Impact of Virtual Simulation vs. Video Refresher Training on NRP Simulation Performance: A Randomized Controlled Trial

Impact of Virtual Simulation vs. Video Refresher Training on NRP Simulation Performance: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Impact of Virtual Simulation vs. Video Refresher Training on NRP Simulation Performance: A Randomized Controlled Trial Rachel Umoren, Megan Gray, Ritu Chitkara, Justin Josephsen, Henry Lee, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4588591/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Aug, 2024 Read the published version in Journal of Perinatology → Version 1 posted 9 You are reading this latest preprint version Abstract Objective To assess the impact of NRP virtual simulations (eSim™), video or no refresher training, on simulation performance, six months after a provider course; and to evaluate eSim™ acceptability. Study Design: In this multi-site randomized controlled trial, NRP providers from four U.S. institutions were randomized to receive refreshers every two months with NRP eSim™, NRP resuscitation video, or no refresher (control). Simulation performance was assessed immediately after an NRP course and six months later. Result 248 participants completed the baseline simulation and 148 completed the six-month follow-up simulation. The majority (71%) of subjects had a decline in resuscitation skills at 6 months. There were no differences in performance between the study groups, but participants who reported using either the video or eSim™ had less decline in performance at the 6-month follow-up (p < 0.05). Conclusion NRP refreshers with either eSim™ or NRP video may mitigate the decline in resuscitation skills after training. Health sciences/Health care/Paediatrics Health sciences/Medical research/Outcomes research Pediatrics neonatal resuscitation simulation Neonatal Resuscitation Program (NRP) online learning refresher video eSim™ virtual simulation Introduction Over 10 million newborns require resuscitation after delivery each year. 1 – 3 Neonatal resuscitation training is vital and life-saving; delivery room personnel need to learn and maintain these skills. While modern data on the benefits of structured newborn resuscitation training in high-resource countries are limited, a Cochrane review showed significant benefits from the global literature to newborn survival following resuscitation by trained providers. 4 In a meta-analysis, Lee et al. found that newborn resuscitation training reduces intrapartum mortality by 30%. 5 Since its release 35 years ago, the Neonatal Resuscitation Program (NRP) has trained 5 million providers in 130 countries. 6 , 7 One of the key educational challenges for NRP is addressing the natural decline in learned skills following training. 8 , 9 As with all skills, resuscitation skills tend to decrease after training. 10 , 11 Therefore, ensuring that NRP skills are regularly reinforced and updated is crucial to ensure optimal resuscitation outcomes. Refresher training has been proposed as one mechanism to help mitigate skills decay. Refreshers have been explored for programs such as Pediatric Advanced Life Support, Helping Babies Breathe, Advanced Cardiovascular Life Support, and other resuscitation initiatives. 12 – 14 While refresher training holds promise in many small studies, there is no consensus on the timing, frequency, method, and structure of these programs. 15 Given the high volume of delivery room attendants who would require refresher training, virtually delivered, asynchronous refreshers are an important area for exploration. However, little is known about the role of virtual simulations for refresher training. The NRP eSim™ virtual simulation platform was developed by Laerdal Medical® with input from neonatal medical providers, nurses, and respiratory therapists from the American Academy of Pediatrics NRP Steering Committee. This screen-based virtual simulation, required to achieve NRP 7th edition provider status and NRP instructor status, featured term and preterm infants requiring resuscitation. 6 The learner interacted as the team leader with virtual objects representing items required for resuscitation in the delivery room in a well-resourced environment. All actions including drying, positive pressure ventilation, endotracheal intubation, laryngeal mask placement, chest compressions, umbilical line placement and epinephrine administration were represented through animations triggered by learner selections. The objective of the virtual simulation was to review and reinforce the NRP 7th edition algorithm. 6 Feedback was provided after each case along with a score, although a passing score was not required to complete the NRP course. 6 , 7 The NRP provider could access the five virtual simulation scenarios at any time during their two-year NRP provider timeframe. We aimed to examine NRP skills retention at six months after an NRP course for providers who received no refresher training, refresher training with an online NRP video, or refresher training with NRP eSim™ virtual simulations every 2 months post-course. The primary outcome was the time to administration of intravenous epinephrine in a newborn requiring extensive resuscitation during a simulated resuscitation conducted six months after NRP course completion. We hypothesized that providers assigned to virtual simulation refreshers would have less NRP skills decay at six months after training than providers assigned to video review or no refreshers (control). Methods Study Design : This single-blinded randomized controlled trial utilized a 1:1:1 allocation ratio with block randomization to one of the two pre-course intervention arms (NRP eSim™ virtual simulation plus NRP textbook study or NRP textbook study alone) and to one of the three post-course arms: every-2-months refresher training with NRP eSim™ virtual simulation (eSim™ group), 6 every-2-months review of a video demonstrating a complex resuscitation (video group), or no structured refresher (control). Inclusion Criteria All pediatric healthcare professionals who enrolled in an NRP course were eligible to participate. Participants were designated as either novices (first-time NRP training) or experienced (at least one prior NRP training). Exclusion Criteria Pediatric healthcare professionals who were unable to complete 6 month follow up test/simulation (e.g. graduating resident/fellow). Setting Trial sites were at four academic institutions located in the Midwest, West and Southern part of the United States. (University of Washington, Seattle, Washington, Stanford University School of Medicine, Palo Alto, California, University of Texas Southwestern, Dallas, Texas, and Saint Louis University, St. Louis, Missouri). The study was approved by the Institutional Review Board at each participating site. Interventions In the NRP eSim™, learners had access to five screen-based simulations, which included a mix of term and preterm neonatal resuscitation scenarios. Access to the online NRP Textbook and other reference materials were available within the scenarios. At the start of the virtual simulation, the learner was presented with the case information and asked to set up the equipment. During the scenario, the learner ‘dragged and dropped’ appropriate equipment over the infant to simulate the resuscitation steps (Supplemental Fig. 1). Before the course, participants were randomized to two arms of preparation: NRP textbook study only and NRP study textbook plus eSim™. Participants then attended a standard NRP course. After the NRP course the groups utilized their randomly assigned refresher. One group was assigned to no structured refresher training. The second group was assigned to review a 10-minute video developed specifically for this study reviewing the steps of the 7th edition neonatal resuscitation algorithm including initial steps of resuscitation, positive pressure ventilation, endotracheal intubation, chest compressions, intravenous (IV) epinephrine adminstration, and a normal saline bolus via an emergently placed umbilical venous catheter. The third group was assigned to complete an NRP eSim™ case featuring a term newborn requiring resuscitation. Both refresher intervention groups (video group and eSim™ group) were sent reminders at 2 and 4 months after their NRP course with links to access the video or the eSim™ platform, depending on their group assignment (Fig. 1 ). Online access to the video and NRP eSim™ was password protected through the NRP learning platform. Outcomes : The primary outcome was time to administration of IV epinephrine during a live, simulated newborn resuscitation conducted six months after the participant completed their NRP training. Secondary outcomes included scoring various NRP skills during the simulated resuscitation (Supplemental File 1: NRP Team Leader Performance Scoring Sheet). The NRP skills performance score was developed as a scoring tool by the study team and includes 25 unique resuscitation