Reduce Complications of Prematurity A Multisite Quality Improvement Project Sponsored by the Indiana State Department of Health Presenter Sandra Hoesli MD MS Objectives Describe the Indiana Vermont Oxford Network Quality Collaborative ID: 747840
Download Presentation The PPT/PDF document "Role of Placental Transfusion to" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Role of Placental Transfusion to Reduce Complications of Prematurity A Multi-site Quality Improvement Project
Sponsored
by the Indiana State Department of
Health
Presenter: Sandra Hoesli, MD, MSSlide2
ObjectivesDescribe the Indiana Vermont Oxford Network Quality Collaborative (IVON QC).Share the successful outcome of a previous IVON QC project that lead to funding for the current placental transfusion project.
Define the goals of the placental transfusion for preterm infants project and its current progress.Slide3
IVON QC: The Creation of a Quality Collaborative for IndianaOrganized in 2009 as an outgrowth of a statewide NICU medical directors networkVision of becoming a robust state collaborative of Indiana’s perinatal care providers
Work together on QI projects to improve pregnancy outcomes and reduce infant mortality in Indiana by disseminating evidence-based clinical practices and processes
First project in 2011 aimed to increase human milk use in preterm infants demonstrated the ability of NICUs in Indiana to collaborate on a single quality improvement
projectSlide4
Example State Perinatal Quality Improvement CollaborativesSlide5
State Perinatal Quality Collaboratives
http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PQC-States.htmlSlide6
Example Quality Improvement Projects by State CollaborativesNeonatalCentral line associated infection prevention
Health
c
are
a
ssociated infection prevention
Breast milk promotion
Delivery room
m
anagement for preterm
i
nfantsCare and management of late preterm infantsNeonatal abstinence syndrome
Promotion of safe sleep practicesSlide7
MaternalReduce elective delivery before 39 weeks gestationMaternal mortalityPromote antenatal corticosteroidsReduce postpartum hemorrhageCardiovascular disease during pregnancyPreeclampsia toolkits
Example Quality Improvement Projects by State
CollaborativesSlide8
Promoting Human Milk to Reduce Necrotizing Enterocolitis in Preterm InfantsFirst IVON QC project aimed to increase human milk use in preterm infants admitted to participating NICUs
12 sites
included
Primary goals were to work on a common project, use quality improvement methods, and share data on breast milk use between
sites
Secondary goal was to reduce the aggregate NEC rate
in infants <1500 grams admitted to participating Indiana NICUs that reported
to Vermont Oxford Network (VON
)Slide9
Promoting Human Milk to Reduce Necrotizing Enterocolitis in Preterm InfantsOutcomesInitiation of a NICU collaboration focused on a single QI project
Developed infrastructure for performing multi-site QI projects
Reduction in aggregate rate of NEC for participating NICUs from 8% in 2010 (n=652) to 3.9% in 2011-2012 (n=1272)
Reduction in aggregate rate of surgical NEC from 2.9% to 1.6%Slide10
Promoting Human Milk to Reduce Necrotizing Enterocolitis in Preterm InfantsOutcomesTrend of increased survival from 81.5% to 84.3% during the IVON QC project
Likely associated with emphasis on human milk, a reduction in the incidence of NEC and other unmeasured factors
This reduction in mortality could translate to 23 more infants surviving extreme prematurity each year in Indiana.Slide11
Placental Transfusion in Preterm Infants Born Less than 34 weeks of Gestation…Role of Delayed Cord Clamping and Umbilical Cord Milking to Reduce Complications of PrematurityMulti-Site IVON QC Project Sponsored by the Indiana State Department of Health
William Engle, MD
Frank Schubert, MD
Kenneth Herman, MD
Sandra Hoesli, MDSlide12
ACOG and AAP Agree: Timed Clamping Is BestBenefits for infants < 34 weeksReduce All Grades of IVH by 5
0%
Reduce NEC by
40%
Cardiovascular
stability after birth improved
Reduced need for RBC
transfusions
Complications
not
significantSlide13
Selected Neonatal Outcomes Following Delayed Cord Clamping in Preterm Infants
Outcome
N
Relative Risk or Mean Difference*
(95% Confidence
Interval)
Intraventricular
hemorrhage all grades
539
0.59 (0.41 – 0.85)
Intraventricular
hemorrhage grades 3 or 4
305
0.68 (0.23
– 1.96)
Necrotizing
enterocolitis
244
0.62 (0.43 – 0.90)
Periventricular
leukomalacia
71
1.02 (0.19 – 5.56)
Sepsis
137
0.29
(0.09 – 0.99)
Apgar at 5 minutes
184
0.12* (-0.20 – 0.43)
Death or neurosensory disability at 2 years
Not available
Hypothermia on admit to NICU
143
0.14*
(-0.03 – 0.31)
Peak total bilirubin
320
15.01* (5.62 – 24.40)
Exchange transfusion
180
1.21 (0.94 – 1.55)Slide14
