Transitioning from NRP to a combined PALS-NRP resuscitation model at a level IV NICU

Neonates admitted to a level IV neonatal intensive care unit (NICU) frequently have complex medical conditions and require prolonged stays beyond 28 days of age. Given the acuity of medical problems and surgeries required, these neonates are at risk for cardiopulmonary events necessitating resuscitation. Two universally accepted programs address these issues - neonatal resuscitation program (NRP) which concentrates on delivery room resuscitation and pediatric advanced life support program (PALS) which focuses on a broader range of cardiopulmonary events^{1, 2}. Over the past ten years, there have been several questions, discussions, and surveys evaluating the best form of resuscitation for neonates outside of the delivery room. In most NICUs, neonates receive NRP until they are discharged from the NICU³. In contrast, if a neonate is transferred to the PICU, they are likely to receive PALS, regardless of their age. Given the increasing population of older, chronic infants present in our level IV NICU, we sought to design and implement a new resuscitation guideline incorporating PALS and NRP for cardiopulmonary events at the University of Wisconsin and UWHealth Kids American Family Children’s Hospital. Our study design did not address improvement in patient care or value of the intervention.

In April 2018, a new resuscitation guideline was developed by a multidisciplinary group and accepted at our neonatal quality improvement guideline meeting in July 2018. From August 2018-March 2019 all neonatologists, fellows, and neonatal nurse practitioners (NNPs) underwent PALS training (respiratory therapists were already certified in both PALS and NRP). Only registered nurse (RN) care team leaders underwent PALS training. A separate ‘Mini PALS course’ was presented to all RNs during their annual education series and they completed a 5-minute hands-on bedside simulation. A bedside resuscitation indicator was developed by the nursing staff and PALS cards were placed in every patient room. The new resuscitation guideline went live on April 1, 2019 (Figure 1a). Utilization of PALS for infants was based on the following criteria: >44 weeks post menstrual age (PMA), previous non-PDA cardiac surgery or intervention, or obvious identified cardiac arrhythmia. Each week, the care team leader identified which patients qualified for PALS and ensured appropriate signage was posted in each patient’s room.

Figure 1:

Panel A shows our combined PALS and NRP guideline we developed. Panel B shows the number of patient days from 2019-2021 divided into who qualified for PALS vs. NRP.

Abbreviations: Pt = Patient.

There have been 13,450 patient days since our PALS/NRP algorithm go-live. Figure 1b displays the number of patient days by year divided by how many infants qualified for PALS or NRP based on our guideline. Overall, 28.9% of patient days have qualified for PALS versus 71.1% for NRP. During this time, there have been six documented codes (defined as requiring chest compressions), five of which qualified for NRP and one for PALS. The mean average gestational age at birth was 32 5/7 weeks while the mean corrected gestational age at the time of the code was 37 2/7 weeks. All of these were initially respiratory in origin and 5 of the 7 required either intubation, re-intubation, or a tracheostomy change. Only 3 of the 7 required epinephrine and 2 of the 7 were considered extensive lasting over 20 minutes and requiring boluses of calcium, saline and/or packed red blood cells. In addition to the codes, there were ten patients treated for arrhythmias (7 supraventricular tachycardia, 1 atrial flutter, 1 Wolf-Parkinson White, 1 ventricular tachycardia). Of these 10 patients, 4 had underlying cardiac disease and two with previous cardiac surgery. The majority were treated with medications though 2 patients required cardioversion.

Initially, both neonatologists and NNPs shared concerns about the need to learn an additional resuscitation program while maintaining their NRP status. These concerns were primarily focused on the time commitment – an initial two-day certification followed by biannual one day re-certification. This sentiment is in line with previous survey data showing that only 37% of neonatologists maintain PALS certification compared to >98% having NRP certification⁴. This survey also noted that 50% of neonatologists felt slightly to very uncomfortable delivering neonatal defibrillation or cardioversion. Similar concerns were expressed amongst our providers, but with the desire to improve skills related to arrhythmias, defibrillation, and cardioversion, our group agreed to complete PALS training. Now three years into the program, all neonatologists, NNPs, fellows, and RN care team leaders have maintained both PALS and NRP certification. Given the lack of published evidence for PALS utilization in the NICU and associated costs, hospital administration has been reluctant to support training for the remaining nursing staff. Considering these constraints, we continue to provide staff with a modified PALS course presentation and hands-on bedside simulation training which have proven valuable. A new quarterly mock code program will be used to re-educate staff on the guideline and both NRP and PALS skills.

In summary, we have effectively introduced a new resuscitation guideline combining both PALS and NRP resuscitation at a level IV NICU. Given the consistent trend of 30% of annual patient days qualifying for PALS based on our guideline, it seems the chosen criteria were indeed appropriate. While most codes in the NICU require NRP, our data indicates PALS knowledge was needed to treat a significant number of arrhythmias further supporting the need for PALS training. Given the high likelihood that level IV NICUs will continue to care for older babies and those with a history of congenital heart defects or arrhythmias, our NRP/PALS resuscitation algorithm could prove beneficial. Therefore, similar to previous publications, we believe it is advantageous for providers working in a level IV NICU to have PALS certification⁵.