1
|
Jegatheesan P, Lee HC, Jelks A, Song D. Quality improvement efforts directed at optimal umbilical cord management in delivery room. Semin Perinatol 2024; 48:151905. [PMID: 38679508 DOI: 10.1016/j.semperi.2024.151905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.
Collapse
Affiliation(s)
- Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
| | - Henry C Lee
- Department of Pediatrics, Division of Neonatology, University of California San Diego, San Diego, CA, USA
| | - Andrea Jelks
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
2
|
Xu C, Zhang Q, Xue Y, Chow CB, Dong C, Xie Q, Cheung PY. Improved neonatal outcomes by multidisciplinary simulation-a contemporary practice in the demonstration area of China. Front Pediatr 2023; 11:1138633. [PMID: 37360368 PMCID: PMC10287162 DOI: 10.3389/fped.2023.1138633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/09/2023] [Indexed: 06/28/2023] Open
Abstract
Background Simulation-based training improves neonatal resuscitation and decreases perinatal mortality in low- and middle-income countries. Interdisciplinary in-situ simulation may promote quality care in neonatal resuscitation. However, there is limited information regarding the effect of multidisciplinary in-situ simulation training (MIST) on neonatal outcomes. We aimed to investigate the impact of MIST on neonatal resuscitation in reducing the incidence of neonatal asphyxia and related morbidities. Methods Weekly MIST on neonatal resuscitation has been conducted through neonatal and obstetrical collaboration at the University of Hong Kong-Shenzhen Hospital, China, since 2019. Each simulation was facilitated by two instructors and performed by three health care providers from obstetric and neonatal intensive care units, followed by a debriefing of the participants and several designated observers. The incidence of neonatal asphyxia, severe asphyxia, hypoxic-ischemic encephalopathy (HIE), and meconium aspiration syndrome (MAS) before (2017-2018) and after (2019-2020) the commencement of weekly MIST were analyzed. Results There were 81 simulation cases including the resuscitation of preterm neonates of different gestational ages, perinatal distress, meconium-stained amniotic fluid, and congenital heart disease with 1,503 participant counts (225 active participants). The respective incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS decreased significantly after MIST (0.64%, 0.06%, 0.01%, and 0.09% vs. 0.84%, 0.14%, 0.10%, and 0.19%, respectively, all P < 0.05). Conclusions Weekly MIST on neonatal resuscitation decreased the incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS. Implementation of regular resuscitation simulation training is feasible and may improve the quality of neonatal resuscitation with better neonatal outcomes in low- and middle-income countries.
Collapse
Affiliation(s)
- Chenguang Xu
- NICU, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Qianshen Zhang
- NICU, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yin Xue
- NICU, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chun-Bong Chow
- NICU, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chunxiao Dong
- Child Health Department, Longhua District Maternal & Child Healthcare Hospital, Shenzhen, China
| | - Qian Xie
- Department of Obstetrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Po-Yin Cheung
- NICU, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
- NICU, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
3
|
Erickson-Owens D, Salera-Vieira J, Mercer J. Midwifery and nursing: Considerations on cord management at birth. Semin Perinatol 2023:151738. [PMID: 37032272 DOI: 10.1016/j.semperi.2023.151738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Mounting evidence overwhelmingly supports the practice of the return of an infant's placental blood volume at the time of birth. Waiting just a few minutes before clamping the umbilical cord can provide health benefits to infants of all gestational ages. Despite the robust evidence, uptake of delayed cord clamping (DCC) into mainstream obstetrical practice is moving slowly. The practice of DCC is influenced by various factors that include the setting in which the birth takes place, the use of evidence-informed guidelines and other influences that facilitate or hinder the practice of DCC. Through communication, collaboration, and unique disciplinary perspectives, midwives and nurses work with other members of their respective care team to develop strategies for best practice to improve an infant's well-being through optimal cord management. Midwifery has been practiced for centuries throughout the world and midwives have supported DCC since the beginning of recorded history. An important tenet of midwifery philosophy is watchful waiting and non-intervention in normal processes. Nurses are vital to care of birthing families in- and out-of-hospitals as well as in prenatal and postpartum ambulatory care. Nurses and midwives are positioned to be involved in the process of adapting to the mounting evidence for DCC. Strategies to increase better utilization of the practice of DCC have been proposed. For all, teamwork and collaboration among disciplines participating in maternity care are essential for adapting to the new evidence. Involving midwives and nurses as partners in an interdisciplinary approach to plan, implement and sustain DCC at birth increases success.
