Division Chief, Neonatology The Barbara Bush Children's Hospital at Maine Medical Center Portland, Maine, United States
Background: Neonatal resuscitation is a high acuity, low-occurrence (HALO) event. Clinicians in rural community hospitals lack regular opportunities to maintain Neonatal Resuscitation Program (NRP®) skills due to low birth volumes. Data used for this analysis was provided from the Northern New England Regional Hypothermia Database of neonates receiving therapeutic hypothermia at three northern New England tertiary care centers. We investigated differences in resuscitative practices in hospitals with varied birth volumes. Objective: We aimed to determine if resuscitations in lower birth volume hospitals are associated with delayed airway placement and increased frequency of chest compressions compared to resuscitations in tertiary care centers. Design/Methods: Variables were stratified by average birth volume of delivery hospital into three groups: small ( < 500 births per year), medium (501-1500 births per year) and large (>1500 births per year). Group differences were assessed by Fisher's Exact Tests for sparse categorical variables, chi-square tests for non-sparse categorical variables, Wilcoxon Rank Sum tests for continuous variables, and Cochran-Armitage trend tests for ordinal variables. Results: We included data from 352 neonates born between 2009 and 2023, including 103, 130, and 224 born at hospitals with small, medium, and large delivery volumes, respectively. The majority of the babies represented term babies (89%), predominantly male representation (58%), with the majority having moderate encephalopathy (90%). Neonates resuscitated in small and medium hospitals received chest compressions more frequently than in large hospitals (29%, 24%, 12% respectively) p< 0.015. In small and medium hospitals, placing an advanced airway took over twice as long as compared to large hospitals (7, 9 and 3 minutes respectively), p< 0.001, and were more likely to perform laryngeal mask airway (LMA) placement.
Conclusion(s): Neonates born in hospitals with lower birth volumes were more likely to receive chest compressions and have delayed airway placement as compared to larger volume hospitals. With NRP’s focus on effective ventilation and importance of advanced airway placement, the results are concerning and may represent more familiarity with pediatric and adult resuscitation, which focus on chest compressions. Increased outreach interventions to lower delivery volume hospitals, such as interprofessional education focused on airway management, including effective bag-mask ventilation and LMA placement training aimed at supporting resuscitations in smaller hospitals, are urgently needed.
