Standardized delivery room management for neonates with a prenatal diagnosis of congenital heart disease: A model for improving interdisciplinary delivery room care

Process Improvement for Family-Centered Congenital Heart Disease Deliveries

BACKGROUND

Perinatal care coordination for the birth of infants with prenatally detected ductal-dependent congenital heart disease (DDCHD) has historically been limited by the siloing of cardiologists and neonatologists and by singular focus on risk reduction. The aim of this study was to increase time for parent-infant bonding and decrease overutilization of medical resources by developing and implementing a standardized delivery stratification system for infants with CHD.

METHODS/INTERVENTIONS

Over the course of multiple Plan-Do-Study-Act cycles from 2015 to 2023, we identified risk factors for respiratory intervention immediately after birth among infants with DDCHD, drivers of unnecessary intervention and resource utilization, and barriers to allowing time for parent-infant bonding. This led to development of standardized documentation and communication and a color-coded risk-stratification system that allowed for the identification of a low-risk cohort of infants eligible for demedicalized, immediate postnatal care despite the presence of critical CHD.

RESULTS

Through a series of process improvements and implementation of a delivery risk-stratification system, we were able to maintain neonatal safety while decreasing use of the operating room for vaginal deliveries from 100% to 10% and increasing the rate of time for parent-infant bonding in the first hours of life from 62% to 91%.

CONCLUSION

Multidisciplinary collaboration and iterative quality improvement work supported the safe improvement in allowing parent-infant bonding after birth for infants with critical CHD with a decrease in unnecessary respiratory intervention and obstetric resource utilization. Our findings support adoption of a collaborative risk-stratification approach for other congenital anomaly cohorts.

Building a sustainable neurocardiac critical care program in a paediatric cardiac ICU: insights and lessons learned

INTRODUCTION

Children with CHD are at increased risk for neurodevelopmental disabilities and neuropsychological impairments throughout their life span. The purpose of this report is to share our experience building a sustainable, novel, inpatient, interdisciplinary Neurocardiac Critical Care Program to mitigate risks and optimize outcomes during the ICU stay.

MATERIAL AND METHODS

A descriptive review was chosen to identify meaningful characteristics, challenges and lessons learned related to the establishment, expansion of and sustainability of Neurocardiac Critical Care Program in a 26-bed pediatric cardiac ICU.

RESULTS

We successfully launched, expanded, and sustained an interdisciplinary Neurocardiac Critical Care Program. Here, we share the foundation, framework, challenges, and lessons learned as we established and sustained the Neurocardiac Critical Care Program. The key elements of our program are (1) consistent engagement by pediatric neurologists in the cardiac ICU, (2) comprehensive education initiatives, (3) evidence-based clinical practice changes, and (4) quality improvement and research projects.

DISCUSSION

The development of a pediatric Neurocardiac Critical Care Program is feasible and sustainable. This program was informed by recent research related to perioperative and psychosocial risk factors that impact brain development and neurodevelopmental outcomes in this vulnerable population. By aligning our efforts, our multidisciplinary team is helping shift the paradigm in pediatric cardiac critical care to actively manage complex heart disease, while simultaneously and proactively mitigating risks to the developing brain and family unit.

Structured pre-delivery huddles enhance confidence in managing newborns with critical congenital heart disease in the delivery room

BACKGROUND

Newborns with critical congenital heart disease (CCHD) require specialized delivery room management, but varying experience and knowledge can reduce confidence and impact care.

METHODS

A pre-delivery, structured huddle checklist was introduced, addressing team roles, expected physiology, and management plans. PDSA cycles incorporated guidelines and simulation-based education to improve confidence in specialized resuscitation strategies. Surveys were conducted at baseline and 6 months.

