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NRP
VOL 22 NO 2 FAL L /W IN T E R 2 0 1 3

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Instructor Update

Suctioning the Newborn at Birth: Questions and Answers
“ALTHOUGH DEPRESSED INFANTS BORN TO MOTHERS WITH MECONIUM-STAINED AMNIOTIC FLUID (MSAF) ARE AT INCREASED RISK TO DEVELOP MAS,TRACHEAL SUCTIONING HAS NOT BEEN ASSOCIATED WITH REDUCTION IN THE INCIDENCE OF MAS OR MORTALITY IN THESE INFANTS. ”

I  hear that the AAP/AHA Neonatal Resuscitation
Guidelines call for tracheal suctioning of the nonvigorous meconium-stained newborn, but that the procedure doesn’t actually make any difference to neonatal outcome. Why are we still doing this procedure if it does not influence outcome or prevent meconium aspiration syndrome?

 The International Liaison Committee on Resuscitation (ILCOR) still recommends tracheal suctioning for the non-vigorous meconium-stained newborn. After reviewing the evidence, the last ILCOR statement regarding this was the following, which answers the question above…(from Kattwinkel et al. Circulation 2010; 122;S909-S919) “Although depressed infants born to mothers with meconium-stained amniotic fluid (MSAF) are at increased risk to develop MAS, tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants. The only evidence that direct tracheal suctioning of meconium may be of value was based on a comparison of suctioned babies with historic controls,

and there was an apparent selection bias in the group of intubated babies included in those studies. In the absence of randomized, controlled trials, there is insufficient evidence to recommend a change in the current practice of performing endotracheal suctioning of nonvigorous babies with meconiumstained amniotic fluid (Class IIb, LOE C). However, if attempted intubation is prolonged and unsuccessful, bag-mask ventilation should be considered, particularly if there is persistent bradycardia.” To summarize, the available evidence was not strong enough to support or refute the practice. The NRP® Steering Committee has been careful to not change from one unfounded practice to another, but rather to advocate for better evidence in order to inform future guidelines. Because the review highlighted how little evidence there was for meconium suctioning of nonvigorous, meconium-stained newborns, there is now a national call for an appropriate clinical trial to be done to assess safety and efficacy of this long-standing clinical practice. In the meantime, it seems prudent to continue with our current practice. continued on page 5

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NRP Acknowledgements
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In This Issue
1  Suctioning the Newborn at Birth: Questions and Answers 3 Improve Your Debriefing Skills 6  Preparing NRP Learners for Success: The Online Examination 8  NRP Online Exam At-A-Glance 10  Tore Laerdal Becomes Honorary Fellow of the AAP 12  Welcome and Farewell 12  NRP Research Grant Award 12  Reminder to Instructors to Complete Exam

The Neonatal Resuscitation Program® (NRP®) Steering Committee offers the NRP Instructor Update to all AAP/AHA NRP Instructors. Editor Eric C. Eichenwald, MD, FAAP Managing Editors Rachel Poulin, MPH Wendy Marie Simon, MA, CAE Robyn Wheatley, MPH Contributor Jeanette Zaichkin, RN, MN, NNP-BC NRP Steering Committee Steven Ringer, MD, PhD, FAAP, Cochair Brigham & Women’s Hospital Boston, MA Myra H. Wyckoff, MD, FAAP, Cochair University of Texas Southwestern Medical Center Dallas, TX Anne Ades, MD, FAAP The Children’s Hospital of Philadelphia Philadelphia, PA Christopher Colby, MD, FAAP Mayo Clinic Rochester, MN Eric C. Eichenwald, MD, FAAP University of Texas-Houston Medical School Houston, TX Kimberly D. Ernst, MD, MSMI, FAAP University of Oklahoma Health Sciences Center Oklahoma City, OK Henry C. Lee, MD, FAAP Stanford University Palo Alto, CA Marya Strand, MD, FAAP Saint Louis University St. Louis, MO

NRP Steering Committee Liaisons John T. Gallagher, MPH, RRT-NPS American Association for Respiratory Care Rainbow Babies & Children’s Hospital Cleveland, OH Linda McCarney, MSN, RN, NNP-BC, EMT-P National Association of Neonatal Nurses The Children’s Hospital in Denver Aurora, CO Patrick McNamara, MB, FRCPC Canadian Paediatric Society The Hospital for Sick Children Toronto, ON, Canada Samuel Mujica Trenche, MD, FAAP Section on Hospital Medicine Las Vegas, NV NRP Steering Committee Consultants Louis P. Halamek, MD, FAAP Stanford University Palo Alto, CA Jeffrey Perlman, MB, ChB, FAAP ILCOR Science Director Liaison AHA Pediatric Subcommittee New York Presbyterian Hospital New York, NY Jerry Short, PhD University of Virginia Charlottesville, VA AAP Staff Liaisons Thaddeus Anderson Kristy Crilly Nancy Gardner Jackie Hughes Kirsten Nadler, MS Rachel Poulin, MPH Wendy Simon, MA, CAE Robyn Wheatley, MPH

