565 - Bedside Improvement of Resuscitation Through mHealth feedback: A Randomized Trial of Debriefing and Real-Time Guidance for Newborn Resuscitation

Publication Number: 3546.565

Jackie Patterson, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States; Daniel Ishoso, Kinshasa School of Public Helth, Kinshasa, Kinshasa, Congo, (Congo – Kinshasa); Sarah E. Sinsel, RTI International, York, PA, United States; Lauren D'Costa, RTI International, Durham, NC, United States; Kourtney Bettinger, University of Kansas School of Medicine, Prairie Village, KS, United States; Patricia Gomez, Jhpiego, Lacey, WA, United States; Joar Eilevstjønn, Laerdal Medical, Stavanger, Rogaland, Norway; Ingunn A. Haug, Laerdal Medical, Sandnes, Rogaland, Norway; Melissa Bauserman, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States; Helge Myklebust, Laerdal Medical, Stavanger, Rogaland, Norway; Tracy Nolen, RTI International, RTP, NC, United States; Benjamin Chi, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States; Eric Musalu. Mafuta, University of Kinshasa School of Public Health, Kinshasa, Kinshasa, Congo, (Congo – Kinshasa)

Background: Neonatal deaths from birth asphyxia in low- and middle-income countries (LMICs) can be prevented with timely and continuous positive pressure ventilation (PPV). However, providers often delay or interrupt PPV to perform suctioning. Feedback strategies such as real-time guidance (RTG) and debriefing could improve care in these settings. Our mobile health application called LIVEBORN provides audio-visual RTG during resuscitation and supports data-driven debriefing after resuscitation.

Objective: To evaluate the effectiveness of LIVEBORN feedback for newborn resuscitation in an LMIC

Design/Methods: We conducted a pre/post interventional trial of LIVEBORN feedback with midwives in 4 maternity hospitals in the Democratic Republic of Congo. In the 6-month standard of care (SOC) phase, midwives received resuscitation training and engaged in frequent simulation practice. Over the 1-year LIVEBORN feedback phase, facilities were randomized to either RTG or debriefing (Figure 1). From a convenience sample of neonates, we extracted clinical data from the medical record and directly observed resuscitation care. Our primary outcome was duration of suctioning. We first compared SOC vs LIVEBORN feedback; we then compared SOC vs each type of feedback (RTG or debriefing).

Results: We directly observed care for 4735 live births during the trial. Birth weight and gestational age at birth were similar between SOC and LIVEBORN feedback phases; cesarean section was 2% more common in the feedback phase. Compared to the SOC phase, the feedback phase resulted in a 26% lower duration of suctioning (aRR 0.74 [95% CI 0.73, 0.75]) and a 24% earlier time to start PPV (aRR 0.76 [95% CI 0.73, 0.79]); neonates not breathing by 60 s were 2.3 times as likely to receive PPV (aRR 2.27 [95% CI 1.40, 3.69]; Table 1). During the feedback phase, 162 acute cases received RTG and 82 were debriefed per the facilities' randomized assignment (Figure 1). Compared to the SOC phase, both RTG and debriefing independently resulted in lower duration of suctioning (aRR 0.68 [95% CI 0.66, 0.70] and aRR 0.74 [95% CI 0.73, 0.75], respectively), earlier time to start PPV (aRR 0.61 [95% CI 0.57, 0.64] and aRR 0.76 [95% CI 0.72, 0.80]) and higher likelihood of receiving PPV for neonates not breathing by 60 s (aRR 2.78 [95% CI 1.21, 6.41] and aRR 2.29 [95% CI 1.26, 4.16]; Table 2).

Conclusion(s): RTG and debriefing were both independently associated with improved resuscitation care among midwives in an LMIC. Future studies are needed to evaluate the effect of feedback strategies for neonatal resuscitation on health outcomes.

Figure 1. LIVEBORN feedback description and study flowchart.
We directly observed births using the LIVEBORN app to record data about resuscitation care and the neonate's breathing status in real-time. In the LIVEBORN feedback phase, LIVEBORN integrated data from the observer and a battery-operated heart rate meter called NeoBeat and compared it to the Helping Babies Breathe algorithm. For facilities randomized to RTG, the app provided audio-visual guidance during resuscitation. For facilities randomized to debriefing, experienced midwives trained as facilitators used LIVEBORN's customized script to facilitate data-driven debriefing after resuscitation. Abbreviations: RTG=real-time guidance

Table 1. Resuscitation care for live births during LIVEBORN feedback vs standard of care


Table 2. Resuscitation care for live births during real-time guidance versus debriefing