Collapse
Affiliation(s)
- Debra Erickson-Owens
- College of Nursing, University of Rhode Island, Kingston RI 02881 USA; 120 Pine Tree Circle, North Kingstown, RI 02852, USA
| | - Jean Salera-Vieira
- Professional Development, Women and Infants Hospital, Providence, RI 02905 USA; 18 Acacia Road, Bristol, RI 02809, USA
| | - Judith Mercer
- College of Nursing, University of Rhode Island, Kingston RI 02881 USA; Alpert School of Medicine, Brown University, Providence, RI 02912 USA; Neonatal Research Institute at Sharp Mary Birch Hospital, San Diego, CA 92123 USA; 670 Front Street, Marion, MA 02738, USA.
| |
Collapse
|
4
|
Improving Communication to Neonatal Resuscitation Team Members During High-Risk Births. Nurs Womens Health 2023; 27:110-120. [PMID: 36773629 DOI: 10.1016/j.nwh.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 11/11/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To determine whether implementation of a written communication tool in labor and delivery during high-risk births improves communication, preparation, and satisfaction of responding neonatal resuscitation team members. DESIGN Quality improvement project with a pretest and posttest design. SETTING/LOCAL PROBLEM Two labor and delivery units and a third labor-delivery-recovery-postpartum unit within a health care system in the southeastern United States. PARTICIPANTS Nurses, nurse practitioners, respiratory therapists, and physicians who are part of the neonatal resuscitation team. INTERVENTIONS/MEASUREMENTS A researcher-designed, written communication tool titled the High-Risk Delivery Communication Tool was implemented in the settings. A researcher-designed measurement tool titled the Neonatal High-Risk Delivery Communication Scale was used as a before-and-after survey to measure communication to the neonatal resuscitation team, preparation for high-risk births, and satisfaction with communication from labor and delivery nurses. RESULTS Findings from all portions of the Neonatal High-Risk Delivery Communication Scale indicated statistically significant improvements in communication, preparation, and neonatal resuscitation team member neonatal resuscitation team satisfaction while attending high-risk births. Scores improved on every item regarding hand-off, risk factor communication, preparation, and satisfaction. CONCLUSION Implementing a communication tool for use in high-risk births may improve communication to neonatal resuscitation team members, enhance preparation for neonatal care, and increase team members' satisfaction with interprofessional communication.
Collapse
|
5
|
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
Collapse
Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
| |
Collapse
|
6
|
Whitesel E, Goldstein J, Lee HC, GuptaMMSc M. Quality Improvement for Neonatal Resuscitation and Delivery Room Care. SEMINARS IN SPINE SURGERY 2022:100961. [PMID: 35574250 PMCID: PMC9080026 DOI: 10.1016/j.semss.2022.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
Collapse
Affiliation(s)
- Emily Whitesel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Henry C Lee
- Stanford University School of Medicine, Stanford, CA
| | - Munish GuptaMMSc
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| |
Collapse
|
7
|
Ediger K, Rashid M, Law BHY. What Is Teamwork? A Mixed Methods Study on the Perception of Teamwork in a Specialized Neonatal Resuscitation Team. Front Pediatr 2022; 10:845671. [PMID: 35498772 PMCID: PMC9046838 DOI: 10.3389/fped.2022.845671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/11/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Neonatal resuscitation is a team-based activity involving many decisions and tasks. Non-technical factors, such as teamwork, are increasingly recognized as impacting how well-neonatal resuscitation is performed, and therefore influencing infant outcomes. Prior studies on teamwork in neonatal resuscitation have focused on quantification of teamwork behaviors, or the effects of team training. This study aimed to explore healthcare providers' own perception of teamwork in this specialized environment to identify perceived barriers and facilitators to effective team functioning. METHODS This single-center exploratory sequential mixed methods study used two phases. First, semi-structured interviews were conducted, and thematic analysis used to identify themes. Subsequently, interview data informed the development of quantitative surveys to explore selected themes in the wider team. RESULTS From ten semi-structured interviews, seven themes were identified including: (1) Team Composition, (2) Effective Communication, (3) Team leadership, (4) Hierarchy, (5) Team Training, (6) Debriefing, and (7) Physical Environment. Perceived teamwork facilitators include role assignment, familiarity, team composition, talking out loud to maintain shared mental models, leadership, and team training. Perceived barriers included time pressures, ad hoc team, ineffective leadership, and space limitations. Selected themes (Communication, Speaking up, Hierarchy, and Leadership) were further explored via electronic surveys distributed via email to all members of the resuscitation team. There were 105 responses; a response rate of ~53%. All respondents agreed or strongly agreed that speaking up is important; however, not all felt comfortable doing so. Neonatal fellows (14%) and nurses (12%) were most likely to report not feeling comfortable speaking up. All respondents agreed that team communication is important to an effective resuscitation. Most respondents (91.5%) agreed that a hierarchy exists within the team; 54.3% believed that hierarchy positively contributes to effective resuscitation. All respondents agreed or strongly agreed that having a clearly defined leader is important in delivery room resuscitations. Ineffective leadership was the most cited reason for poor team communication. CONCLUSIONS In this mixed methods study of perceptions of teamwork within a specialized, multi-disciplinary neonatal resuscitation team, communication, hierarchy, and leadership were positively perceived and facilitates teamwork. However, even in this environment, some nurses and trainees expressed discomfort with speaking up.
