia and massive blood aspiration may lead to a clinical picture similar to meconium aspiration. Squamous debris associated with amniotic fluid aspiration may persist in a lung for some days.19
Thus, implementation of NRP training that resulted in better medical care of high-risk neonates in the delivery rooms seems to be the logical explanation for the improvement in 1-minute and 5-minute Apgar scores seen in our study.
There are a number of limitations in this study. First, the study is retrospective or historical and thus limited by the availability of a common newborn database on the birth certificate files between 1985 and 1995. For example, type of delivery was not transferred to the computerized birth certificate file before 1989. Changes in annual cesarean rates at different hospitals, which may have altered the results, could not be studied. Attempts were made to use as much of the common information as possible to control for possible differential bias over the 11-year time period. Second, a number of changes were made in the type of data and the method of recording data on the birth certificate starting for births in 1989. A revised birth certificate was introduced in 1989.20 The reliability of different data elements may have changed after the introduction of the new form. For example, the prevalence of recorded newborn abnormal conditions and congenital anomalies was generally higher after 1989. The exclusion criteria applied in this study attempted to limit the effect of changes in coding practices. Third, the Apgar scores may be assigned by different health care personnel at different hospitals, possibly by differently trained personnel by level of hospital over the 11-year time period. Observer bias (Schmidt) is also a concern. Rothberg et al21 demonstrated that some staff tended to assign higher Apgar scores than independent observers. Systematic changes in the assignment of Apgar scores between 1985 and 1995 may introduce some bias.22,23 The emphasis placed on Apgar categories (0-3, 4-6, 7-10) rather than unit changes in an Apgar score was an attempt to minimize bias and reduce effect of interrater variability among health care personnel at different hospital levels. Fourth, the type and ability of health care personnel providing immediate care to newborns may have changed over the 11-year study period, and possibly changed differentially by hospital level. Although resuscitation teams consisting of physicians experienced in newborn resuscitation have increased in number over the 11-year study period, it is unlikely that they are present more often after the NRP instruction. Finally, secular changes in rapid advances in understanding neonatal physiology and new devices and procedures in the delivery room24 and changes in maternal-newborn risk profile and birth outcomes1 are complex and interact to minimize ability to historically evaluate the effect of the NRP intervention. Several strategies were used to increase our ability to test the hypothesis about the effect of NRP. These included use of logistic regression to control for several maternal factors and stratified analyses by birth weight which are associated with Apgar scores and application of different exclusion and deletion criteria to obtain a high-risk birth cohort.
The goal of the NRP instruction is to assure that the health care
personnel in the delivery room in all rural, suburban, and urban
hospitals have the necessary knowledge and skills and that they use
these skills appropriately to provide optimal care to newborns
immediately after birth. This national program was intended to have the
greatest impact on designated Level I and Level II nurseries in
hospitals in rural and urban Illinois. Level I and Level II hospitals,
which often have a lower number of annual births, did not routinely
have trained staff and have less technologic support
all of which are
common in university hospitals or medical centers designated as Level
II+ and Level III hospitals.
The improvement in low 1-minute Apgar to a higher 5-minute Apgar score and corresponding reduction in the percentage of neonates who continue to have a low 1-minute Apgar scores occurred during the post-NRP training years with the largest positive impact on very low birth weight newborns.
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ACKNOWLEDGMENTS |
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We gratefully acknowledge the support of the American Academy of Pediatrics and Loretta Johnson, the secretary of neonatology at St Joseph Hospital.
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FOOTNOTES |
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Received for publication Jun 14, 1999; accepted Aug 14, 2000.
Reprint requests to (D.P.) Saint Joseph Hospital, 2900 N Lake Shore Dr, Chicago, IL 60657
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ABBREVIATIONS |
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NRP, Neonatal Resuscitation Program.
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REFERENCES |
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References
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