Statements and opinions expressed in this publication are those of the authors and are not necessarily those of the American Academy of Pediatrics or American Heart Association. Comments and questions are welcome and should be directed to: Eric C. Eichenwald, MD, FAAP Editor, NRP Instructor Update 141 Northwest Point Blvd., PO Box 927 Elk Grove Village, IL 60009-0927 www.aap.org/nrp © American Academy of Pediatrics/ American Heart Association, 2013

NRP Editors John Kattwinkel, MD, FAAP University of Virginia Charlottesville, VA Gary M. Weiner, MD, FAAP Saint Joseph Mercy Hospital Ann Arbor, MI Jeanette Zaichkin, RN, MN, NNP-BC Providence St. Peter Hospital Olympia, WA

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Improve Your Debriefing Skills
NRP® introduced the simulation-based curriculum nearly two years ago. By now, most NRP instructors have had an opportunity to conduct provider courses that include the required simulation and debriefing component. Most instructors feel confident creating learning objectives and setting up scenarios; however, many instructors ask the following questions about debriefing.

 How can I prepare my learners for a successful debriefing?  Prepare your learners ahead of time for what they can expect during debriefing. Your provider course should include a short orientation about how the course is set up, including learner responsibilities for participation. If participants are new to simulation and debriefing, they should be told that debriefing is when the instructor helps the learners talk to each other about what went well and what could have gone better during the scenario. As participants gain experience with simulation and debriefing, their skills at eliciting meaningful discussion from their colleagues also improve. Debriefing is guided by the instructor, but participants must engage in the process.  What is the first question to ask at a debriefing?  Some instructors fear “instructor freeze,” which occurs when an instructor faces the scenario participants and cannot think of a single word to begin the debriefing except, “So…” Avoid instructor freeze by remembering that your first question should always establish the existence of a shared mental model. Based on your information about the infant’s gestation and risk factors, did your learners see the newborn’s presentation as you had planned? Ask, “Tell me what you thought you would need to do when the newborn first came to the radiant warmer.” It’s a good idea to address this first question to a less dominant member of the team because this person is unlikely to challenge a more assertive team member who voices a different view of the newborn’s initial status. For example, imagine that your learning objectives include tracheal suction for a non-vigorous meconiumstained newborn. However, team members fail to ask if the fluid was meconium-stained, and you do not

apply any substance to the newborn that resembles meconium. The newborn was placed on the radiant warmer where the team quickly proceeded through initial steps and positive-pressure ventilation. Your first question at the debriefing, addressed to a quieter team member, is, “Tell me what you thought you would need to do when the newborn first came to the radiant warmer.” The reply, “The newborn was limp, apneic, and had a low heart rate so we proceeded with initial steps.” It is then clear to you that the team did not anticipate or see meconium-stained fluid, and you did not have a shared mental model of this scenario. You may now conclude that the team did not necessarily fail to intervene properly – they simply missed the cues they needed to manage a non-vigorous, meconiumstained newborn at birth. You would correct this prior to the next scenario by reminding team members to ask the four questions prior to the birth to assess risk (if the team does not recognize this during this debriefing) and you would apply a meconium-like substance to the infant to provide an essential visual clue about the newborn’s condition.

“DEBRIEFING IS A FACILITATED INTERACTIVE DISCUSSION ABOUT A PRIOR SERIES OF EVENTS. THE INSTRUCTOR GUIDES THE DISCUSSION WITH OPEN-ENDED QUESTIONS AND ALLOWS REFLECTION AND SELF-DISCOVERY. DEBRIEFING IS WHEN LEARNING OCCURS.”

