Saving Newborn Lives: Inside the Neonatal Advanced Life Support Program

Hello, good afternoon to folks on the East Coast and good morning to those on the West Coast. I'm so glad to have you here today. I am Marie Manning. I work in marketing communications within the training services division of the Red Cross. We are here today to discuss the Red Cross Neonatal Advanced Resuscitation Program, excuse me, Neonatal Advanced Life Support Program. and we launched it a year ago. I have two guests today. I'll let them introduce themselves in a minute, but I'd like to start by seeing where folks are coming from. I am coming in from Washington, D.C. We don't have any snow, although we still have mounds left over from our big storm in January, and I hope that's not the same for you. So with that said, our two guests are Jonathan Epstein, who is a paramedic, and Julie Bacon, who is a chief flight nurse. And we're here today to talk about the program that both played big roles in developing. So, Julie, I'm going to kick it off to you. Well, good morning, afternoon from balmy, sunny, 77 degrees, St. Petersburg, Florida.

So, I love the sun and we love the people that come down and enjoy it with us. Excellent. And Jonathan? And again, good afternoon and good morning to everyone. Again, Jonathan Epstein came from the Boston area where we got snow yesterday and last night, Julie. So, we're just living the dream. Okay. Well, I know both of you were involved in creating this program, putting it together. Julie, you have a specialty in neonates. Jonathan, you are my go-to for all things healthcare. And let's get started, shall we? So, let's first set the stage for our viewers here. For those who are maybe hearing about it for the first time, what is NOWS? What is Neonatal Advanced Life Support? And can you walk through a little, just give us a taste as to why the Red Cross developed this program? Sure, Marie, and Julie, jump in if you want to along the way, but neonatal advanced life support is really a resuscitation-based program training clinicians, both nurses, physicians, nurse practitioners, paramedics, midwives, certified midwives, licensed midwives, doulas and others of how to care and resuscitate a newborn. So, this course is really focusing on newborn resuscitation predominantly, although the course is broad. It is built around an audience for both in the hospital, so if you're working in a labor delivery unit, an emergency department, or in the NICU, but also actually what's special about NALS is that the course broadened from what was the traditional training to allow for audiences outside those traditional areas. So, think about a newborn born in a home setting, EMS is arriving and EMS having to care for that newborn. in a birthing center potentially, or somewhere else that's outside that traditional location. So even an emergency department, while we think ERs are part of hospitals, they're not really the traditional place where babies are born every day. So, we wanted to look at the resuscitation of a newborn where that happens. And I think Julie says this best, the delivery room is where the baby is born, not a location in the hospital. So, this course is really broad to care for that newborn that needs resuscitation. So now, Julie, if you want to jump in and talk, you do such a great job talking about the percentages of who needs resuscitation.

Well, you know, you said it so well as far as this broad scope of what NALS is. And I have been doing neonatal flight nursing for almost 35 years. And I have been certified in resuscitating those neonates for 35 years and also recognizing that there was a gap. So as we as I was approached a few years ago to say, we really want to take this high-level science that's out there, that's available. But, you know, high level science isn't great unless you can grab it, get the knowledge and present it to the people that are on the front lines. So we have recognized for years that there is a gap. So I was so excited about the fact that we were not only going to be addressing the traditional audience, the NICU nurse, the flight nurse, the physician in the neonatal ICU, but anyone who is in the position of having to resuscitate a newborn, of which we know stats say about 10% across the board of all newborns need some degree of resuscitation. We believe, and we're starting to look into, that's probably higher outside of the traditional OB labor and delivery setting. So this is truly a big step that's been needed.

So just tell me, why is it that neonates and newborns need this type of resuscitation? It has something to do with the development process, right? And the development of their lungs? It does. And I love this part. Well, you know, we've heard for years, and I'm sure that there are folks online, primarily medical, that we have heard for years and years, kids are not just little adults. Well, I'm going to take that one step further. Newborns are neither. They're their own little mutant population that need to be addressed specifically. And if we do it wrong, we've missed the boat. We have a short time period. to do very critical interventions that quite frankly are pretty easy and easy to teach to get out there that make a big difference. If you are a provider and you think about it, your neonatal, your newborn patient is the only patient you will ever take care of that has never taken a breath. ever in their lifetime. So, when you look at that and you, and you say, oh, well, I'm going to start doing chest compressions to what end you have to look at neonates as carving them out in their own little unique subsection over here. And we need to; we need to really reverse how we've been thinking about resuscitating our patients. And that's the biggest first message.