steps with a scale from not done, partially correct, and completely correct for each step. The tool was designed to focus on the study participant leading the resuscitation and did not evaluate any performance on the part of the embedded, confederate team members. Simulation event times and performance were compared to baseline times and performance from simulations conducted immediately following NRP training. Simulations used a standard case prompt, high-fidelity newborn manikin, and equipment (Supplemental File 2). The participant was instructed to lead the resuscitation team which included embedded personnel who responded to the study participant’s questions and requests. The manikin’s vital signs were programmed to follow a standard timeline with heart rate and oxygen saturations not recovering until placement of an endotracheal tube, provision of chest compressions, and administration of IV epinephrine. All simulated resuscitations were video recorded for review by study authors with extensive experience who were blinded to the participant's demographics and group allocation. Each video was reviewed for the time required to complete key NRP algorithm steps and scored using a checklist. Video reviewers received training on the scoring checklist. All reviewers rated performance on a set of training videos to ensure consistency before scoring participant videos. Sample Size Sample size was calculated using an assumed mean of 330 +/- 45 seconds between birth and the administration of IV epinephrine 16 , 17 . We aimed to show a 30-second difference in time to IV epinephrine and assumed a 15% dropout rate between NRP training and six-month follow-up. The goal sample size was 72 people per group. Due to higher-than-expected dropout rates, the initial recruitment goal was increased from 248 to 315 participants. Recruitment closed at 306 participants in March 2020 due to the COVID-19 pandemic and the inability to complete live simulations. Randomization Participants were randomized to 3 allocation groups stratified by experience (novice vs. experienced) and profession (physician vs. non-physician). Randomization was performed online (randomizer.org) using blocks of 4, and allocations were printed and placed in sequentially numbered opaque envelopes at each site by personnel not on the study team. Study team members running the simulations were blinded to the allocation group, and NRP staff notified participants of their assignment via email. Video reviewers were blinded to both allocation groups and whether the video was immediately post-NRP training or from the six-month follow-up simulation. Statistical methods All study data was collected and stored in REDCap. Statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). P-values < 0.05 were considered statistically significant. Baseline demographic data for the groups were compared using chi-square for categorical characteristics and one-way ANOVA for continuous data. We used one-way ANOVA to examine associations of the time to each action and performance scores for NRP between the 3 arms. Primary analyses used the intention-to-treat principle. The Kruskall Wallis test was used for a secondary comparison of performance scores based on the trajectory of performance between the initial and follow-up simulation. Additional secondary analysis included examining performance scores based on self-reported utilization of refreshers was done using Kruskall Wallis tests. Results In total, 306 participants were enrolled at the four sites, of which 248 completed the baseline simulation, and 148 completed the six-month simulation. These 148 participants are included in the primary outcome analysis (Fig. 1 ). Baseline demographic data are presented in Table 1 . Before the study, half of participants had no previous NRP training. The majority of participants reported few (0–5 in 6 months) recent newborn resuscitation experiences and had limited experience with newborn resuscitation in general. Physicians comprised approximately two-thirds of all groups, with residents being the most common level of training. Around one-third of participants worked in newborn care areas. Table 1 Demographics Characteristics Total n = 148 Control n = 54 Video n = 51 eSim(TM) n = 43 P value Prior NRP training 0.53 No previous NRP courses 76 (51.4) 29 (53.7) 23 (45.1) 24 (55.8) At least 1 previous NRP course 72 (48.6) 25 (46.3) 28 (54.9) 19 (44.2) Profession group 0.58 Physician 103 (69.6) 35 (64.8) 36 (70.6) 32 (74.4) Non-physician 45 (30.4) 19 (35.2) 15 (29.4) 11 (25.6) Main area of work 0.77 NICU 46 (31.3) 18 (34.0) 17 (33.3) 11 (25.6) Newborn nursery 10 (6.8) 2 (3.8) 3 (5.9) 5 (11.6) Labor and delivery or postpartum unit 2 (1.4) 0 1 (2.0) 1 (2.3) Inpatient wards 48 (32.7) 19 (35.8) 14 (27.5) 15 (34.9) Outpatient medicine 2 (1.4) 1 (1.9) 0 1 (2.3) Other 39 (26.5) 13 (24.5) 16 (31.4) 10 (23.3) Current position 0.64 Attending physician 11 (7.5) 5 (9.4) 5 (9.8) 1 (2.3) Resident physician 78 (53.1) 27 (50.9) 25 (49.0) 26 (60.5) Fellow physician 10 (6.8) 2 (3.8) 6 (11.8) 2 (4.7) Advanced care provider (NP,PA) 4 (2.7) 3 (5.7) 0 1 (2.3) R.N. 27 (18.4) 9 (17.0) 10 (19.6) 8 (18.6) R.T. 4 (2.7) 2 (3.8) 1 (2.0) 1 (2.3) Trainee non-physician 1 (0.7) 0 1 (2.0) 0 Other 12 (8.2) 5 (9.4) 3 (5.9) 4 (9.3) Years experience providing newborn resuscitation, median (IQR) 1(0,3) 1(0,4) 1(0,4) 0(0,3) 0.78 Number of infants resuscitated in the prior 6 months 0.67 1 ~ 5 36 (24.5) 17 (32.1) 10 (19.6) 9 (20.9) 6 ~ 10 7 (4.8) 3 (5.7) 4 (7.8) 0 11 ~ 15 8 (5.4) 2 (3.8) 3 (5.9) 3 (7.0) 16 ~ 20 12 (8.2) 2 (3.8) 6 (11.8) 4 (9.3) 21 ~ 25 5 (3.4) 1 (1.9) 2 (3.9) 2 (4.7) > 25 21 (14.3) 6 (11.3) 7 (13.7) 8 (18.6) None 58 (39.5) 22 (41.5) 19 (37.3) 17 (39.5) Age in years, median (IQR) 29(27,33) 29(27,33) 30(28,34) 28(27,31) 0.73 Gender 0.60 Female 113 (76.9) 41 (77.4) 37 (72.5) 35 (81.4) Male 34 (23.1) 12 (22.6) 14 (27.5) 8 (18.6) Race/Ethnicity Asian 39 (26.5) 17 (32.1) 10 (19.6) 12 (27.9) Black/African American 5 (3.4) 0 4 (7.8) 1 (2.3) Hispanic 12 (8.2) 4 (7.5) 5 (9.8) 3 (7.0) Other Race/Ethnicity 6 (4.1) 0 3 (5.9) 3 (7.0) White non-hispanic 90 (61.2) 32 (60.4) 31 (60.8) 27 (62.8) Declined to answer 2 (1.4) 2 (3.8) 0 0 Time to key NRP steps For the primary outcome, there was no difference in time to IV epinephrine administration between allocation groups (Supplemental Table 2). The median time to IV epinephrine was 316 (IQR 275, 364) seconds. There were no differences in the timing of any of the major NRP steps between refresher groups. PPV was started at a median of 29 (IQR 21, 39) seconds, just before the recommended 60-second goal for initiating PPV in depressed infants. Overall NRP performance Overall performance scores on simulated resuscitations did not vary between allocation groups (Fig. 2 ). Individual participant performance scores varied widely, but overall, performance scores were lower at the six-month follow-up simulation compared to the simulation completed immediately after course completion. Most participants (72%) had lower scores at the six-month follow-up compared with their initial scores, 5% had the same score, and 23% increased their performance scores after initial training. The participants who increased their performance scores during the six months had significantly lower initial scores (median 16.5 IQR 15,18) compared to those who had the same (median 19, IQR 17, 19.5) or lower scores six months later (median 20.5 IQR 18, 22; p = 0.0001). Self-reported clinical exposure On the six-month follow-up survey, the median number of self-reported clinical resuscitations attended during the refresher period was low (Table 2 ), and few participants had attended an advanced resuscitation. The number of self-reported newborn deliveries attended between the initial course and the follow-up simulation did not correlate with the direction of score change (p = 0.28), nor did the number of advanced resuscitations attended (p = 0.77). Table 2 Participation in Resuscitations and Refreshers in the Study Period Characteristics Total Control(n = 54) Video(n = 51) eSim (n = 43) p value Delivery room resuscitations attended in the past 6 months, median (IQR) 1(0,4) 1(0,4) 1(0,4) 0(0,5) 0.92 Resuscitations requiring advanced NRP attended in the past 6 months, median (IQR) 0(0,1) 0(0,1) 0(0,1.5) 0(0,1) 0.36 Used the eSim™ program in the past 6 months 65 (48.9) 18 (36.0) 20 (44.4) 27 (71.1) .004* Viewed the NRP videos in the past 6 months 54 (40.6) 12 (24.0) 24 (53.3) 18 (47.4) .009* Post-hoc analysis On the post-survey participants self-reported use of refreshers during the 6 month follow up period. The use of assigned refreshers varied by group (Supplemental Table 1). More participants in the eSim™ group reported using their assigned refresher than those in the video group (71% vs. 53%). Despite efforts to restrict exposure to the refresher interventions to designated study NRP accounts, many participants in the control and NRP video groups reported using the eSim™ program (36% and 