IVON QC Placental Transfusion QI ProjectPurpose: Disseminate the practice of placental transfusion at the time of birth of premature infants throughout the 9 participating hospitals. These hospitals care for over half of infants born less than 34 weeks gestation in Indiana
Statistical estimates calculate that as many of 15 neonatal deaths in this group of preterm infants will be prevented by implementing delayed cord clamping
Additionally, reducing NEC and IVH will reduce important morbidities and healthcare costsSlide15
Target: Gestational Age less 34 weeks gestationAbsence of Contraindicationsplacental abruption/severe vaginal bleeding/vasaprevia/uterine rupturetight true knot in umbilical
cord/tight nuchal cord
suspected
twin-twin transfusion syndrome (monochorionic-mono amniotic and monochorionic-
diamniotic
twins
)
maternal
resuscitation at
delivery/
perimortem
circumstancesneonate who is a non-resuscitation
candidateclinician preference—if OB has any questions may wish to discuss with Neonatologyother conditions with blood volume overload (eg: hydrops, heart failure)
IVON QC Placental Transfusion QI ProjectSlide16
ProtocolHold baby supine, below the level of the placenta for 30-60 seconds60 seconds for infants <27 weeks30 seconds for infants 28-33 weeksCord milking should be reserved for when expedited delivery is necessaryLess supporting data available from clinical studies
Approximately 20cm of cord is milked toward the infant 4 times over 15-20 seconds
The baby is dried and stimulated during placental transfusion
Continue resuscitation per NRP guidelines
IVON QC Placental Transfusion QI ProjectSlide17
IVON QC Placental Transfusion QI ProjectQuality Improvement Metrics to be collectedPercent of infants without contraindications receiving placental transfusionPercent of infants with contraindications who received placental transfusionInfants <30 weeks gestation or <1500 grams
IVH all stages
IVH grades 3 or 4
PVL
NEC
Sepsis
Death
Exchange transfusionSlide18
IVON QC Placental Transfusion QI ProjectProgress to dateAll centers have completed education regarding placental transfusion to OB and NICU teamsAll centers have begun implementing changes to achieve delayed cord clamping for preterm infants as of October 1, 2014
Data from centers is being entered into centralized
REDCap
data base
Report cards being sent to each site with progress report
Working on consistent documentation at all sitesSlide19
Key Points to RememberThe goal of this QI project is to implement the recommended practice of delayed cord clamping for infants born less than 34wk gestationDelayed cord clamping has significant benefits for preterm infants: 5
0% reduction in
intraventricular
hemorrhage
40% reduction in necrotizing
enterocolitis
Improved cardiovascular stability for the first 48 hours
postnatally
Reduced risk of late onset sepsis
Reduced need for PRBC transfusion
No clinically significant risk to preterm infants identified
Cord milking for preterm infants should be reserved for situations when delayed cord clamping cannot be achieved and the OB/NICU team feels the baby would benefit from placental transfusionSlide20
Selected ReferencesACOG Committee Opinion Number 543. Timing of umbilical cord clamping after birth. Obstet Gynecol 2012;120(6):1522-1526Aladangady N, McHugh S, Aitchison TC,
Wardrop
CAJ and Holland BM. Infants’ blood volume in a controlled trial of placental transfusion at preterm delivery. Pediatrics 2006;117:93-98
Bauer K, Brace RA,
Stonestreet
BS. Fluid distribution in the fetus and neonate. In Polin RA, Fox WW, Abman SH (eds) Fetal and Neonatal Physiology 4
th
edition 2011 Elsevier Philadelphia, PA: 1436-150 ? year
Dock DS, Kraus WL, McGuire LB, Hyland JW, Haynes FW, Dexter L. The pulmonary blood volume in man. J Clin Invest 1961;40(2):317-328
Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA 2007;297:1241-1252
Kakkilaya
V,
Pramanik
AK, Ibrahim H, Hussein S. Effect of placental transfusion on the blood volume and clinical outcome of infants born by cesarean section. Clin Perinatol 2008;35:561-570
Rabe H et al. Cochrane Database of Systematic Reviews 2012 Issue 8 Art Nl. CD003248
doi
: 10.1002/14651858.CD003248.pub3.
Rabe
H,
Jewison
A, Alvarez RF, Crook D, Stilton D, Bradley R, Holden D; Brighton Perinatal Study Group. Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial.
Obstet
Gynecol. 2011 Feb;117(2 Pt 1):205-11.
Raju
TNK. Optimal timing for clamping of the umbilical cord after birth. Clin Perinatol 2012; 39 (4):889-900
Raju TNK. Timing of umbilical cord clamping after birth for optimizing placental transfusion. Curr Opin Pediatr 2013;25:180-187
Weeks A. Umbilical cord clamping after birth. Better not to rush. MJ 2007;335:312-313
Yao AC,
Hirvensalo
M, Lind J. Placental transfusion rate and uterine contraction. Lancet 1968;1:380-383
Yao AC, Lind J. Effect of gravity of placental transfusion. The Lancet 1969;
September;505-508