Yeah, I think Julie, when you, and when, you know, sorry, Marie, but when Julie talks about that, when you think about why we built NALS and from a Red Cross perspective, you know, we looked at one, some of these gaps, but also looked at kind of where education existed and where it didn't exist.

And when we talk about broadening that reach, now as a paramedic and someone's been teaching in health care environments, both hospital and EMS, but also working in the field in EMS for greater than 30 years, we really trained from a pediatric perspective with a PALS program, Pediatric Advanced Life Support program, which doesn't really address what Julie just talked about from a neonatal perspective. is actually flipping the switch in our brains from a skills perspective of what to do first and really focus on ventilation, ventilation, ventilation. And that is a real role reversal from how we're taught and how we think of other resuscitation courses, compression, compression, compression. And we have to kind of flip that around, especially for these audiences that are seeing a higher case volume. More babies are being born out of the hospital, more babies being born in the home setting, home births, and in birthing centers as we have a national crisis growing around maternity care deserts, which I know Julie's going to talk about here in a moment. That's really why we built this program, to address those gaps, really get the education where it needs to be, and serve really all audiences with this program. All right. So let's talk about these maternity care deserts. And I believe Desli, our producer is going to put up a slide to illustrate them. But Julie, if you could go into this.

You know, the first time I really became aware, and I've done this for a very long time, but the first time I became aware of maternity care deserts is really when we started looking at NOWS. And I was already excited about the fact that we were bringing high-level science in a very clear, concise, presentable way to all of us neonatal ICU folks. But now when you take a look here, we assume, I assume that living where I do in Florida, in the US, that everyone has the same access to high level, high quality healthcare. And quite frankly, that's not so. The March of Dime has done a great job of putting together the stats. And basically somewhere between 35 and 40%, of all counties in the United States. And I know it's small, but if you look at it really quickly, look at those bright red ones, have maternity care deserts. This means that in that county, and first thing I do is I look to see where I live. And even in St. Petersburg, Florida, I have multiple counties in the state of Florida. Take a look at that Midwest there. That has such an impact on neonatal health on maternal health too, but on neonatal health, in that these counties have no maternity services available. That means no hospital with designated L&D services. That means no providers, no OBs, no nurse midwives. That means, okay, let's take it, no prenatal care. If you live in one of these counties, you have to go outside of your county. You have to seek out prenatal care. So what's happening to our prenatal care? It's going up, the lack of prenatal care. And the fact that if you're in that county and you go into labor and you have a community hospital nearby, you may go straight to that ER, even though they don't have labor and delivery services. You may call EMS to come to your house and deliver the baby. You may have that unplanned home birth. So now you've got complications with maternal. You have these babies, and I said the percentage a little earlier, we believe that in from the March of Dimes stats, about 150,000 births right now happen in these maternity care desert counties. Well, if you apply that 10%, that means 15,000 or so babies are born in counties without resources available that need resuscitation. And about 10,000 of those are preterm. So if we don't provide the resource, the information, the skills, the classes to those people in those places, and by the way, you'd think that once we recognize a problem, it gets better. It's not. the number is rising as we have realignment of healthcare systems and providers moving, this number isn't coming down. So in addition to providing high level scientific information to the traditional neonatal advanced life support audience, we are also bringing in the midwives, the birthing centers, the EMS, the community hospitals. So, You make a good point here. There is also, though, a split between there's a difference between someone who sees a newborn in a hospital setting and then someone who sees a newborn outside of the hospital setting just because of the equipment and the availability of the different personnel and the items that you need. to successfully resuscitate a newborn. So Jonathan, tell me a little bit about how the course addresses these two very different audiences. The course does have sections intended for pre-hospital versus in-hospital, yes? It does, Marie, and it's a great point. We were very specific about how we went to put NOWS together. And if you think of NOWS from a structural perspective, first, it's two courses. So there's a comprehensive level course and there's a foundational level course. That foundational level course is really for all those clinicians and providers that may be caring for a newborn. where there's additional help on the way. It's really about time. So it's really the foundational course is what are those critical first few minutes, all those things that need to happen. to get through the concept of positive pressure ventilation. It is pure ventilation of that newborn and getting that resuscitation started. Back to Julie's comment, this is their first breath or no breaths at all. How do we get them breathing on their own? So foundations is really about those first few minutes, those key critical recognition and preparation aspects. while you're waiting for other help to arrive. The comprehensive course is really for those that are going to be at a resuscitation of a newborn but are expected to be that advanced care. And so it's everything that Foundations has, but then on top of Foundations, we go through a very rich case-based environment to walk through situations and concepts around the broader resuscitation, including kind of that continued care in the hospital setting once a child would arrive post transport by EMS or transfer from the ED upstairs to the NICU or L&D to the NICU. So, it's a very broad program. Now, that's kind of the course perspective when we think about NALS, but it's also when we look at audience perspective, we recognize we have that traditional in-hospital perspective. So, we have an in-hospital track of our cases in the NALS program, and we have an out-of-hospital track, which is more geared for those pre-hospital. So, think of EMS, a lot of the home births, a lot of the midwives and the broad spectrum midwife professionals that are out there. really to focus on those scenarios that are something happening in a home, in a car, en route to the hospital. So, you really choose your, I don't say choose your adventure, but it is choose your discipline or choose your pathway of I'm an in-hospital traditional learner. I'm working in a NICU, working in an ICU, maybe an ED, or I'm an out-of-hospital person. I'm in an ambulance as the EMT or a paramedic, or I'm a midwife or someone in a birthing center. But also, it could just be I resonate with one audience more than the other of how you would choose that program. The material's identical from an actual perspective. care perspective. The treatment recommendations are the same. But if you look through, whether it be the robust participant manual and reference manuals that we have, the e-learning program really talks about, we understand what equipment you have. So if I'm in EMS, there's certain equipment that I don't have access to that Julie, as a chief flight nurse, is certainly working in a large hospital with a NICU, has access to like an oxygen blender, a radiant warmer. I don't have that in an ambulance. So how do I use what I have for these deliveries that are beyond the delivery room, how do I incorporate that equipment to maximize effectiveness and outcomes for that delivery? Okay. And so, you talked about case-based environments. That's exactly what you were saying. Like, am I, my case is X because I identify with that or, you know, I identify with this scenario and that's unique to the Red Cross, yes? I think it is fairly unique that we've kind of separated these out. I mean, I think there's a lot of case-based learning out there in a lot of scenarios, but we were very intentional to, one, look at the evidence and look at the medicine and the science and really clinically vet through these robust scenarios, which are more summative in nature. So, the comprehensive course is made up of the foundational program and plus that series of cases. And so they're setting you up for either you have arrived on scene to find or you're at a birthing center and this has happened versus I'm in the labor and delivery unit or the emergency department. So it's really just setting up the context for the learner because we know not just from a medical science perspective, from an educational science perspective, putting learners in the setting where they work every day where they practice every day where they perform every day is so important from a learning perspective so we're using the best of learning science and medical clinical science and kind of merge them together to give those robust cases and that kind of overview of how you would respond to that newborn.