44% respectively) and some participants assigned to the control and eSim™ groups also reported that they viewed a NRP video (24% and 47%, respectively) during the 6 month follow up period. A post-hoc analysis based on self-reported refresher group participation showed significant differences in 6-month NRP performance scores between participants who self reported using at least one refresher modality (eSim™ or video), or both refresher modalities (eSim™ and video) and those who reported using no refresher modalities (p = 0.03, Fig. 3 b). Similarly there were differences in the 6-month follow up NRP performance scores for those who self-reported participation in any refresher vs. those who reported using no refreshers (p = 0.02, Fig. 3 c). Participant feedback Most participants agreed that the eSim™ program and the study-provided NRP refresher video were valuable, realistic, and easy to access. The eSim™ program was rated more highly for realism and use in practicing clinical skills than the study video, but more challenging to access. About 20% of eSim™ users felt the online simulation was not easy to navigate. The eSim™ feedback was felt to be valuable by the majority of those who used the program. Discussion This is the first study to evaluate different types of asynchronous modalities for NRP refresher training. Individual performance of NRP skills varied immediately after a standard in-person NRP course and at six-month follow up, with a decline in NRP skills in a majority of study participants, and no significant difference in performance between groups assigned to no refresher, video refresher, or eSim™ refresher. While compliance with the assigned refreshers was low, post-hoc secondary analysis showed potential beneficial differences in skills retention for those who utilized a refresher. Participants who used the refresher training (video or eSim™) reported it was valuable. The performance of NRP skills immediately after the course was variable, with many participants missing resuscitation steps on an evaluative simulated complex neonatal resuscitation. This finding is supported by other studies in both high and low resource settings 18 , 19 and is relevant because this may translate to poor adherence in clinical practice. 20 This finding is also concerning in that it suggests that NRP courses do not always align with NRP recommendations for course structure and outcomes. NRP courses are designed using a deliberate practice mastery learning framework. Deliberate practice has been demonstrated to improve learning outcomes and aligns with Ericsson’s deliberate practice theory, in which learners intentionally focus on performance gaps until skill mastery is achieved. 21 , 22 Strategies to ensure learners attain competence by utilizing deliberate practice to support mastery learning during the in-person course is needed to ensure that all NRP guidelines are met and may support maintaining those skills over time. NRP skills performance declined further at the six months follow-up assessment, regardless of refresher training or participation in real-life newborn resuscitations. This decline has been described in other studies 23 , 24 . In our study, only a minority of participants increased their resuscitation performance irrespective of usage of refresher interventions (p = 0.95). Many variables can impact the effectiveness of a refresher training such as frequency, modality, and accessibility. The ideal frequency of refresher training is unknown for NRP and in our study, refreshers on 2 month intervals might have been too infrequent. It is also possible that neither eSim™ nor a video were effective modalities. Immediate introduction of refresher training materials and access to refresher training with a low dose and high frequency (weekly or monthly) approach may help solidify skills attained during in-person training and decrease the decay rate in performance over time. 25 , 26 While refresher training is essential to maintain skills, standard in-person refresher training may be challenging due to time, space, personnel and equipment requirements. Virtual simulations can avoid the space and personnel requirements and still support acquiring and maintaining neonatal resuscitation skills. 18 , 27 However, use of virtual simulation also presents challenges, including lack of technologic expertise/difficulty or unfamiliarity with the technology, lack of time (particularly for resident physicians and other busy clinicians), 28 lack of interest on the part of individuals who are not actively engaged in neonatal care, and lack of opportunity to practice essential motor skills such as face-mask ventilation and endotracheal intubation. The primary limitations of this study are the inability to verify use of the assigned refreshers and potential crossover between groups. While individual user accounts were restricted from accessing unassigned refresher materials, some participants’ reported accessing a refresher not available in their NRP account. This inconsistency may have reflected participants’ reporting their use of eSim™ during the pre-course rather than follow up period, access to the refresher training interventions through another NRP account, watching non-study NRP videos, or even reporting use of a refresher when none were used. A comprehensive individual review of each participant's NRP platform use was not feasible. An externally validated record of actual refresher use would have potentially led to different results and should be used in future studies of online refresher systems. In addition, the dropout over the six-month follow-up period was high (38% vs. a planned 15% dropout rate). This dropout rate, combined with slow recruitment and the inability to further increase the recruitment numbers due to the start of the COVID-19 pandemic, led to fewer total paired scores than planned. It is possible the results would have been different if the full sample size had been reached, though there were no trends toward differences in timing or overall performance. Finally, the performance score used for this study was unweighted, so it does not account for whether participants missed more minor or major steps in the algorithm. A subanalysis of key challenges in the NRP algorithm and a validation study on the score itself is planned to help inform future studies of resuscitation skills. Conclusion This is the first multi-site randomized controlled trial of interprofessional NRP providers to evaluate the effect of a virtual refresher on simulated NRP performance. While there was no significant difference between groups, there was potential benefit to any refresher use on skill retention. Further evaluation of asynchronous refresher training modalities is needed, particularly in individuals with limited clinical exposure to neonatal resuscitation, to solidify acquisition and maintenance of NRP skills. Declarations Conflict of Interest The authors declare no conflicts of interest. Ethics Approval and Consent to Participate IRB approval was obtained at all participating institutions. Availability of Data and Materials All relevant data has been included in the results and supplemental materials. Funding This study was supported by the American Academy of Pediatrics Author Contributions RU, MG and AA conceptualised and designed the study, drafted the initial manuscript, designed the data collection tools and reviewed and revised the manuscript. TS and MG designed the data collection tools and reviewed and revised the manuscript. RC, HL, SR, GW, JZ, PK, and GP collected data, and reviewed and revised the manuscript. MG carried out the initial analyses and reviewed and revised the manuscript. JJ and MS conceptualised and designed the study, collected data and critically reviewed the manuscript for important intellectual content. All authors participated in the revision of the manuscript, approved the final version and agreed to be accountable for all aspects of the work. Acknowledgements We would like to acknowledge eSim study collaborators Zeenia Billimoria, Alexandria Kristensen-Cabrera, Maricel N. Maxey, Patrick Motz, Lilian Sie, Thomas Strandjord, and Katherine Stumpf who assisted with scheduling and conducting NRP courses, study simulations and video reviews. The study video used for video refreshers was created by Gary Weiner, MD. We would also like to acknowledge assistance from Annabelle Kotler in formatting and preparing the manuscript for publication. References Little M, Järvelin M, Neasham D, Lissauer T, Steer P. 