Simulation and educationThe accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: Implications for delivery of care, training and technology design☆
Introduction
According to the current guidelines of the Neonatal Resuscitation Program (NRP) based on the consensus on science published by the International Liaison Committee on Resuscitation, a newborn's heart rate (HR) may be determined by either listening to the precordium with a stethoscope or feeling pulsations at the base of the umbilical cord.1, 2, 3 Interventions are either administered or withheld based upon the numeric HR value determined by the healthcare professionals (HCPs) at the bedside. There exist defined HR cut-offs (100 beats per minute [BPM], 60 BPM) below which certain interventions (positive pressure ventilation [PPV], chest compressions [CC], epinephrine administration) are recommended; failure to do so may result in cardiac arrest and death. Similarly, underestimation of the true HR and inappropriately applied interventions may also result in harm. Thus if HR is not accurately determined, certain therapeutic interventions may be inappropriately withheld or administered, potentially resulting in serious injury or death.
This study sought to determine the accuracy of auscultation of the precordium (with a stethoscope) and palpation of the umbilical cord in the detection of HR during simulated neonatal resuscitation. To provide appropriate clinical context, the frequency of errors of omission (failure to perform appropriate interventions) and errors of commission (performance of inappropriate interventions) was also assessed. Using a neonatal patient simulator capable of generating a HR that is fixed in rate, volume, tone and location, and umbilical cord pulsations that are fixed in frequency, amplitude and location, we hypothesized that: (1) the detection of HR by auscultation or palpation will vary by more than ±15 BPM from actual HR, and (2) the inability to accurately determine HR will be associated with errors of omission and/or commission.
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Study population
Residents in general pediatrics, fellows in neonatal–perinatal medicine, attending physicians in neonatology, hospitalists, neonatal nurse practitioners and neonatal nurses (all of whom attend deliveries at Lucile Packard Children's Hospital and hold current NRP Provider status) were recruited via electronic mail and asked to participate in a study of techniques in neonatal resuscitation. Informed written consent was obtained from all subjects. This study was approved by the Institutional
Results
A total of 64 subjects were recruited for participation in the study: 22 residents, 7 fellows, 9 attending physicians, 9 hospitalists, 7 nurse practitioners, and 10 nurses. Thirty-three subjects were randomized to auscultation and 31 to palpation. Errors in HR determination were frequent, ranging from 26% to 52% (Table 2). There was no statistically significant difference in accuracy between the pre- and post-intervention assessments of HR when compared by technique (auscultation, palpation) or
Discussion
Heart rate is the best indicator of the response of a neonate to resuscitative efforts and accurate assessment of HR is the key to making the right decisions during neonatal resuscitation. Unfortunately numerous aspects of resuscitation make it a difficult aspect of clinical medicine to study in an objective manner. By controlling the number of environmental variables and eliminating the risk to actual human patients simulation allows the investigation of issues that are difficult to study in
Conclusion
Using a highly standardized simulated clinical environment, this study demonstrates that experienced HCPs trained in NRP are unable to accurately determine HR on a consistent basis during simulated neonatal resuscitation whether using auscultation or palpation. This inability was associated with numerous errors of omission and commission that, if they were to be replicated in the real environment during the care of actual newborns, are capable of producing patient harm. Optimal human
Funding
This work was sponsored in part by the Endowment for the Center for Advanced Pediatric and Perinatal Education at Packard Children's Hospital at Stanford. This had no role in the study design, collection, analysis or interpretation of data, writing of the manuscript or in the decision to submit the manuscript for publication.
Conflict of interest statement
Dr. Halamek is a consultant to Laerdal Medical, Inc. There are no conflicts of interest to report.
References (9)
- et al.
Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
Resuscitation
(2010) - et al.
Determination of heart rate in the baby at birth
Resuscitation
(2004) - et al.
Accuracy of clinical assessment of infant heart rate in the delivery room
Resuscitation
(2006) - et al.
A randomised, simulated study assessing auscultation of heart rate at birth
Resuscitation
(2010)
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2012.07.035.