A cognitive aid for neonatal resuscitation: a randomized controlled trial
Authors: Bould M.D. , Hayter M.A. , Campbell D.M. , Chandra D.B. , Joo H.S. , Naik V.N. 
Published: June 2009

Introduction:  Anaesthetists are among several health care practitioners responsible for neonatal resuscitation in Canada. The Neonatal resuscitation program (NRP) courses are the North American educational standard. NRP has been shown to be an effective way of learning skills and knowledge but retention has been found to be problematic [1]. The use of cognitive aids is mandatory in industries such as aviation, to avoid dependence on memory when decision making in critical situations. Visual cognitive aids have been studied retrospectively in resuscitation and performance was found to correlate to the frequency of use of the aid [2]. Cognitive aids have been found to be of benefit in an unblinded prospective study [3]. We aimed to conduct the first blinded study on the effect of a cognitive aid on the performance of simulated resuscitation.

Methods:  We conducted a single‐blind randomized controlled trial to investigate whether the presence of a cognitive aid improved performance in a simulated neonatal resuscitation. After ethics board approval we recruited 32 anaesthesia residents who had previously passed the NRP. Subjects were randomized to an intervention group that had a poster detailing the NRP algorithm and a control group without the poster. The cognitive aid was positioned so that it could not be seen on the video recordings of the simulation that was used to assess performance. The scenario was piloted to confirm adequate blinding. Both groups had their performance in a simulated neonatal resuscitation recorded and subsequently analyzed by a peer, an expert anaesthetist and an expert neonatologist, using a previously validated checklist. A further rater observed the scenario in real time to examine frequency of use of the cognitive aid.

Results:  The inter‐rater reliability of the checklist was excellent with an intraclass correlation coefficient of 0.88. Consequently the mean of the scores assigned by all three raters was used for analysis. The median checklist score in the control group 18.2 [15.0–20.5 (10.7–25.3)] was not significantly different from that in the intervention group 20.3 [18.3–21.3 (15.0–24.3)] (P = 0.08). Retention of NRP skills and knowledge of was poor: when evaluated by the neonatologist none of the subjects correctly performed all life‐saving interventions necessary to pass the checklist. Although only one subject in the intervention group did not use the aid at all, only 26.7% used the aid frequently and none used it extensively.

Discussion:  Retention of skills after NRP training was poor. Our study confirms previous findings of poor retention of skills after NRP training: Kaczorowski et al. investigated family medicine trainees and found that none of 44 residents that were retested 6–8 months after an NRP course would have passed the course due to errors in life‐saving interventions [1]. Previous research has shown that the presence of a cognitive aid can improve performance in the simulated management of a rare, high stakes scenario: malignant hyperthermia [3]. Our negative findings contrast with this and another previous study [2]. A potential reason for this discrepancy is that the raters in the previous studies were not blinded to group allocation, nor were the rating scales used validated. The infrequent use of the cognitive aid may be the reason that it did not improve performance in. Further research is required to investigate whether cognitive aids can be useful if their use is incorporated into NRP training.

Conclusion:  A randomized single‐blinded trial found that a cognitive aid did not improve performance at simulated resuscitation, in contrast to previous retrospective and unblended studies. Retention of skills and knowledge after resuscitation training remains an ongoing challenge for medical educators.