Okay. And there are skills, Julie, you know, I know you've seen your share of births, but there are people who may not have who need to practice and put their skills in order. And so how does this course go from the didactic learning part to the skills testing part? That's a great question. And I think Val also just brought it up. in the chat there, there is that piece that's knowledge, right? You go online, it's a blended learning, it's a very robust program online itself, whether it's foundations or comprehensive, it starts from talking about the very unique anatomic and physiologic differences of a newborn because you need to understand people do better when they understand why they're doing right. So we want them to understand why it's so important. But to be honest, the first thing people tell me is, oh, these little things scare me and they throw up their hands. because you're afraid to touch them, right? They are little, they're fragile. We want them to touch. Now it may be a mannequin, but the second piece of that, the skills, what are the important skills? Ventilation, different types of ventilation that are out there. Certainly, compressions down the line, IV access, umbilical vein access. Those are things you can read about and you do in that first section of the course. But we focus totally for that last piece that's in person is really very much hands on and it's hands on multiple times. So depending on how many learners you have in the group, they're usually small groups, like three to six, you are going to go over skills multiple times, have a chance to bag valve mask with those tiny little ones multiple times, and then put it within a team scenario. And that's really important. And your team may look different. In the NICU, your team may be 200,000 people because everyone wants to come watch and you have to shoot people away. Or it may be the professional midwife who has one or two or the EMS that has one or two. What do these skills look like to you when you put them together? And that's where the scenarios come in. So by the time we finish that hands-on piece, the learner has had the opportunity to take that knowledge, to understand why we're doing the skills in the order that we are, and to ask questions, practice, and apply them in a team setting four, five, six times. And that's one of the things that I hear in feedback. And one of the things that I love as an instructor is to watch the first, can I use the term clunky-ish, uncomfortable, how do I do this, to watching teams work three hours later in the class as they've gone over and over again to say, this is how we put these steps together. This is what it's going to look like next time in the field. That is a great feeling. Just to come back to Julie's comment about this team dynamic piece, it is so critical. I know that Val, I think you had a question about other skills is just the Internet. Those hands-on skills when you're in the NALIS program, You're doing that online piece, spending that foundations or comprehensive piece, which is adaptive. So if you're a very experienced person, you've taken resuscitation programs before, you may get through that foundational content faster, the adaptive nature of the program. But once you finish that content, you come to the classroom, you're really going through a series of skill stations We're going to hone in on just practicing a piece by piece. We're just going to focus on a new piece of equipment, maybe the T-piece resuscitator, maybe an LMA, maybe an endotracheal tube or how to administer epinephrine, those skill sets. But it's that team-based environment and team practice scenarios, which is really a hallmark of the of all the Red Cross Association programs right now. And to broaden that contextual piece, and Maria, you'll always ask me about this anyway, so I'll beat you to the punch maybe, but this concept of the Red Cross around practices you perform, we really want to ensure that participants, clinicians, providers, when you're either in the classroom or what you're doing in the classroom mirrors what you'll do in the field. So Julie talked about, you may only have one or two EMS providers, or maybe you have a midwife and a paramedic that has responded to help the midwife at a birth where resuscitation is needed. We want you to practice with the equipment that you have within the protocol and scope of practice that you have with medical oversight and guardrails that are built into the program. But we really want people to practice with what they're going to do every day in the field or in the hospital, the same way in the classroom. So we take our team-based practice and really accommodate it or adapt it to what happens in your environment. So we're not teaching you one thing and say, forget what you learned. Now I want you to do it this way in the hospital. We want you to practice the same way you perform every single day. And those team-based scenarios are so critical for that.