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Improve Your Debriefing Skills
 What other debriefing questions keep the discussion moving forward?  Most provider courses have limited time for debriefing. After the shared mental model question described above, the most important questions to ask include the following: • What went well with your scenario? • What could have gone better? • What will you do differently next time? • Look at this list of NRP Key Behavioral Skills and give an example of a skill you used (or should have used to improve performance) Do not allow team members to simply read off the list of NRP Key Behavioral Skills, such as, “I used all available resources.” The response requires an example such as, “When I paged anesthesia to help with this difficult intubation, I used all available resources.” Team members may not initially recognize their behaviors as NRP Key Behavioral Skills. For example, in response to your question about what went well, a team member may state that she checked equipment prior to the birth to make sure she had everything needed, and she called an NNP to attend the birth because of meconium-stained fluid. This team member might need your help to recognize these actions as “Know Your Environment” and “Plan and Anticipate.” By naming the Behavioral Skills team members may not even be aware that they use, they can translate these skills into use when they participate on teams that do not function well. If the scenario is complex or if something unexpected occurs such as a medication error or a breach of professional behavior, it may be helpful to plan the debriefing agenda with team members. Prior to asking the shared mental model question, ask participants to identify the issues they wish to discuss. List these on a whiteboard or screen to help keep the discussion focused on the issues at hand. Stay alert for responses such as, “I wish she would have told me…” and “I didn’t know…” Or “All I needed was…” When these occur, this is your opportunity to help improve team performance by asking, “How would that sound?” or “How could she have told you…” or “How could you have gotten the help you needed?” Before your provider course adjourns, ask each learner, “What did you learn today?” This helps reinforce the concept that simulation and debriefing is for learning, not for demonstrating perfect skills and behaviors.  How can I get a quiet learner to speak up?  Begin a debriefing by asking a less dominant team member the first question, which is the shared mental model question, “Tell me what you thought you would need to do when the newborn first came to the radiant warmer.” Because there is no right or wrong answer to this question, it may help put nervous learners at ease. Quiet learners can also be brought into the discussion by directing questions to them by name, for example, “Steve, how effective was the first try at positive-pressure ventilation and how did the team respond?” Give the learner some time to formulate an answer. Silence is not necessarily a bad thing. The instructor who asks rapid-fire questions and answers them without waiting for the team’s response soon has a silent and passive team who allows the instructor to do all the talking. This is not beneficial learning for anyone.  How can I strengthen my debriefing skills?  • Review the NRP Instructor DVD. •D  ebrief everything. If you practice debriefing only during NRP courses, it will take a long time to become a skilled debriefer. Use debriefing skills after every birth and after any event or procedure that requires teamwork and communication. •F  ilm yourself debriefing and view it after the course. Assess your skills by using the “NRP Instructor Simulation and Debriefing Checklist” on page 140 of the Instructor Manual for Neonatal Resuscitation.

LEARN MORE BY READING THE CHAPTERS ABOUT SIMULATION AND DEBRIEFING IN THE INSTRUCTOR MANUAL FOR NEONATAL RESUSCITATION (2011).

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Suctioning the Newborn at Birth Q&A…
 What research is in progress on this topic? Is it possible that the guideline for tracheal suctioning will change with the next AAP/AHA guidelines?  It is possible, but it will depend on timing of when studies are completed and the results of those studies.  What is the current advice about intubating and suctioning the trachea twice when suctioning meconium from the trachea?  If during tracheal suctioning there is return of meconium, the provider may intubate a second time as long as the heart rate allows. If the heart rate is < 100 bpm then one attempt is all that should be done, and then PPV should be initiated. If PPV does not result in an increase in the heart rate, additional steps to improve ventilation should be initiated. These include checking the mask seal, repositioning the infant in the open airway position, suctioning the mouth and nose again, opening the mouth, increasing pressure and placement of an advanced airway (MRSOPA). The best indicator that effective ventilation is in progress is stabilization of the heart rate above 100 bpm.  Can you explain why there is no difference in risk between thin vs. thick meconium? I know this is old information, but healthcare providers at our hospital still consider thick meconium a more ominous sign than thin meconium. Is there any way to predict the neonatal risk based on the consistency of meconium?  The term “thin” versus “thick” is very subjective. In addition, there is no data to support that meconium consistency predicts risk or outcome. If the amniotic fluid is meconium-stained and the infant is vigorous, no matter what the consistency, the infant should be treated like any other newborn. If the amniotic fluid is meconium-stained and the infant is non-vigorous, the medical provider should attempt to clear the airway with tracheal suctioning prior to stimulation, regardless of the consistency. The continued use of the terms in some hospitals is likely a vestige of the out of date practice in NRP editions 1 through 3 when the various recommendations for meconium management depended on the designation of thin versus thick.

These recommendations were not evidence-based, but rather came from expert opinion. Starting in 2000, the NRP Steering Committee joined ILCOR to review the available science for resuscitation recommendations. At that time meconium management strategies were changed from being based on the consistency of the meconium to being based merely on the presence of any meconium in accordance with the best available evidence.  The current resuscitation guidelines discourage the use of bulb suction for a newborn who has no impedance to breathing. Does this also apply to the OB provider who delivers the infant? Our OB providers are not allowed to have a bulb suction device on their instrument tray, although it seems that a little suction might be a good idea for term vigorous newborns who are breathing and crying, but bubbling and gargling on secretions.  ACOG gives no specific guidance on this issue in the circumstance of clear fluid. The authors of William’s Obstetrics textbook suggest what the AAP/AHA guidelines suggests, that routine suctioning of every infant is not needed. Suctioning should be reserved for those newborns who are unable to clear their own airway (either apneic or choking on copious secretions). Thus, it would seem prudent to allow the OB provider to have access to a bulb syringe to use with good clinical judgment about when to suction. In the circumstance of a newborn born through meconium-stained amniotic fluid, the current ACOG statement (reaffirmed in 2013) mirrors what is said in the AAP/AHA guidelines. There is no evidence to support routine intrapartum suctioning of meconium by the OB provider. If meconium is present and the newborn is depressed, the clinician should intubate the trachea and suction meconium from beneath the glottis. If the newborn is vigorous, there is no evidence that tracheal suctioning is necessary.