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Supplementary Files eSIMSupplementalFilefinal.pdf Cite Share Download PDF Status: Published Journal Publication published 28 Aug, 2024 Read the published version in Journal of Perinatology → Version 1 posted Editorial decision: revise 27 Jun, 2024 Review # 1 received at journal 24 Jun, 2024 Review # 2 received at journal 21 Jun, 2024 Reviewer # 2 agreed at journal 20 Jun, 2024 Reviewer # 1 agreed at journal 19 Jun, 2024 Reviewers invited by journal 19 Jun, 2024 Submission checks completed at journal 17 Jun, 2024 Editor assigned by journal 16 Jun, 2024 First submitted to journal 16 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4588591","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":316290494,"identity":"0747c124-d643-47ab-ba3e-5d2841fc7838","order_by":0,"name":"Rachel Umoren","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnElEQVRIiWNgGAWjYBADOTDJQ4oWY9K1JDYQrcV8Rnbi44qKO+kbbiQwPnjbRoQWmRu5mw3PnHmWC9TCbDiXGC0SErnbJBvbDuduuJ3AJs1LvJZ/h9MNbiew/yZBS8PhBKAWNmbitPC83WzYcOyw4cz7D5sl55wjRgt77saHDTWH5fnOHD744U0ZEVqQAGMDaepHwSgYBaNgFOAGANaeN1zxpq2xAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-2356-9278","institution":"University of Washington School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Umoren","suffix":""},{"id":316290495,"identity":"c6f6026e-e87a-499e-a752-63d45f0de379","order_by":1,"name":"Megan Gray","email":"","orcid":"https://orcid.org/0000-0002-3272-9432","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Megan","middleName":"","lastName":"Gray","suffix":""},{"id":316290496,"identity":"516b42f7-a577-45a8-be71-e66d7b394fa5","order_by":2,"name":"Ritu Chitkara","email":"","orcid":"","institution":"Stanford University","correspondingAuthor":false,"prefix":"","firstName":"Ritu","middleName":"","lastName":"Chitkara","suffix":""},{"id":316290497,"identity":"dcf676bc-bf51-44a6-a50d-e02d26bc86ce","order_by":3,"name":"Justin Josephsen","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Justin","middleName":"","lastName":"Josephsen","suffix":""},{"id":316290498,"identity":"f83ac71e-8646-465c-8913-ceef6b6c4b7a","order_by":4,"name":"Henry Lee","email":"","orcid":"https://orcid.org/0000-0001-8383-1720","institution":"University of California San Diego","correspondingAuthor":false,"prefix":"","firstName":"Henry","middleName":"","lastName":"Lee","suffix":""},{"id":316290499,"identity":"1d5bc452-9a2f-431d-bb39-67128e911e3b","order_by":5,"name":"Marya Strand","email":"","orcid":"https://orcid.org/0000-0001-9998-3948","institution":"Akron Childrens","correspondingAuthor":false,"prefix":"","firstName":"Marya","middleName":"","lastName":"Strand","suffix":""},{"id":316290500,"identity":"44e0eec9-cad0-4d5d-9422-e2d726686957","order_by":6,"name":"Taylor Sawyer","email":"","orcid":"https://orcid.org/0000-0002-3908-8957","institution":"University of Washington School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Taylor","middleName":"","lastName":"Sawyer","suffix":""},{"id":316290501,"identity":"bde4d21e-afef-456b-9e0c-73f5c0410fe4","order_by":7,"name":"Shalini Ramachandran","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Shalini","middleName":"","lastName":"Ramachandran","suffix":""},{"id":316290502,"identity":"ffec5be1-966b-416e-bfbd-8f788a72cb66","order_by":8,"name":"Gary Weiner","email":"","orcid":"https://orcid.org/0000-0002-9026-6149","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Gary","middleName":"","lastName":"Weiner","suffix":""},{"id":316290503,"identity":"8b5411cb-b282-4041-b702-e56e077cc93f","order_by":9,"name":"Jeanette Zaichkin","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jeanette","middleName":"","lastName":"Zaichkin","suffix":""},{"id":316290504,"identity":"ae435aed-845e-4096-9516-bccf450c3554","order_by":10,"name":"Peiyi Kan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Peiyi","middleName":"","lastName":"Kan","suffix":""},{"id":316290505,"identity":"03bd3f55-9448-4b72-806e-e35efb00cd6a","order_by":11,"name":"Gina Pantone","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Gina","middleName":"","lastName":"Pantone","suffix":""},{"id":316290506,"identity":"66564663-e2d3-4148-ad37-238d3c0e88ae","order_by":12,"name":"Anne Ades","email":"","orcid":"","institution":"Children's Hospital of Philadelphia","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Ades","suffix":""}],"badges":[],"createdAt":"2024-06-16 06:05:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4588591/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4588591/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41372-024-02100-4","type":"published","date":"2024-08-28T04:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63526218,"identity":"63ca275d-275b-4e19-9ca1-eade137df548","added_by":"auto","created_at":"2024-08-29 07:10:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":587595,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4588591/v1/29a989b0-71a5-4697-acec-1b4a163bf148.pdf"},{"id":60595488,"identity":"7028e91c-1906-45c6-9acd-e528186541e8","added_by":"auto","created_at":"2024-07-18 15:30:34","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":692388,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"eSIMSupplementalFilefinal.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4588591/v1/72041da18ba9c5fd8df24915.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Impact of Virtual Simulation vs. Video Refresher Training on NRP Simulation Performance: A Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver 10\u0026nbsp;million newborns require resuscitation after delivery each year.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Neonatal resuscitation training is vital and life-saving; delivery room personnel need to learn and maintain these skills. While modern data on the benefits of structured newborn resuscitation training in high-resource countries are limited, a Cochrane review showed significant benefits from the global literature to newborn survival following resuscitation by trained providers.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In a meta-analysis, Lee et al. found that newborn resuscitation training reduces intrapartum mortality by 30%.\u003csup\u003e5\u003c/sup\u003e Since its release 35 years ago, the Neonatal Resuscitation Program (NRP) has trained 5\u0026nbsp;million providers in 130 countries.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e One of the key educational challenges for NRP is addressing the natural decline in learned skills following training.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs with all skills, resuscitation skills tend to decrease after training.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Therefore, ensuring that NRP skills are regularly reinforced and updated is crucial to ensure optimal resuscitation outcomes. Refresher training has been proposed as one mechanism to help mitigate skills decay. Refreshers have been explored for programs such as Pediatric Advanced Life Support, Helping Babies Breathe, Advanced Cardiovascular Life Support, and other resuscitation initiatives.\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e While refresher training holds promise in many small studies, there is no consensus on the timing, frequency, method, and structure of these programs.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Given the high volume of delivery room attendants who would require refresher training, virtually delivered, asynchronous refreshers are an important area for exploration. However, little is known about the role of virtual simulations for refresher training.\u003c/p\u003e \u003cp\u003e The NRP eSim\u0026trade; virtual simulation platform was developed by Laerdal Medical\u0026reg; with input from neonatal medical providers, nurses, and respiratory therapists from the American Academy of Pediatrics NRP Steering Committee. This screen-based virtual simulation, required to achieve NRP 7th edition provider status and NRP instructor status, featured term and preterm infants requiring resuscitation.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e The learner interacted as the team leader with virtual objects representing items required for resuscitation in the delivery room in a well-resourced environment. All actions including drying, positive pressure ventilation, endotracheal intubation, laryngeal mask placement, chest compressions, umbilical line placement and epinephrine administration were represented through animations triggered by learner selections. The objective of the virtual simulation was to review and reinforce the NRP 7th edition algorithm.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Feedback was provided after each case along with a score, although a passing score was not required to complete the NRP course.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The NRP provider could access the five virtual simulation scenarios at any time during their two-year NRP provider timeframe.\u003c/p\u003e \u003cp\u003eWe aimed to examine NRP skills retention at six months after an NRP course for providers who received no refresher training, refresher training with an online NRP video, or refresher training with NRP eSim\u0026trade; virtual simulations every 2 months post-course. The primary outcome was the time to administration of intravenous epinephrine in a newborn requiring extensive resuscitation during a simulated resuscitation conducted six months after NRP course completion. We hypothesized that providers assigned to virtual simulation refreshers would have less NRP skills decay at six months after training than providers assigned to video review or no refreshers (control).