RESULTS

Baseline, all-respondent confidence in managing "all types of CCHD" was somewhat confident (median 3/5; IQR 2-4) increasing to moderately confident (4/5; IQR 2-4) at 6 months (p = 0.59). Respondents with 0-3 years' experience showed increased confidence over 6 months in identifying unstable infants (from baseline 24% to 67% moderately/very confident, p = 0.005), prostaglandin E1 needs (from 24% to 62%, p = 0.013) and sedation requirements (from 5% to 33%, p = 0.045).

CONCLUSION

Structured huddles improved confidence among less experienced team members, emphasizing the importance of shared mental models before CCHD deliveries.

Neurodevelopmental Outcomes for Individuals With Congenital Heart Disease: Updates in Neuroprotection, Risk-Stratification, Evaluation, and Management: A Scientific Statement From the American Heart Association

Over the past decade, new research has advanced scientific knowledge of neurodevelopmental trajectories, factors that increase neurodevelopmental risk, and neuroprotective strategies for individuals with congenital heart disease. In addition, best practices for evaluation and management of developmental delays and disorders in this high-risk patient population have been formulated based on literature review and expert consensus. This American Heart Association scientific statement serves as an update to the 2012 statement on the evaluation and management of neurodevelopmental outcomes in children with congenital heart disease. It includes revised risk categories for developmental delay or disorder and an updated list of factors that increase neurodevelopmental risk in individuals with congenital heart disease according to current evidence, including genetic predisposition, fetal and perinatal factors, surgical and perioperative factors, socioeconomic disadvantage, and parental psychological distress. It also includes an updated algorithm for referral, evaluation, and management of individuals at high risk. Risk stratification of individuals with congenital heart disease with the updated categories and risk factors will identify a large and growing population of survivors at high risk for developmental delay or disorder and associated impacts across the life span. Critical next steps must include efforts to prevent and mitigate developmental delays and disorders. The goal of this scientific statement is to inform health care professionals caring for patients with congenital heart disease and other key stakeholders about the current state of knowledge of neurodevelopmental outcomes for individuals with congenital heart disease and best practices for neuroprotection, risk stratification, evaluation, and management.

Call to action: prioritizing delivery room care for neonates with critical congenital heart disease

Managing high-risk newborns with critical congenital heart disease (CCHD) in the delivery room is a unique challenge, characterized by complex physiology, heightened urgency, the coordinated efforts of multiple medical teams, and depending on the facility, the infrequent occurrence of such cases. Currently, there is a lack of unified guidance for resuscitation of these newborns in the delivery room. In this commentary, we advocate for an integrated approach involving maternal-fetal medicine specialists, fetal cardiologists, neonatologists, and cardiac intensivists. The proposed approach emphasizes collaborative pre-delivery planning, focusing on anticipated risk factors, postnatal physiology, and clinical management plans. We stress the importance of simulation-based education specifically addressing CCHD scenarios and advocate for research collaborations to establish evidence-based guidelines and track outcomes. Ultimately, a comprehensive, collaborative, and standardized approach, involving prenatal coordination, communication, and education, is essential for optimizing the delivery room management of neonates with CCHD.

Impact of Prenatal Diagnosis of Critical Congenital Heart Disease on Preoperative and Postoperative Outcomes

The objective of this study was to assess the relationship of prenatal diagnosis of critical congenital heart disease (CHD) to preoperative and postoperative patient findings. Retrospective analysis of neonates with critical CHD who underwent cardiothoracic surgery at one of four centers in North Carolina between 2008 and 2013. Surgical data collected by sites for submission to the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and the North Carolina CHD Lifespan Database were queried. There were 715 patients with STS records; 558 linked to the NC-CHD database. Patients with prenatal diagnosis had a lower incidence of preoperative risk factors, including need for mechanical ventilation and presence of shock. However, prenatally diagnosed patients had worse short-term outcomes, including higher operative mortality, higher incidence of select postoperative complications, and longer LOS. There was no difference in one-year mortality. Our findings are consistent with current literature which suggests that prenatal diagnosis of critical CHD is associated with a more optimized preoperative clinical status. However, we found that patients with prenatal diagnoses had less favorable postoperative outcomes. This needs to be investigated further, but may be secondary to patient-specific factors, such as CHD disease severity.