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Preparing NRP Learners for Success: The Online Examination
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ealthcare professionals who are required to take an NRP Provider course every two years can be unaware of course requirements. Many errors are related to the NRP online exam. NRP instructors report frustration with colleagues who: • Seem surprised to learn that the NRP online exam should have been taken (and passed) prior to the course. • Take only Lessons 1-4 and 9 when their hospital requirement is actually Lessons 1-9. • Wait until the night before the course to take the online exam, fail it, and do not know how to access another exam before the next day. This type of miscommunication can be avoided. As an NRP instructor, you can make essential course information, especially about the online exam, accessible and easy to understand. If you send NRP information as an email, make the subject line direct and informative, such as “NRP Course 2/14 at 0900: Pre-course Requirements.” Put the most important information at the beginning of the message. Create a standardized process for NRP participants and keep it consistent to avoid confusion. Leave white space between facts to facilitate comprehension for those who skim quickly for information. Use bold print or color only for the most important information. Avoid fancy backgrounds, distracting fonts, and overuse of photos and diagrams. The NRP instructor is responsible for making clear and concise information easily accessible to course participants in a timely manner. The course participant is equally responsible for reading the information and following instructions.

Managing Failed Exams It is important to communicate your institution’s policy for how to handle a failed online exam. For example, your course information might include a bold-print sentence such as “This hospital covers the cost of the first NRP Exam attempt. If you fail any lesson twice, you must begin the entire exam again. You are responsible for the cost of another exam. Please call ___-___-____ if you need to purchase an exam from the course coordinator or go to http://healthstream.com/hlc/aap to create an account to purchase an exam with your credit card as a Self-Registration.” You may also set an internal policy that indicates that students will reimburse the facility for additional exams after test failure. Your HealthStream site allows you to run a Failed Course report to monitor failures and identify students who owe reimbursement for secondary attempts. Alternatively, you can turn off the autoreassign feature and learners will not be able to enroll in the exam subsequent times. They will need to contact their administrator for the exam to be reassigned and at that point they can pay for the exam if required. Occasionally, a student will repeatedly fail the NRP online exam. After several failed attempts, this student requires a remediation plan. This plan may be individualized for each learner or may be a standard plan developed by an institution. The learning requirements of the plan are at the discretion of the instructor and/or the institution. The plan should include additional time for study and test practice using the review sections for selfassessment and summaries of Key Points in each lesson. The instructor’s role in the remediation plan is to assess potential reasons for repeated failure. Many experienced neonatal providers simply fail to study the textbook or accompanying DVD-ROM prior to taking the exam. Others may rush through the exam and misread questions and potential answers. When reading comprehension is clearly the issue, it may be necessary for the instructor to sit with the student during the exam and read the questions and potential answers aloud. The instructor should not coach or correct wrong answers for the student.

FOR MORE INFORMATION ABOUT THE NRP ONLINE EXAMINATION AND SAMPLE LETTER TEMPLATES, SEE CHAPTER 4 OF THE INSTRUCTOR MANUAL FOR NEONATAL RESUSCITATION (2011).

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Sample NRP Provider Course Information
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“AS AN NRP INSTRUCTOR, YOU CAN MAKE ESSENTIAL COURSE INFORMATION, ESPECIALLY ABOUT THE ONLINE EXAM, ACCESSIBLE AND EASY TO UNDERSTAND.”

u You Have Registered for an NRP Provider Course Date: Time:

