Five serious incidents were identified in 2006 in JHH delivery and operating suites regarding the resuscitation of newborn babies. These incidents involved babies requiring extensive, active resuscitation where system issues were a cause in the adverse outcome. Anecdotal evidence indicated there were multiple complex issues surrounding resuscitation success. Communication was highlighted as critical to all events. The five incidents were an under-representation of adverse events, as reporting of these issues was a relatively new concept for staff. Prior to 2006 no critical events were reported concerning neonatal resuscitation.

Families are also present in these stressful circumstances and it is important to recognize the parents’ perception regarding their baby’s resuscitation, their observations of competence and communication and their understanding of how this may have impacted on the outcome for their baby.

Although the higher number of critical incidents may be influenced by an increased birth rate, causation had to be identified by RCA.

In 2006 JHH / JHCH had five critical incidents related to neonatal resuscitation that required an RCA. (Figure 1.)

Figure 1. Initial response and escalation related to neonatal resuscitation.

In 2005, JHH had the greatest percentage of births in NSW with Apgar* score < = 4, indicating the need for resuscitation (Figure 2.)

• The Apgar score test quickly evaluates a newborn's physical condition after delivery and determine any immediate need for extra medical or emergency care. Scores obtainable are between 10 and 0, with 10 being the highest possible score

Figure 2. Percentage of births with an Apgar score < = 4, in NSW Hospitals.

 The increased number and percentage of births with Apgar < = 4 is accompanied by an increased birth rate. (Figure 3.)

Figure 3. Total births at John Hunter Hospital delivery suite 2000 - 2007.

The RCA team represented neonatal medicine, nursing, obstetric, midwifery, consumer representative, patient safety and anesthesia.

The RCA process involved the team reviewing events based on the medical record and interviewing staff who had been involved in the incidents to obtain additional information, gauge their perspective on events and any suggestions for improvement or prevention that they might offer. Team members undertook a review of processes regarding resuscitation including equipment and communication processes. The RCA team established the chronology of events and determined what actions or inactions related to the incidents could be considered root causes, contributing factors or system issues. There was a review of “best evidence based practice” including policy, procedure and relevant guidelines.

The contributing factors and recommendations to address them are shown in Table 1. Staff responsible for implementation of the recommendations were consulted in their development. Senior managers were approached to provide support and endorse the recommendations.

Table 1.

All trolleys have been standardized and introduced with an education program for all staff. The flow chart and description of the equipment to be stocked on each trolley is being distributed to all appropriate HNE Health facilities. Feedback to staff is facilitated by forums, providing information about incidents and the improvements in processes.
Staff orientation continues to promote understanding of the multidisciplinary nature of neonatal resuscitation and consideration of the parent’s perspective. Complaints and compliments concerning neonatal patients and family will continue to be monitored.

Staff members from HNE Health are active in the development of NSW guidelines. The flip-chart, will be reviewed as ARC guidelines are developed.

• ABS, 2006. Media Release: ABS: Australian fertility rate highest in 10 years 
• NSW Health, 2005, Children – Clinical Care/ Resuscitation / Newly Born Infant - AHS Development of Policy/procedures
• NSW Health, 2004, Chief Health Officers Report: Pregnancy and the newborn period - Neonatal morbidity
• American academy of Pediatrics/ American Heart Association, 2000, International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science.  Pediatrics Vol. 106, No. 3 September 2000; e29
• Center for Epidemiology and Research NSW Department of  Health, 2007, NSW Mothers and Babies 2005, NSW Public Health Bulletin 2007; Vol. 18(S-1)

Co-Authors

• Janet Wallace, Patient Safety Officer, Clinical Governance, Hunter New England Health
• Marianne Knox, Clinical Midwife Specialist , Delivery Suite, John Hunter Hospital
• Dr Paul Craven, Neonatologist, John Hunter Children’s Hospital

Team members

RCA 300

• Janet Wallace, Patient Safety Officer, Clinical Governance Unit
• Mark Amey, Clinical Nurse Specialist, NICU, John Hunter Children’s Hospital
• Dr Vishal Kapoor, Registrar, NICU, John Hunter Children’s Hospital
• Carol Chapman (consumer representative)
• Dr Andrea Walker, Staff Specialist, Obstetrics and Gynaecology, John Hunter Hospital
• Marianne Knox, Clinical Midwife Specialist, Delivery Suite, John Hunter Hospital
• Patrick Farrell, Director of Anaesthesia, John Hunter Hospital

RCA 390

• Janet Wallace, Patient Safety Officer, Clinical Governance Unit
• Dr Nandini Somanathan, Staff Specialist, Obstetrics and Gynaecology, John Hunter Hospital
• Jackie Allabyrne, Clinical Midwife Consultant, High Risk Pregnancies
• Dr Paul Craven, Neonatologist, John Hunter Children’s Hospital
• Carol Chapman, Consumer Representative,  Obstetrics and Gynaecology, John Hunter Hospital

NICU / delivery suite communication strategy for neonatal resus - working party

• Janet Wallace, Patient Safety Officer, Clinical Governance Unit
• Denise Kinross, Clinical Nurse Consultant Newborn Services, John Hunter Children's Hospital
• Shirley Graham, Nurse Unit Manager, NICU
• Dr Paul Craven, Neonatologist, John Hunter Children’s Hospital
• Sue Kuter, Midwifery Unit Manager, Delivery Suite, John Hunter Hospital
• Marie Mannion, Nurse Unit Manager, NICU

Acting Area Quality Manager, Clinical Governance
Hunter New England Area Health Service
Phone: 02 6767 7233