/
Role of Role of

Role of - PowerPoint Presentation

test
test . @test
Follow
407 views
Uploaded On 2016-03-02

Role of - PPT Presentation

Placental Transfusion to Reduce Complications of Prematurity A Multisite Quality Improvement Project Sponsored by the Indiana State Department of Health Presenter Sandra Hoesli MD MS ID: 239494

transfusion infants cord placental infants transfusion placental cord project preterm clamping ivon quality indiana reduce milk delayed improvement umbilical

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Role of" 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.


Presentation Transcript

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