Location: (Insert link to directions if necessary.) u Course Requirements: • Read the Textbook of Neonatal Resuscitation, 6th edition or view the textbook DVD-ROM. Access a textbook and/or DVD-ROM. (Insert instructions specific to your institution.) • Pass the NRP online examination prior to the course, but no sooner than 30 days before the course date. See below for instructions about the online examination. • Bring your printed online examination verification from the NRP online examination to the course. You will not be admitted to the course without this document. You Are Assigned: q Lessons 1-4 and Lesson 9 q Lessons 1-9 q Lessons 1-4, Lessons __, __, __, __, and Lesson 9 • Demonstrate the above assigned neonatal resuscitation lessons within the context of a clinical scenario in correct sequence according to the NRP flow diagram, with correct timing and proper technique. See textbook pages 299-302 as your guide. • Participate in simulation training and debriefing exercises • After you have attained NRP Provider status, we recommend that you register with the American Academy of Pediatrics for an online reminder before your next renewal date: www2.aap.org/nrp/provider_info-notify_service.html. u Information About the NRP Online Examination Access the NRP online exam by . (Insert instructions here specific to your institution.) If you fail any of the lesson exams twice, you will not be able to continue the exam. The American Academy of Pediatrics deems that you must begin again with a new examination. If you must begin anew, . (Insert instructions specific to your institution.) After exam completion, print your online examination verification and bring this with you to the NRP course. You will not be allowed to do the hands-on portion of the course without this document. You may start and stop the exam at your convenience, but you must finish testing within 14 days of your original start date. Most learners require about one hour when testing on all nine lessons. Take Lesson 9 last. If you take Lessons 1-4 and then take Lesson 9, the application perceives that you have finished the exam and locks you out of Lessons 5-8. If you pass a lesson exam, you may print the questions you missed. If you fail the lesson exam, you will not know which questions you missed. If you have questions, contact (Insert course contact’s information here.) .

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NRP Online Exam At-A-Glance
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Pricing Grid HealthStream/HLC Customer Non-HLC Customer Individual Purchaser
Current NRP Instructor

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Definitions • The HealthStream Learning Center™ LMS, also known as the HLC, is the most adopted learning management system in the healthcare industry with more than 3.2 million healthcare workers actively using our system. The HLC provides a robust yet easy to use learning platform for scheduling, assigning, tracking, delivering, and reporting on classroom and online learning. The HLC supports more than 70,000 online course completions and over 100,000 student log-ins every day, all from users in a healthcare setting. •H  ealthStream Content Express (HEX) is an online LMS for healthcare organizations who don’t need all the features of the HLC. HEX features access to online learning and student self-registration. Content Express allows customers to assign and manage specific HealthStream content without leverage the full LMS functionality of the HLC. Consider this a very basic version of the HLC. •H  ealthStream Connect is a custom integration that uses AICC protocols to pass progress and completion data for online courses from HealthStream to a client’s own LMS. HealthStream has built Connect integrations with Learn.com, SABA, SumTotal, Plateau and other leading LMS’s so that customers can continue to use their existing LMS to access HealthStream content without switching to the full HLC. For more information, visit www.healthstream.com/products/learning-center.aspx.

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Questions are commonly received regarding implementation of the NRP Online Exam. As we are constantly innovating, what follows is current information about the pricing structure for the exam, as well as updated and complete information about continuing education credit availability by discipline.

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Individual Purchase N/A N/A $23.50 No Charge

First 50 Exams/Yr. $16.00 $20.00 N/A N/A

Next 51-250 Exams/Yr. $12.80 $16.00 N/A N/A

Next 250+ Exams/Yr. $11.20 $14.00 N/A N/A

Continuing Education Credit The NRP online exam offers up to 9 CEUs. One credit hour is awarded for each lesson successfully completed. To obtain Continuing Education Credit, you must enter your licensure information in your HealthStream record. To enter this information click on the My Profile tab, click on Manage Discipline and License Information, click on Add Discipline/ License and enter your information. If you did not enter your license information before completing the exam, you may add this information later. To have the CE document you need appear, click on My Transcript, click on Neonatal Resuscitation Program Online Examination, 6th Edition, scroll to the bottom of the page and click Refresh Credits.

Medical Credits Accrediting/Approval Body: Accreditation Council for Continuing Medical Education Credit Units: 9.00 AMA PRA Category 1 Credit(s)™ Expiration Date: 5/15/2014 Statement: The American Academy of Pediatrics is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity was designated for 9.00 AMA PRA Category 1 Credit(s) ™. This program is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 9 NAPNAP Contact Hours of which 0 are pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 5 Hanover Sq., Suite 1401, New York, NY 10004. The American Academy of Physician Assistants accepts AMA PRA Category 1 Credit(s)™ from organizations accredited by the ACCME. Disciplines: Emergency Physicians, Family and General Practitioners, Gastroenterologists, Obstetricians and Gynecologists, Pathologists, Pediatricians, Physicians, Physicians – Public Health Certificate, Physicians – Public Psychiatry Certificate, Physicians – Area Clinical Need, Physicians – Limited License, Physicians – Osteopathic, Podiatrists, Podiatrists – Limited, Radiologists, Surgeons, Pedorthist, General Internists, Non-practicing Physician States: AK, AL, AR, AS, AZ, CA, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MP, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UM, UT, VA, VI, VT, WA, WI, WV, WY