They really are. And it's not, you know, the other thing, though, so you practice, you take your didactic, then you take your skills and you're practicing and you're trying to build that muscle memory. But sometimes, you know, like pilots who go through a checklist, you could do the same thing if you are in one of these situations now with the new resuscitation suite app. Because that does address now scenarios, yes? So tell us a little bit, Jonathan, about that. Yeah, so the Resuscitation Suite app from the Red Cross, and again, right now, for Red Cross learners, instructors, there's no cost for this app. It's an app that addresses both really four elements or four resuscitative programs. So basic life support, our advanced life support for adults, our pediatric, which is really all our kids, excluding the newborns, but it does have an entire now section. So it has a newborn section. This app, one, gives clinical guidance. So, it actually knows the algorithm. It knows the protocol. It knows the code cards. So, as you're going through a resuscitation, if you're in that data or recorder role, or you're working with the infant, it's going to have a timer. And if we know, well, you're supposed to ventilate for 30 seconds and adjust effectiveness. And chest isn't rising. If the timer is going to go off, what do I do next? It's going to tell you, reposition the airway or suction the airway. Eventually, when you put compressions and so the app is all the digital Red Cross reference material. But it's actually that clinical guidance that you bring into those team based scenarios, but also can bring to actually patient side actual resuscitation newborn. And it will guide you through the process of not just documenting, but actually giving you clinical guidance and clues. as you go through that resuscitation. And then ultimately that data can be actually extracted or downloaded and used as part of your record keeping. So, it's a really powerful app. And again, it's on the Android and iOS stores. And if you just look for resuscitation suite with the Red Cross logo, that's the app. And it's available for everyone today. So, I download it, look at it. You can practice with it. It's a fantastic resource that we want people to use in the classroom, but also use the patient care because we can't remember everything. I was a paramedic long ago. We were forced to remember everything. And we learned from the airline industry. that using checklists and using cognitive aids, and the app is just one of the new group of three or four cognitive aids the Red Cross has produced to assist you so we reduce medical error and improve outcome. You know, as you were talking about that, I think the term resource is so important here. And when I teach my classes, and by the way, Jonathan, I've been using those as we are teaching and saying, take a look at this. And it's such a great resource. And reminder, if you couldn't do algebra in the eighth grade, what makes us think we can do calculations of code drugs in the middle of an emergency, right? Use your resource. But secondly, it is a resource, just like you said with the pilots and Marie earlier, when I first got into this, it was super important to me that we have other resource, we have the book, we have that online training, but do you have a hands-on? Pilots go through, they have their checklist, they have their resources, they have their apps, but would you feel comfortable in an aircraft in which the pilot had never put hands even on a simulator? You would not. Where's that muscle memory? So I think when you put all of these things, the resources, the hands on the knowledge base together, that's what really made me. I said this. This is a quality product.