Cardiac problems in the fetus: a review for pediatric providers

PURPOSE OF REVIEW

The aim of this study was to provide pediatric providers with a review of the diagnosis and management of fetal cardiac disease in the current era.

RECENT FINDINGS

Prenatal detection of congenital heart disease (CHD) has improved but is still imperfect. In experienced hands, fetal echocardiography can detect severe CHD as early as the first trimester and a majority of more subtle conditions in the second and third trimesters. Beyond detection, a prenatal diagnosis allows for lesion-specific counseling for families as well as for development of a multidisciplinary perinatal management plan, which may involve in-utero treatment. Given the diversity of cardiac diagnoses and the rarity of some, collaborative multicenter fetal cardiac research has gained momentum in recent years.

SUMMARY

Accurate diagnosis of fetal cardiac disease allows for appropriate counseling, pregnancy and delivery planning, and optimization of immediate neonatal care. There is potential for improving fetal CHD detection rates. Fetal interventions are available for certain conditions, and fetal and pediatric cardiac centers have developed management plans specific to the expected postnatal physiology.

Multicentre study protocol comparing standard NRP to deveLoped Educational Modules for Resuscitation of Neonates in the Delivery Room with Congenital Heart Disease (LEARN-CHD)

INTRODUCTION

Infants born with critical congenital heart defects (CCHDs) have unique transitional pathophysiology that often requires special resuscitation and management considerations in the delivery room (DR). While much is known about neonatal resuscitation of infants with CCHDs, current neonatal resuscitation guidelines such as the neonatal resuscitation programme (NRP) do not include algorithm modifications or education specific to CCHDs. The implementation of CCHD specific neonatal resuscitation education is further hampered by the large number of healthcare providers (HCPs) that need to be reached. Online learning modules (eLearning) may provide a solution but have not been designed or tested for this specific learning need. Our objective in this study is to design targeted eLearning modules for DR resuscitation of infants with specific CCHDs and compare HCP knowledge and team performance in simulated resuscitations among HCPs exposed to these modules compared with directed CCHD readings.

METHODS AND ANALYSIS

In a prospective multicentre trial, HCP proficient in standard NRP education curriculum are randomised to either (a) directed CCHD readings or (b) CCHD eLearning modules developed by the study team. The efficacy of these modules will be evaluated using (a) individual preknowledge/postknowledge testing and (b) team-based resuscitation simulations.

ETHICS AND DISSEMINATION

This study protocol is approved by nine participating sites: the Boston Children's Hospital Institutional Review Board (IRB-P00042003), University of Alberta Research Ethics Board (Pro00114424), the Children's Wisconsin IRB (1760009-1), Nationwide Children's Hospital IRB (STUDY00001518), Milwaukee Children's IRB (1760009-1) and University of Texas Southwestern IRB (STU-2021-0457) and is under review at following sites: University of Cincinnati, Children's Healthcare of Atlanta, Children's Hospital of Los Angeles and Children's Mercy-Kansas City. Study results will be disseminated to participating individuals in a lay format and presented to the scientific community at paediatric and critical care conferences and published in relevant peer-reviewed journals.

Management of Hypertrophic Cardiomyopathy in a Newborn with Dextro-Transposition of the Great Arteries

Impaired maternal glucose metabolism during pregnancy can have significant effects on the cardiovascular system of the developing fetus. Early in pregnancy the teratogenic effects may lead to structural heart defects, while later in gestation a form of hypertrophic cardiomyopathy can develop due to overgrowth driven by fetal hyperinsulinism. We describe an infant with the uncommon combination of both dextro-transposition of the great arteries and hypertrophic cardiomyopathy. We emphasize the importance of a longitudinal multi-disciplinary approach, from fetal diagnosis to post-operative management, that allowed for an excellent outcome in this rare combination of severe cardiac malformations.