Nursing Credits Accrediting/Approval Body: American Nurses Credentialing Center Credit Units: 9.00 Contact Hour(s) Expiration Date: 3/7/2015 Statement: This continuing nursing education activity was approved by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Program approved for 9 contact hours; approval valid through March 7, 2015. Disciplines: Advanced Practice Registered Nurses, Anesthetists, Certified Registered Nurse, Cardiovascular Technologists and Technicians, Dietitians and Nutritionists, Licensed Practical Nurses, Licensed Vocational Nurses, Medical Assistants, Midwives, Certified Nurse, Nurse Practitioners, Nursing Aides, Registered Nurses, Registered Nurses – Advanced Registered Nurse Practitioner, Respiratory Therapists, Respiratory Therapists – Certified Respiratory Care Therapist, Respiratory Therapists – Critical Care Practitioner, Respiratory Therapists – Non-critical Care Practitioner, Clinical Nurse Specialist, Prehospital Registered Nurse States: AK, AL, AR, AS, AZ, CA, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MP, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UM, UT, VA, VI, VT, WA, WI, WV, WY Respiratory Therapy Credits Accrediting/Approval Body: American Association for Respiratory Care Credit Units: 9.00 Contact Hour(s) Expiration Date: 1/1/2014 Statement: This program has been approved for a maximum of 9 contact hours of Continuing Respiratory Care Education (CRCE) credit by the American Association for Respiratory Care, 9425 N. MacArthur Blvd., Suite 100, Irving, TX 75063, Course #128636000.

EMS Credits Accrediting/Approval Body: Continuing Education Coordinating Board for Emergency Medical Services Credit Units: 9.00 Contact Hour(s) Expiration Date: 1/31/2015 Statement: This continuing education activity is approved by the American Academy of Pediatrics, a CECBEMS accredited organization. You have participated in a continuing education program that has received CECBEMS approval for continuing education credit. If you have any comments regarding the quality of this program and/or your satisfaction with it, please contact CECBEMS at: CECBEMS, 12200 Ford Rd., Suite 478, Dallas, TX 75234, Phone: 972/247-4442, Email: [email protected]. CECBEMS represents only that its accredited programs have met CECBEMS’ standards for accreditation. These standards require sound educational offerings determined by a review of its objectives, teaching plan, faculty, and program evaluation processes. CECBEMS does not endorse or support the actual teachings, opinions or material content as presented by the speaker(s) and/or sponsoring organization. CECBEMS accreditation does not represent that the content conforms to any national, state or local standard or best practice of any nature. No student shall have any cause of action against CECBEMS based on the accreditation of the material.

FOR QUESTIONS ABOUT PRICING, DELIVERY METHODS, OR TECHNICAL QUESTIONS, CONTACT YOUR HEALTHSTREAM REPRESENTATIVE AT 800/521-0574, SELECTION #6 OR BY EMAIL AT [email protected].

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Tore Laerdal Becomes Honorary Fellow of the AAP
In October 2013, Mr Tore Laerdal, Chairman of Laerdal Medical, was made an honorary Fellow of the American Academy of Pediatrics. This honor has been awarded to only a few non-pediatricians who have demonstrated tremendous commitment to children and whose heroic efforts have helped further the AAP mission.

Laerdal Medical has been a leading supplier of training materials and therapeutic equipment for acute medicine. Tore Laerdal’s contributions to simulation technology, patient safety, and global efforts to save lives of mothers and newborns in the developing world are too numerous to mention in this limited space. Here are highlights of Mr Laerdal’s most outstanding accomplishments. • Since the late 1990s and 2000s, Mr Laerdal’s focus shifted from defibrillator access and technology to education of healthcare providers through patient simulation. Laerdal Medical has introduced developments in both hardware and software that have changed educational methodologies. He is responsible for the shift in the simulator industry to include appropriate human models for neonatal and pediatric populations. Through partnership with the AAP, he is responsible for development of SimNewB®, SimJunior®, SimplyNRP®, and the new MicroSimulation platform. • Recognizing that learning technologies are effective only when integrated within delivery of validated educational programs, Mr Laerdal has fostered partnerships with the American Heart Association and the National League for Nursing. He also provided educational curriculum to support nursing, medicine, EMS, military, and voluntary organizations. • In the past 20 years, the Laerdal Foundation has provided funding to nearly 2,000 projects to advance resuscitation science, educational science, and good will initiatives. • In 2007, Mr Laerdal was influenced by the NRP Steering Committee’s vision of a neonatal resuscitation curriculum for low resource settings. The Laerdal Foundation provided the AAP with $600,000 in startup funds, along with the services of an educational designer and medical illustrator, to develop materials that would become Helping Babies Breathe (HBB) www.helpingbabiesbreathe.org.