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cem\u003eStudy Design\u003c/em\u003e: This single-blinded randomized controlled trial utilized a 1:1:1 allocation ratio with block randomization to one of the two pre-course intervention arms (NRP eSim\u0026trade; virtual simulation plus NRP textbook study or NRP textbook study alone) and to one of the three post-course arms: every-2-months refresher training with NRP eSim\u0026trade; virtual simulation (eSim\u0026trade; group),\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e every-2-months review of a video demonstrating a complex resuscitation (video group), or no structured refresher (control).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion Criteria\u003c/strong\u003e \u003cp\u003eAll pediatric healthcare professionals who enrolled in an NRP course were eligible to participate.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eParticipants were designated as either novices (first-time NRP training) or experienced (at least one prior NRP training).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion Criteria\u003c/strong\u003e \u003cp\u003ePediatric healthcare professionals who were unable to complete 6 month follow up test/simulation (e.g. graduating resident/fellow).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSetting\u003c/strong\u003e \u003cp\u003eTrial sites were at four academic institutions located in the Midwest, West and Southern part of the United States. (University of Washington, Seattle, Washington, Stanford University School of Medicine, Palo Alto, California, University of Texas Southwestern, Dallas, Texas, and Saint Louis University, St. Louis, Missouri). The study was approved by the Institutional Review Board at each participating site.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInterventions\u003c/strong\u003e \u003cp\u003eIn the NRP eSim\u0026trade;, learners had access to five screen-based simulations, which included a mix of term and preterm neonatal resuscitation scenarios. Access to the online NRP Textbook and other reference materials were available within the scenarios. At the start of the virtual simulation, the learner was presented with the case information and asked to set up the equipment. During the scenario, the learner \u0026lsquo;dragged and dropped\u0026rsquo; appropriate equipment over the infant to simulate the resuscitation steps (Supplemental Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eBefore the course, participants were randomized to two arms of preparation: NRP textbook study only and NRP study textbook plus eSim\u0026trade;. Participants then attended a standard NRP course. After the NRP course the groups utilized their randomly assigned refresher. One group was assigned to no structured refresher training. The second group was assigned to review a 10-minute video developed specifically for this study reviewing the steps of the 7th edition neonatal resuscitation algorithm including initial steps of resuscitation, positive pressure ventilation, endotracheal intubation, chest compressions, intravenous (IV) epinephrine adminstration, and a normal saline bolus via an emergently placed umbilical venous catheter. The third group was assigned to complete an NRP eSim\u0026trade; case featuring a term newborn requiring resuscitation. Both refresher intervention groups (video group and eSim\u0026trade; group) were sent reminders at 2 and 4 months after their NRP course with links to access the video or the eSim\u0026trade; platform, depending on their group assignment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Online access to the video and NRP eSim\u0026trade; was password protected through the NRP learning platform.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eOutcomes\u003c/em\u003e: The primary outcome was time to administration of IV epinephrine during a live, simulated newborn resuscitation conducted six months after the participant completed their NRP training. Secondary outcomes included scoring various NRP skills during the simulated resuscitation (Supplemental File 1: NRP Team Leader Performance Scoring Sheet). The NRP skills performance score was developed as a scoring tool by the study team and includes 25 unique resuscitation steps with a scale from not done, partially correct, and completely correct for each step. The tool was designed to focus on the study participant leading the resuscitation and did not evaluate any performance on the part of the embedded, confederate team members. Simulation event times and performance were compared to baseline times and performance from simulations conducted immediately following NRP training. Simulations used a standard case prompt, high-fidelity newborn manikin, and equipment (Supplemental File 2). The participant was instructed to lead the resuscitation team which included embedded personnel who responded to the study participant\u0026rsquo;s questions and requests. The manikin\u0026rsquo;s vital signs were programmed to follow a standard timeline with heart rate and oxygen saturations not recovering until placement of an endotracheal tube, provision of chest compressions, and administration of IV epinephrine. All simulated resuscitations were video recorded for review by study authors with extensive experience who were blinded to the participant's demographics and group allocation. Each video was reviewed for the time required to complete key NRP algorithm steps and scored using a checklist. Video reviewers received training on the scoring checklist. All reviewers rated performance on a set of training videos to ensure consistency before scoring participant videos.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSample Size\u003c/strong\u003e \u003cp\u003eSample size was calculated using an assumed mean of 330 +/- 45 seconds between birth and the administration of IV epinephrine\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. We aimed to show a 30-second difference in time to IV epinephrine and assumed a 15% dropout rate between NRP training and six-month follow-up. The goal sample size was 72 people per group. Due to higher-than-expected dropout rates, the initial recruitment goal was increased from 248 to 315 participants. Recruitment closed at 306 participants in March 2020 due to the COVID-19 pandemic and the inability to complete live simulations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRandomization\u003c/strong\u003e \u003cp\u003eParticipants were randomized to 3 allocation groups stratified by experience (novice vs. experienced) and profession (physician vs. non-physician). Randomization was performed online (randomizer.org) using blocks of 4, and allocations were printed and placed in sequentially numbered opaque envelopes at each site by personnel not on the study team. Study team members running the simulations were blinded to the allocation group, and NRP staff notified participants of their assignment via email. Video reviewers were blinded to both allocation groups and whether the video was immediately post-NRP training or from the six-month follow-up simulation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical methods\u003c/strong\u003e \u003cp\u003eAll study data was collected and stored in REDCap. Statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina). P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. Baseline demographic data for the groups were compared using chi-square for categorical characteristics and one-way ANOVA for continuous data. We used one-way ANOVA to examine associations of the time to each action and performance scores for NRP between the 3 arms. Primary analyses used the intention-to-treat principle. The Kruskall Wallis test was used for a secondary comparison of performance scores based on the trajectory of performance between the initial and follow-up simulation. Additional secondary analysis included examining performance scores based on self-reported utilization of refreshers was done using Kruskall Wallis tests.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e In total, 306 participants were enrolled at the four sites, of which 248 completed the baseline simulation, and 148 completed the six-month simulation. These 148 participants are included in the primary outcome analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Baseline demographic data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Before the study, half of participants had no previous NRP training. The majority of participants reported few (0\u0026ndash;5 in 6 months) recent newborn resuscitation experiences and had limited experience with newborn resuscitation in general. Physicians comprised approximately two-thirds of all groups, with residents being the most common level of training. Around one-third of participants worked in newborn care areas.