Using Simulation to Improve Outcomes During Prehospital Neonatal Resuscitation

Most live births proceed without difficulty, but up to 10% will need aggressive interventions, including assistance with breathing[1]. While out-of-hospital deliveries are rare in the United States, this low-frequency, high-risk scenario can present EMS providers with specific challenges. Recent studies have shown that they often lack training and practice opportunities in neonatal resuscitation techniques [2]. As such, simulation can be a useful learning modality to train and enhance EMS providers’ skillsets in neonatal resuscitation and ensure newborns receive safe and effective care.

Many EMS providers lack training in neonatal resuscitation protocols

A study published in the July 2020 issue of Pediatrics found that providers lacked knowledge of and practice in neonatal resuscitation protocols (NRP). The study found that EMS providers rarely performed basic protocols like drying, warming, and stimulating within the first 30 seconds after birth, as recommended by NRP guidelines. They also often supplemented respiration at a rate too slow to provide adequate neonatal resuscitation[3].

Timing is key to a positive outcome for an infant born in the prehospital setting. Providers have about a minute after birth to evaluate and stimulate the newborn and begin interventions if they are not breathing[4]. However, since neonatal resuscitation happens so infrequently outside of a hospital, EMS providers do not normally have the opportunity to practice these skills. As a result, appropriate care can be delayed and cause poor outcomes for the patient.

NRP training is often overlooked in many EMS education programs

Furthermore, 66% of EMS providers report that they had never received NRP training or that their last training was over two years ago3. Skills and knowledge deteriorate if they are not utilized frequently, so providers fall back on skills they use most often in the field. For example, they will use adult resuscitation protocols like ACLS on newborns despite their different physiology[5].

Therefore, EMS programs must include neonatal training in their curriculum and offer skill refresher training periodically. Since providers have limited exposure to newborns in the field, simulation-based training can help to fill that gap and give them valuable experiences. Likewise, providers can practice and gain proficiency in neonatal resuscitation, so vital actions are not missed when a real emergency event occurs. 

Utilizing simulation to teach and help retain newborn resuscitation skills 

Research has shown that simulation-based training is a useful tool to increase skill retention and prevent skill decay[6]. Therefore, incorporating periodic training on newborn simulators can help EMS programs teach NRP and allow providers to rehearse these skills in a safe environment, so they do not decay from a lack of practice. Thus, EMS providers will be ready to perform neonatal resuscitation whenever these rare cases occur.

Just as nursing and medical programs struggle to provide relevant clinical experiences, EMS programs face similar challenges. Besides, it would be unethical for an inexperienced provider to treat a newborn patient. However, without exposure to newborn and school-aged patients, EMS providers do not have an opportunity to practice and develop the specific skills needed to treat those patients.

In response, the National Association of EMS Educators (NAEMSE) released a Vision Paper supporting replacing some clinical hours with time spent working on simulators. The paper argues that simulation allows learners to gain experience providing care for various clinical scenarios in newborn patients.

For example, cases involving neonatal resuscitation are high-stress and require quick action from providers. Simulated scenarios can recreate the stress and demands of real emergencies, so learners respond as they would in the field. As they repeatedly rehearse on the simulator, learners become familiar with newborn physiology, develop routines, and practice safe behaviors, thereby improving their decision-making skills and response time. 

Moreover, EMS educators can integrate patient safety and teamwork goals into scenarios. This ensures that learners incorporate and practice these specific skills during the simulation. When a mistake is made, educators can review the scenario with the learners and provide feedback. As they learn from their mistakes and continue to practice, those safety and teamwork principles become ingrained in the learner.    

The study by Huynh et al. (2020) may have found a lack of training in neonatal resuscitation among EMS providers, but simulation can help close knowledge and training gaps. EMS educators can address this deficiency by incorporating simulation into their programs, ensuring providers know how to better respond to neonatal emergencies.      

To learn more about Gaumard or any of our newborn patient simulators, please click on the links.

[1] Aziz, Khalid, et al. “Part 13: Neonatal Resuscitation 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” Circulation, Accessed 28 Sept. 2020.

[2] “Study identifies challenges to neonatal resuscitation outside of hospitals.” Medical Xpress, 25 Oct. 2019,

[3] Huynh, Trang, et al. “When Seconds Matter: Neonatal Resuscitation in the Prehospital Setting.” Pediatrics, vol. 146, no. 1, 2020.

[4] Tomek, Scott. “Newborn Resuscitation: The Golden Minute.” EMS World, Accessed 17 Sept. 2020.

[5] Duby, Rebecca, et al. “Safety Events in High Risk Prehospital Neonatal Calls.” Prehospital Emergency Care, vol. 22, no. 1, 2017, pp. 34-40.

[6] Ades, Anne, et al. “Acquiring and Maintaining Technical Skills Using Simulation: Initial, Maintenance, Booster, and Refresher Training.” Cureus, vol. 11, no. 9, 2019, pp. 1-8.

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