f you have ever attended an AAP National Convention and Exhibition or a major simulation technology conference, you may have run into Tore Laerdal at the Laerdal Medical booth in the exhibition hall. Mr Laerdal enjoys chatting with conference attendees and exchanging ideas about professional education and simulation science. You may not have known that you were in the company of the Chairman of Laerdal Medical, a Norwegian family-owned company started by Asmund S. Laerdal in the 1940s and directed by Tore Laerdal, his son, for more than 30 years. The Laerdal Company in Stavanger, Norway began by making children’s books and wooden toys in the 1940s. The company’s toy doll “Anne” was the first doll in Europe made of soft PVC with natural stitched hair, soft unbreakable parts, and sleeping eyes. At that time, no one could have imagined where the Anne doll would lead the Laerdal Company in its mission, which is “Helping Save Lives.” When Tore Laerdal was 2 years old, his father saved him from drowning. This experience, combined with new late 1950s techniques in CPR, led the senior Mr Laerdal to develop a life-size doll for training in mouth-to-mouth breathing. Resusci Anne was the first in the Laerdal family of manikins that have since been used to train several hundred million people around the world in CPR techniques. Since the 1960s,

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“IN THE PAST 20 YEARS, THE LAERDAL FOUNDATION HAS DONATED OVER $120 MILLION TO ADVANCE RESUSCITATION SCIENCE, EDUCATIONAL SCIENCE, AND GOOD WILL INITIATIVES.”

• Mr Laerdal spearheaded a team of engineers to develop an affordable and portable neonatal simulator to complement HBB (The NeoNatalie Newborn Simulator). NeoNatalie includes 3 squeeze bulbs to simulate crying, breathing, and umbilical pulse. It is now available on a not-for-profit basis to Millennium Development Goal countries through Laerdal Global Health. • Concerned with risk of infection due to reuse and poor cleaning of suction devices in low resource settings, Mr Laerdal worked with engineers to develop a suction unit known as the NeoNatalie “Penguin” suction device (www.laerdal.com/us/doc/2244/Penguin-Suction-Device) which is made in one piece of silicone that can be boiled or autoclaved and withstands hundreds of uses. This device was recognized by the World Health Organization as one of 20 breakthrough innovative technologies to help advance the United Nation’s Millennium Development Goals (MDG) to reduce child and maternal mortality. Read about the MDG 4 and 5 at www.unmillenniumproject.org/goals/gti.htm. • Mr Laerdal’s commitment to HBB led to the signing of the landmark HBB Global Development Alliance (GDA) between USAID, AAP, NICHD, Save the Children, and Laerdal Medical. The tremendous scale up efforts and momentum within 18 months by GDA partners were recognized in 2011 as GDA of the Year. Three years after the GDA launch in 2010, Helping Babies Breathe has been introduced in more than 60 countries and aims at training 1 million birth attendants by the end of 2015. Close to 50,000 NeoNatalie simulators and 150,000 Penguin suction devices are now in use in low resource settings. • At the launch of the Saving Lives at Birth initiative, Secretary of State Hillary Clinton stated that the U.S. Government had partnered with Laerdal to develop breakthrough innovation in newborn resuscitation. • As part of HBB scale up efforts in Tanzania, Mr Laerdal provided country-level support to coordinate a 2-year outcomes study. The results, published in Pediatrics® in February 2013, define the success of the collaboration between the AAP and Laerdal. After introduction of HBB, the percentage of fresh-stillborns decreased by 24% and infant mortality in the first 24 hours of life decreased by an astounding 47%.

• Mr Laerdal, concerned about maternal postpartum hemorrhage, developed the MamaNatalie simulator to train birth attendants about intrapartum care, postpartum hemorrhage, and effective communication. MamaNatalie received a 2011 EMS World Innovation Award. Read more at www.emsworld.com/article/10445661/2011-ems-worldinnovation-awards?page=5. • The Laerdal Foundation funded the development of Helping Mother’s Survive (HMS), currently being piloted by Jhpiego, an international, non-profit health organization affiliated with The Johns Hopkins University that develops strategies to help countries care for themselves by training competent health care workers, strengthening health systems, and improving delivery of care. www.jhpiego.org • The Laerdal Foundation has earmarked $10 million for United Nation’s MDG 4 and 5 projects over the next 5 years. Read more at www.laerdalfoundation.org/ developing_countries.html. • In September 2013, Laerdal Global Health received the Index Award (BODY Category) for its Natalie Collection (NeoNatalie, Penguin Suction device, and MamaNatalie contained in a backpack). The Index Awards are recognized as the most important design awards in the world, for designing “sustainable solutions for global challenges.” Laerdal donated the large cash prize to the International Confederation of Midwives (ICM) to support distribution of Helping Mothers Survive and Helping Babies Breathe among its members in developing countries. Read more about the Index Awards at www.designtoimprovelife. dk/trio-of-life-saving-devices-reduce-childbirth-mortality. Tore Laerdal is a worthy recipient of the honorary AAP Fellow title. The American Academy of Pediatrics is privileged and fortunate to have such a friend and advocate in Mr Tore Laerdal.