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;148\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl n\u0026thinsp;=\u0026thinsp;54\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVideo n\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eeSim(TM) n\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior NRP training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo previous NRP courses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (55.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least 1 previous NRP course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (44.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32 (74.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (25.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain area of work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (34.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (25.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewborn nursery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (11.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabor and delivery or postpartum unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInpatient wards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (35.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (34.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 (23.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttending physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResident physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (53.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (49.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (60.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFellow physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced care provider (NP,PA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR.N.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR.T.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrainee non-physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears experience providing newborn resuscitation, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of infants resuscitated in the prior 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"7\" rowspan=\"8\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026thinsp;~\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (20.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026thinsp;~\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026thinsp;~\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026thinsp;~\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026thinsp;~\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (4.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (37.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (39.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(27,33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(27,33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30(28,34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28(27,31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113 (76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (77.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (81.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (22.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace/Ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack/African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther Race/Ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite non-hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (61.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (60.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (62.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeclined to answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTime to key NRP steps\u003c/strong\u003e \u003cp\u003eFor the primary outcome, there was no difference in time to IV epinephrine administration between allocation groups (Supplemental Table\u0026nbsp;2). The median time to IV epinephrine was 316 (IQR 275, 364) seconds. There were no differences in the timing of any of the major NRP steps between refresher groups. PPV was started at a median of 29 (IQR 21, 39) seconds, just before the recommended 60-second goal for initiating PPV in depressed infants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOverall NRP performance\u003c/strong\u003e \u003cp\u003eOverall performance scores on simulated resuscitations did not vary between allocation groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Individual participant performance scores varied widely, but overall, performance scores were lower at the six-month follow-up simulation compared to the simulation completed immediately after course completion. Most participants (72%) had lower scores at the six-month follow-up compared with their initial scores, 5% had the same score, and 23% increased their performance scores after initial training. The participants who increased their performance scores during the six months had significantly lower initial scores (median 16.5 IQR 15,18) compared to those who had the same (median 19, IQR 17, 19.5) or lower scores six months later (median 20.5 IQR 18, 22; p\u0026thinsp;=\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSelf-reported clinical exposure\u003c/strong\u003e \u003cp\u003eOn the six-month follow-up survey, the median number of self-reported clinical resuscitations attended during the refresher period was low (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and few participants had attended an advanced resuscitation. The number of self-reported newborn deliveries attended between the initial course and the follow-up simulation did not correlate with the direction of score change (p\u0026thinsp;=\u0026thinsp;0.28), nor did the number of advanced resuscitations attended (p\u0026thinsp;=\u0026thinsp;0.77).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipation in Resuscitations and Refreshers in the Study Period\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVideo(n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eeSim (n\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelivery room resuscitations attended in the past 6 months, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResuscitations requiring advanced NRP attended in the past 6 months, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0,1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0(0,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsed the eSim\u0026trade; program in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (48.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (36.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViewed the NRP videos in the past 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.009*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePost-hoc analysis\u003c/strong\u003e \u003cp\u003eOn the post-survey participants self-reported use of refreshers during the 6 month follow up period. The use of assigned refreshers varied by group (Supplemental Table\u0026nbsp;1). More participants in the eSim\u0026trade; group reported using their assigned refresher than those in the video group (71% vs. 53%). Despite efforts to restrict exposure to the refresher interventions to designated study NRP accounts, many participants in the control and NRP video groups reported using the eSim\u0026trade; program (36% and 44% respectively) and some participants assigned to the control and eSim\u0026trade; groups also reported that they viewed a NRP video (24% and 47%, respectively) during the 6 month follow up period. A post-hoc analysis based on self-reported refresher group participation showed significant differences in 6-month NRP performance scores between participants who self reported using at least one refresher modality (eSim\u0026trade; or video), or both refresher modalities (eSim\u0026trade; and video) and those who reported using no refresher modalities (p\u0026thinsp;=\u0026thinsp;0.03, Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). Similarly there were differences in the 6-month follow up NRP performance scores for those who self-reported participation in any refresher vs. those who reported using no refreshers (p\u0026thinsp;=\u0026thinsp;0.02, Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eParticipant feedback\u003c/strong\u003e \u003cp\u003eMost participants agreed that the eSim\u0026trade; program and the study-provided NRP refresher video were valuable, realistic, and easy to access. The eSim\u0026trade; program was rated more highly for realism and use in practicing clinical skills than the study video, but more challenging to access. About 20% of eSim\u0026trade; users felt the online simulation was not easy to navigate. The eSim\u0026trade; feedback was felt to be valuable by the majority of those who used the program.