Frequent brief on-site simulation training and reduction in 24-h neonatal mortality—An educational intervention study

Abstract

Aim of the study

“Helping Babies Breathe” (HBB) is a simulation-based educational program developed to help reduce perinatal mortality worldwide. A one-day HBB training course did not improve clinical management of neonates. The objective was to assess the impact of frequent brief (3–5 min weekly) on-site HBB simulation training on newborn resuscitation practices in the delivery room and the potential impact on 24-h neonatal mortality.

Methods

Before/after educational intervention study in a rural referral hospital in Northern Tanzania. Baseline data was collected from 01.02.2010 to 31.01.2011 and post-intervention data from 01.02.2011 to 31.01.2012. All deliveries were observed by research assistants who recorded information about labor, newborn delivery room management, perinatal characteristics, and neonatal outcomes. A newborn simulator was placed in the labor ward and frequent brief HBB simulation training was implemented on-site; 3-min of weekly paired practice, assisted by local-trainers. Local-trainers also facilitated 40-min monthly re-trainings. Outcome measures were; delivery room management of newborns and 24-h neonatal outcomes (normal, admitted to a neonatal area, death, or stillbirths).

Results

There were 4894 deliveries pre and 4814 post-implementation of frequent brief simulation training. The number of stimulated neonates increased from 712(14.5%) to 785(16.3%) (p = 0.016), those suctioned increased from 634(13.0%) to 762(15.8%) (p ≤ 0.0005). Neonates receiving bag mask ventilation decreased from 357(7.3%) to 283(5.9%) (p = 0.005). Mortality at 24-h decreased from 11.1/1000 to 7.2/1000 (p = 0.040).

Conclusion

On-site, brief and frequent HBB simulation training appears to facilitate transfer of new knowledge and skills into clinical practice and to be accompanied by a decrease in neonatal mortality.

Introduction

Globally, around 2.9 million newborn infants die each year with as much as 36–70 per cent of these deaths occurring within the first day of life [1], [2], [3], [4], [5]. Moreover, neonatal mortality accounts for a steadily increasing proportion of under-five child mortality [1], [3], [5], [6]. Therefore, to meet Millennium Developmental Goal 4 of reducing under-five child mortality by two thirds by 2015, a major focus on optimizing basic newborn care is needed [4], [7].

Simulation-based education is increasingly used worldwide as a method of learning- and performance-assessment. Several studies have demonstrated sustained improvement in management of simulated medical emergencies after simulation training [8], [9], [10], [11], but very few studies have evaluated whether the acquired skills are translated into clinical practice with improvement in patient outcomes [12], [13]. Due to the gaps in knowledge between performance in classroom assessment as compared to clinical practice, evaluation of educational programs during local implementation, designed to facilitate skills translation to clinical practice may in part narrow these gaps.

The simulation-based “Helping Babies Breathe” (HBB) program was developed by the American Academy of Pediatrics with global partners to train providers in basic neonatal care and resuscitation aimed at reducing perinatal mortality worldwide [14]. Currently, HBB is being implemented in more than 60 low-resourced countries [14]. Tanzania was the first country to initiate a National implementation of HBB in 2009, and Haydom Lutheran Hospital (HLH), a rural referral hospital, was one of eight HBB study sites selected to evaluate the effects and impact of local implementation strategies on reducing neonatal mortality (Fig. 1) [15]. At HLH, an observational study started in the delivery rooms in July 2009. Simultaneously, care providers were assessed simulating newborn resuscitation pre and post a one-day HBB course (Fig. 1), and the pass-rate increased from 18 to 74% (p ≤ 0.0001) [16]. However, basic neonatal resuscitation management, i.e. suctioning, stimulation and application of bag mask ventilation (BMV), coupled with neonatal outcomes as observed in the delivery rooms during the corresponding time-period did not change [16]. No re-trainings were performed in this period.

As a consequence of these observations, frequent and brief on-site (FBOS) HBB simulation-training was initiated, as an effort to enhance clinical translation of simulation training into routine practice. The aim of the study was to assess if FBOS HBB simulation-training would impact clinical practice and reduce 24-h neonatal mortality.