N R P I N STR U C TOR UPDAT E

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2014 NRP Research Grant and Young Investigator Award Call for Applications
®

Welcome and Farewell
The NRP Steering Committee is in the midst of a very exciting transition as it plans and develops the next generation of NRP materials. In July, the transition continued as the committee welcomed a new cochair and general member and celebrated the achievements of those who rotated off the committee. The NRP and AAP welcome these new members and applaud those leaving for their efforts, commitment, and dedication.

! ing Soon m o C

The America Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) Steering Committee is pleased to announce the upcoming availability of the 2014 NRP Research Grant and Young Investigator Awards. The awards are designed to support basic science, clinical, or epidemiological research pertaining to the broad area of neonatal resuscitation.

Steven Ringer, MD, PhD, FAAP

Physicians in training or individuals within four years of completing fellowship training are eligible to apply for up to $15,000 through the NRP Young Investigator Award. Any health care professional with an interest in neonatal resuscitation can submit a proposal for up to $50,000 through the NRP Research Grant Program. Grants are currently available to fund research projects in the United States and Canada. The NRP Steering Committee is particularly interested in the following research and pilot programs: • Effective delivery of ventilation • Use of oxygen • Chest compressions in the newborn • Optimization of NRP education For more details, please review: Perlman J, Kattwinkel J, Wyllie J, Guinsburg R, Velaphi S. Neonatal resuscitation: in pursuit of evidence gaps in knowledge. Resuscitation. May 2012; 83(5):545-550 The NRP Research Grant and Young Investigator Award Program Guidelines and Intent for Application will be available in January 2014. To obtain a copy of the guidelines, a list of potential research topics, or a list of previously funded studies, please visit the NRP website at www.aap.org/nrp and select the “Science” tab.

Over the years, Jane E. McGowan, MD, FAAP has watched many people come and go from the NRP Steering Committee. In July, it was her turn to step aside as her tenure came to end after serving 10 years on the committee, first as a member and then for the last four years as a committee cochair. “During the 10 years I spent as a member of the NRP Steering Committee, I had the privilege of working with many very talented individuals who were truly dedicated to improving outcomes for newborns throughout the world. As a group, we have embraced innovative educational methodologies and, more importantly, have never been afraid to change the paradigm if we thought it would be best for the babies. I know of no other long-standing committees that were as willing as the members of the NRPSC to make major program changes when deemed necessary. I will always be grateful to Dr. David Boyle for inviting me to join the committee, and am honored to have been able to contribute to the committee’s progress. I hope to continue my participation in NRP activities throughout my career.” Taking the cochair reins from Dr McGowan is Steven Ringer, MD, PhD, FAAP. Dr Ringer, Assistant Professor of Pediatrics at Harvard Medical School and editor of the NRP Online Examination is making the transition from committee member to cochair. He is overseeing the ongoing revisions for the NRP Online Examination and actively involved in the NRP Strategic Plan to further science and research. “It is a great honor to serve with Myra Wyckoff, MD, FAAP as cochair of NRP Steering Committee! Beyond our responsibility to the babies, I am proud of the committee’s deep sense of responsibility to the instructors who work hard to ensure that the principles and evidence behind NRP are brought to the learners. I look forward to continuing the long tradition of ensuring that NRP Steering Committee members are available and responsive to your needs and ideas,” said Dr Ringer. Marya Strand, MD, MS, FAAP joined the Committee to fill the general member vacancy left by Dr Ringer. Dr Strand is an Associate Professor of Clinical Pediatrics at Saint Louis University. She also serves as the Director of the Simulation-based Medical Education Program at Saint Louis University. Dr Strand is very excited to join the NRP Steering Committee, “I have had an opportunity to work with some of the members through the International Liaison Committee on Resuscitation (ILCOR) Neonatal Task Force and admire the dedicated work that the Steering Committee does. My clinical interests are in neonatal resuscitation as well as educational methods for teaching residents, fellows and resuscitation teams, so the NRP Steering Committee is a great fit with my interests. I hope to contribute to the work of the Committee and help continue the great progress in education that NRP is providing to medical providers.”

NRP Online Examination Reminder
®

As a reminder, all Hospital-based Instructors and Regional Trainers are required to complete the NRP online examination every 2 years, based on their renewal date. However, instructors do not need to wait until just before their renewal date to take the online examination. The exam will be provided at no charge to instructors once per calendar year. NRP instructors can take the online examination at any time during their 2 year instructor status period by going to the NRP homepage www2.aap.org/nrp and clicking on “NRP Online Exam” and following the instructions for NRP instructors. Not sure if you’ve already taken the Online Examination during your 2 year instructor period? Go to the NRP homepage, click on “NRP Course Database” and enter your ID and password. Then click on “Update Information” to see the expiration date of your NRP Instructor period and the date of the last time your passed the NRP Online Examination.

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