\u003c/p\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to evaluate different types of asynchronous modalities for NRP refresher training. Individual performance of NRP skills varied immediately after a standard in-person NRP course and at six-month follow up, with a decline in NRP skills in a majority of study participants, and no significant difference in performance between groups assigned to no refresher, video refresher, or eSim\u0026trade; refresher. While compliance with the assigned refreshers was low, post-hoc secondary analysis showed potential beneficial differences in skills retention for those who utilized a refresher. Participants who used the refresher training (video or eSim\u0026trade;) reported it was valuable.\u003c/p\u003e \u003cp\u003eThe performance of NRP skills immediately after the course was variable, with many participants missing resuscitation steps on an evaluative simulated complex neonatal resuscitation. This finding is supported by other studies in both high and low resource settings\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e and is relevant because this may translate to poor adherence in clinical practice.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e This finding is also concerning in that it suggests that NRP courses do not always align with NRP recommendations for course structure and outcomes. NRP courses are designed using a deliberate practice mastery learning framework. Deliberate practice has been demonstrated to improve learning outcomes and aligns with Ericsson\u0026rsquo;s deliberate practice theory, in which learners intentionally focus on performance gaps until skill mastery is achieved.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Strategies to ensure learners attain competence by utilizing deliberate practice to support mastery learning during the in-person course is needed to ensure that all NRP guidelines are met and may support maintaining those skills over time.\u003c/p\u003e \u003cp\u003eNRP skills performance declined further at the six months follow-up assessment, regardless of refresher training or participation in real-life newborn resuscitations. This decline has been described in other studies\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. In our study, only a minority of participants increased their resuscitation performance irrespective of usage of refresher interventions (p\u0026thinsp;=\u0026thinsp;0.95). Many variables can impact the effectiveness of a refresher training such as frequency, modality, and accessibility. The ideal frequency of refresher training is unknown for NRP and in our study, refreshers on 2 month intervals might have been too infrequent. It is also possible that neither eSim\u0026trade; nor a video were effective modalities. Immediate introduction of refresher training materials and access to refresher training with a low dose and high frequency (weekly or monthly) approach may help solidify skills attained during in-person training and decrease the decay rate in performance over time.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile refresher training is essential to maintain skills, standard in-person refresher training may be challenging due to time, space, personnel and equipment requirements. Virtual simulations can avoid the space and personnel requirements and still support acquiring and maintaining neonatal resuscitation skills.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e However, use of virtual simulation also presents challenges, including lack of technologic expertise/difficulty or unfamiliarity with the technology, lack of time (particularly for resident physicians and other busy clinicians),\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e lack of interest on the part of individuals who are not actively engaged in neonatal care, and lack of opportunity to practice essential motor skills such as face-mask ventilation and endotracheal intubation.\u003c/p\u003e \u003cp\u003eThe primary limitations of this study are the inability to verify use of the assigned refreshers and potential crossover between groups. While individual user accounts were restricted from accessing unassigned refresher materials, some participants\u0026rsquo; reported accessing a refresher not available in their NRP account. This inconsistency may have reflected participants\u0026rsquo; reporting their use of eSim\u0026trade; during the pre-course rather than follow up period, access to the refresher training interventions through another NRP account, watching non-study NRP videos, or even reporting use of a refresher when none were used. A comprehensive individual review of each participant's NRP platform use was not feasible. An externally validated record of actual refresher use would have potentially led to different results and should be used in future studies of online refresher systems. In addition, the dropout over the six-month follow-up period was high (38% vs. a planned 15% dropout rate). This dropout rate, combined with slow recruitment and the inability to further increase the recruitment numbers due to the start of the COVID-19 pandemic, led to fewer total paired scores than planned. It is possible the results would have been different if the full sample size had been reached, though there were no trends toward differences in timing or overall performance. Finally, the performance score used for this study was unweighted, so it does not account for whether participants missed more minor or major steps in the algorithm. A subanalysis of key challenges in the NRP algorithm and a validation study on the score itself is planned to help inform future studies of resuscitation skills.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first multi-site randomized controlled trial of interprofessional NRP providers to evaluate the effect of a virtual refresher on simulated NRP performance. While there was no significant difference between groups, there was potential benefit to any refresher use on skill retention. Further evaluation of asynchronous refresher training modalities is needed, particularly in individuals with limited clinical exposure to neonatal resuscitation, to solidify acquisition and maintenance of NRP skills.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIRB approval was obtained at all participating institutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data has been included in the results and supplemental materials.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the American Academy of Pediatrics\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRU, MG and AA conceptualised and designed the study, drafted the initial manuscript, designed the data collection tools and reviewed and revised the manuscript. TS and MG designed the data collection tools and reviewed and revised the manuscript. RC, HL, SR, GW, JZ, PK, and GP collected data, and reviewed and revised the manuscript. MG carried out the initial analyses and reviewed and revised the manuscript. JJ and MS conceptualised and designed the study, collected data and critically reviewed the manuscript for important intellectual content. All authors participated in the revision of the manuscript, approved the final version and agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge eSim study collaborators Zeenia Billimoria, Alexandria Kristensen-Cabrera, Maricel N. Maxey, Patrick Motz, Lilian Sie, Thomas Strandjord, and Katherine Stumpf who assisted with scheduling and conducting NRP courses, study simulations and video reviews. The study video used for video refreshers was created by Gary Weiner, MD. We would also like to acknowledge assistance from Annabelle Kotler in formatting and preparing the manuscript for publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLittle M, J\u0026auml;rvelin M, Neasham D, Lissauer T, Steer P. Factors associated with fall in neonatal intubation rates in the United Kingdom\u0026ndash;prospective study. BJOG 2007; 114: 156\u0026ndash;164.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAziz K, Chadwick M, Baker M, Andrews W. Ante- and intra-partum factors that predict increased need for neonatal resuscitation. Resuscitation 2008; 79: 444\u0026ndash;452.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiles DE, Cines C, Insley E, Foglia EE, Elci OU, Sk\u0026aring;re C et al. Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital. Resuscitation 2017; 115: 102109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDempsey E, Pammi M, Ryan A, Barrington K. Standardised formal resuscitation training programmes for reducing mortality and morbidity in newborn infants. Cochrane Database Syst Rev 2015; 9: 1\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee A, Cousens S, Wall S, Niermeyer S, Darmstadt G, Carlo W et al. Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect. BMC Public Health 2011; 3: 1\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner G. Textbook of Neonatal Resuscitation, 7th ed. American Academy of Pediatrics: 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaichkin J, McCarney L, Weiner G. NRP 7th Edition: Are You Prepared?. Neonatal Netw. 2016; 35: 184\u0026ndash;191.