So I've heard. from a couple of EMS agencies that have taken this course. One of them actually put it into practice. They're right across the river from me in Maryland. And Julie, I imagine that you've seen some scenarios where this course has been put into practice itself. And I'm assuming you also have the app on your phone and have looked at it or possibly even referenced it. Tell me, what feedback have you got on this course? First off, absolutely. I reference it because again, you're never too old or too smart to need to use your resources, right? My feedback is that it has taken terrifying situation. This is not something that unless you are in a, an L and D a women's services scenario that you're going to see often. And when you do, it's absolutely terrifying. And What I've heard and seen is that I am now no longer terrified. I feel prepared. I know about my equipment. I know what I'm going to do with my equipment. And most importantly, I know what I'm going to do in that important first minute, right? Because unfortunately with neonates, you don't have 15 minutes to sit back and decide what your next step is. That essential first few minutes is so important. So, as I watch the students and as they have taken it out and said, we responded and we knew what to do. We did not know where to start before and now we do. And now we understand why. So those are the things that really and the really good thing is, is that we are making instructors, high quality instructors that were never able to take that role before. And they are spreading the word. They are spreading the science. They are. um preaching the message of those important steps like Jonathan said earlier ventilation so hopefully some of the issues that we're seeing in these maternity care deserts i have a lot of equipment right Jonathan says i have a nifty helicopter and a lot of equipment but I'm not the one there in the first four minutes. That is why it's so important. And June, I want to think about almost the opposite as well, because we talked a lot about the impact in pre-hospital, and we know there are services and there are EMS agencies using this course today, and it is impacting outcomes already. We are seeing we are getting callbacks from those who have taken the course and have had to resuscitate a newborn and that confidence level has increased. But we also have feedback on the hospital side. And we didn't mention it before, but when we think of This program, we co-developed this program very intentionally with A1. So it's the Association of Women's Health Obstetric and Neonatal Nurses. So, this course is backed by kind of one of the leading standard setters from a nursing perspective in labor and delivery, women's health as well. And even their team and very experienced A1 members have also taken this course and have given it really rave reviews. At their conference, we did a session and we watched a video from one of their nurses really talk about the robustness and the nature of this program. So, this isn't just about EMS and maternity care deserts. This is about urban environments and NICUs and hospitals, and really it is serving all audiences. But that feedback from the hospital side is just as important and inspiring as what we're getting from the EMS environment as well. So we couldn't be prouder of our work we did with A1 to kind of to build that, but as well as really making sure that we are addressing the needs across the spectrum as this maternity care desert crisis expands, but also just as challenges in health care expand throughout the United States. Yeah. Well, and we had a comment come in that said from Janet and she referenced the map that that we put up and she said, that's a scary map and it really is. And so this this course couldn't come at a better time in where we are with birthing and being able to respond to a new born emergency when it happens. That's all the time I have right now. And I really appreciate this. It's such a robust course. It's not just a bunch of, you know, you get on a computer and watch a bunch of videos. No, there's that skills practice that is just so, so, so important. And I see you both nodding your head. Jonathan, I do want to ask you, if someone is watching this, is interested in taking this course, how do they access it? That's a great question because I think there's a couple of different ways to access it based on where you are and what your background is. Certainly, coming to the Red Cross website, RedCross.org, you can actually search, and I think it's up in the box right now, kind of to learn about NOWS itself. But if you're a large hospital system and you're working with HealthStream, HealthStream's one of our big partners, you can get through your HealthStream channel. If you're an EMS agency, from the midwives and others that are looking for this program, coming through the Red Cross side. And there's a lot of ways to access this program that really is about if you really just want to find out going onto the website and just filling out that form, and we'll get you to the right place. Or certainly reach out to anyone in the kind of Red Cross training services side of the house. We'd be happy to talk about the program. It's fantastic. It's actually serving a need, which is really, really special. This isn't just about compliance training. This is really about really great learning, taking superior online content and engagement and tying it with those hands-on team-based scenarios and really bringing that confidence and competence to a new level. Right. And I know, too, if people are listening to this and they don't see the comments up on the screen, it's redcross.org/nals. And there's a form there that you can just put your information in and someone will be taking a look at it. and can get back to you on this. And thank you, Desley, for popping this up on the screen. That's all the time we have for today. Jonathan, Julie, any last words before we close out this session? No, just appreciate the opportunity to talk about making our babies healthier. Absolutely. Let's keep them safe. Let's keep their mom safe. Let's keep the baby safe. And this has been very enlightening. Thank you so much. And to all of those who have tuned in, have a great rest of your day. Thank you. Thank you.