Collapse
Affiliation(s)
- Krystyna Ediger
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Marghalara Rashid
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | |
Collapse
|
8
|
Simulation to Support Standardization of Delivery Room Management of the Very Low Birth-Weight Infant. Adv Neonatal Care 2021; 21:E153-E161. [PMID: 32604128 DOI: 10.1097/anc.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The birth of a very low birth-weight (VLBW) infant occurs infrequently, especially in the community hospital setting. It is critical that the team managing care of the infant in its first minutes of life follow evidence-based resuscitation guidelines and practices to optimize outcomes for this population. PURPOSE To implement a simulation program in a community hospital setting that supports standardized evidence-based delivery room practices of the premature infant born less than 30 weeks' gestation. METHODS Two VLBW emergent delivery scenarios were developed utilizing the neonatal resuscitation program scenario template. Special care nursery interprofessional team members from a community hospital were invited to participate in the simulation program (n = 28). Participants were asked to complete a neonatal version of the Emergency Response Confidence Tool, then view a short presentation related to delivery room management of VLBW infants. Participants attended a simulation program and completed the confidence tool after simulation. The simulation facilitator and unit educator documented team actions during each simulation session. FINDINGS/RESULTS Fifteen opportunities for improvement within 4 simulation sessions were identified and categorized. Fourteen paired pre- and postsurveys were analyzed. Reported confidence increased in 22 of 23 resuscitation-related items. IMPLICATIONS FOR PRACTICE Education and simulation programs providing opportunities to experience high-risk, low-frequency VLBW delivery situations can assist in identifying areas for improvement and may improve team member confidence. IMPLICATIONS FOR RESEARCH Additional research is needed to assess whether results would be similar if this program were provided at all levels of neonatal care throughout the healthcare system.
Collapse
|
9
|
A Web-Based Nursing Education for Thermoregulation. J Nurses Prof Dev 2021; 37:249-256. [PMID: 34191470 DOI: 10.1097/nnd.0000000000000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neonatal nurses provide essential care in the hospital setting for improving infants' morbidity and mortality outcomes by preventing hypothermia after delivery. This quality improvement project describes the development and implementation of a web-based educational activity, demonstrating that online education effectively increases nurse knowledge and commitment to thermoregulation practices. A learning management system provides nursing professional development practitioners an effective method of improving nursing knowledge using a web-based educational curriculum in the clinical setting.
Collapse
|
10
|
Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S524-S550. [DOI: 10.1161/cir.0000000000000902] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
11
|
A Framework to Harness the Power of Quality Collaboratives to Improve Perinatal Outcomes. Clin Obstet Gynecol 2019; 62:606-620. [DOI: 10.1097/grf.0000000000000462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Anton O, Jordan H, Rabe H. Strategies for implementing placental transfusion at birth: A systematic review. Birth 2019; 46:411-427. [PMID: 30264508 DOI: 10.1111/birt.12398] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Enhanced placental transfusion reduces adverse neonatal outcomes, including death. Despite being endorsed by the World Health Organization in 2012, the method has not been adopted widely in practice. METHODS We performed a systematic literature search and included quality improvement projects on placental transfusion at birth and studies on barriers to implementation. We extracted information on population, methods of implementation, obstacles to implementation, and strategies to overcome them. RESULTS We screened 99 studies out of which 18 were included in the review. The preferred methods of implementation were protocol development (86% of studies) reinforced by targeted education (64% of studies) and multidisciplinary team involvement (43% of studies). Barriers to implementation were mentioned in 12 studies and divided into four categories: general factors such as lack of staff awareness (5 studies) and professional resistance to change (5 studies); obstetrician-specific concerns, including the impact during cesarean (3 studies) and the risk of postpartum hemorrhage (3 studies); pediatrician-specific concerns, including the need for resuscitation (5 studies), risk of jaundice (3 studies), and polycythemia (2 studies); and logistical difficulties. The main strategies to facilitate placental transfusion at birth included effective multidisciplinary team collaboration, protocol development, targeted education, and constructive feedback sessions. CONCLUSIONS Placental transfusion implementation requires a multidisciplinary approach, with obstetricians, midwives, nurses, and pediatricians central to adoption of the practice. Understanding the obstacles to implementation informs strategies to increase placental transfusion adoption of practice worldwide. We suggest a stepwise approach to implementation and enhancement of placental transfusion into practice.
Collapse
Affiliation(s)
- Oana Anton
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK
| | - Harriet Jordan
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK
| | - Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal Alexandra Hospital for Children, Brighton, UK.,Academic Department of Paediatrics, Brighton and Sussex Medical School, Brighton, UK
| |
Collapse
|
13
|
Meyer MP, Nevill E. Optimizing Cord Clamping in Preterm Infants: One Strategy Does Not Fit All. Front Pediatr 2019; 7:46. [PMID: 30873393 PMCID: PMC6400845 DOI: 10.3389/fped.2019.00046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael P. Meyer
- Middlemore Hospital, Auckland, New Zealand
- Department of Paediatrics, The University of Auckland, Auckland, New Zealand
| | | |
Collapse
|