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCusack J, Fawke J. Neonatal resuscitation: are your trainees performing as you think they are? A retrospective review of a structured resuscitation assessment for neonatal medical trainees over an 8-year period.Arch Dis Child Fetal Neonatal Ed. 2012; 4: 246\u0026ndash;248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatterson H, Szyld D, Green B, Howell H, Pusic M, Mally P et al. Neonatal resuscitation experience curves: simulation based mastery learning booster sessions and skill decay patterns among pediatric residents. J Perinat Med 2018; 46: 934\u0026ndash;941.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBang A, Patel A, Bellad R, Gisore P, Goudar S, Esamai F et al. Helping Babies Breathe (HBB) training: What happens to knowledge and skills over time? BMC Pregnancy Childbirth 2016; 16: 364.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith K, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation 2008; 78: 59\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaju S, Tofil N, Gaither S, Norwood C, Zinkan J, Godsey V et al. The Impact of a 9-Month Booster Training Using Rapid Cycle Deliberate Practice on Pediatric Resident PALS Skills. Simul Healthc. 2021; 16: 168\u0026ndash;175.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCaw J, Yelton S, Tackett S, Rapal R, Gamalinda A, Arellano-Reyles A et al. Effect of repeat refresher courses on neonatal resuscitation skill decay: an experimental comparative study of in-person and video-based simulation training. Adv Simul (Lond) 2023; 8: 1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGugelmin-Almeida D, Tobase L, Maconochie I, Polastri T, Gesteria E, Williams J. What can be learned from the literature about intervals and strategies for paediatric CPR retraining of healthcare professionals? A scoping review of literature. Resusc Plus. 2022; 12: 1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAu K, Lam D, Garg N, Chau A, Dzwonek A, Walker B et al. Improving skills retention after advanced structured resuscitation training: A systematic review of randomized controlled trials. Resuscitation 2019; 138: 284\u0026ndash;296.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalling C, Sparks JE, Christie L, Wyckoff MH. Efficacy of intravenous and endotracheal epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. The Journal of pediatrics. 2017;185:232\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsayama T, Mildenhall L, Schm\u0026ouml;lzer GM, Kim HS, Rabi Y, Ziegler C, Liley HG. The route, dose, and interval of epinephrine for neonatal resuscitation: a systematic review. Pediatrics. 2020;146(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmoren R, Bucher S, Hippe DS, Ezenwa BN, Fajolu IB, Okwako FM et al. eHBB: a randomised controlled trial of virtual reality or video for neonatal resuscitation refresher training in healthcare workers in resource-scarce settings. BMJ open 2021; 11: 1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSk\u0026aring;re C, Boldingh AM, Kramer-Johansen J, Calisch TE, Nakstad B, Nadkarni V, Olasveengen TM, Niles DE. Video performance-debriefings and ventilation-refreshers improve quality of neonatal resuscitation. Resuscitation. 2018;132:140\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindback C, KC A, Wrammert J, Vitrakoti R, Ewald U, Malqvist M. Poor adherence to neonatal resuscitation guidelines exposed; an observational study using camera surveillance at a tertiary hospital in Nepal. BMC Pediatr. 2014; 14: 233.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEricsson K. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79: 70\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStocker M, Burmester M, Allen M. Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework. BMC Med Educ. 2014; 14: 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlo WA, Wright LL, Chomba E, McClure EM, Carlo ME, Bann CM, Collins M, Harris H. Educational impact of the neonatal resuscitation program in low-risk delivery centers in a developing country. The Journal of pediatrics. 2009;154(4):504\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel J, Posencheg M, Ades A. Proficiency and retention of neonatal resuscitation skills by pediatric residents. Pediatrics. 2012;130(3):515\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMduma E, Ersdal H, Svensen E, Kidanto H, Auestad B, Perlman J. Frequent brief on-site simulation training and reduction in 24-h neonatal mortality\u0026mdash;An educational intervention study. Resuscitation 2015; 93: 1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmoren R, Schmolzer G. Virtual Simulations for Neonatal Education. Semin Perinatol. 2023; 47: 151826.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzenwa B, Umoren R, Fajolu I, Hippe D, Bucher S, Purkayastha S et al. Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial). JMIR Med Educ. 2022; 8: 1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee H, Arora V, Brown T, Lyndon A. Thematic analysis of barriers and facilitators to implementation of neonatal resuscitation guideline changes. J Perinatol. 2017; 37: 249\u0026ndash;253.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pediatrics, neonatal, resuscitation, simulation, Neonatal Resuscitation Program (NRP), online learning, refresher, video, eSim™, virtual simulation","lastPublishedDoi":"10.21203/rs.3.rs-4588591/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4588591/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess the impact of NRP virtual simulations (eSim\u0026trade;), video or no refresher training, on simulation performance, six months after a provider course; and to evaluate eSim\u0026trade; acceptability.\u003c/p\u003e\u003ch2\u003eStudy Design:\u003c/h2\u003e \u003cp\u003eIn this multi-site randomized controlled trial, NRP providers from four U.S. institutions were randomized to receive refreshers every two months with NRP eSim\u0026trade;, NRP resuscitation video, or no refresher (control). Simulation performance was assessed immediately after an NRP course and six months later.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003e248 participants completed the baseline simulation and 148 completed the six-month follow-up simulation. The majority (71%) of subjects had a decline in resuscitation skills at 6 months. There were no differences in performance between the study groups, but participants who reported using either the video or eSim\u0026trade; had less decline in performance at the 6-month follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNRP refreshers with either eSim\u0026trade; or NRP video may mitigate the decline in resuscitation skills after training.\u003c/p\u003e","manuscriptTitle":"Impact of Virtual Simulation vs. Video Refresher Training on NRP Simulation Performance: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 15:22:29","doi":"10.21203/rs.3.rs-4588591/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2024-06-27T10:46:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-06-25T00:02:40+00:00","index":1,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2024-06-21T19:07:32+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-06-20T14:00:29+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2024-06-20T00:17:47+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2024-06-19T08:33:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-17T10:45:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-16T06:04:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Perinatology","date":"2024-06-16T06:04:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-perinatology","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jp","sideBox":"Learn more about [Journal of Perinatology](http://www.nature.com/jp/)","snPcode":"41372","submissionUrl":"https://mts-jper.nature.com/cgi-bin/main.plex","title":"Journal of Perinatology","twitterHandle":"@jperinatology","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8022c4d1-8e0e-4a92-aa3a-08e18a093cbd","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":33445965,"name":"Health sciences/Health care/Paediatrics"},{"id":33445966,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2024-08-29T07:10:10+00:00","versionOfRecord":{"articleIdentity":"rs-4588591","link":"https://doi.org/10.1038/s41372-024-02100-4","journal":{"identity":"journal-of-perinatology","isVorOnly":false,"title":"Journal of Perinatology"},"publishedOn":"2024-08-28 04:00:00","publishedOnDateReadable":"August 28th, 2024"},"versionCreatedAt":"2024-07-18 15:22:29","video":"","vorDoi":"10.1038/s41372-024-02100-4","vorDoiUrl":"https://doi.org/10.1038/s41372-024-02100-4","workflowStages":[]},"version":"v1","identity":"rs-4588591","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4588591","identity":"rs-4588591","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}