infant mortality summit quality improvement project placental transfusion the women’s hospital,...
TRANSCRIPT
Infant Mortality Summit
Quality Improvement ProjectPlacental Transfusion
The Women’s Hospital, Newburgh, IN
Beth Durham, MSN, RNC-NIC
Severe IVH & NEC Frequent in Lowest Birth Weights
< 501
501-600
601-700
701-800
801-900
901-1000
1001-
1100
1101-
1200
1201-
1300
1301-
1400
> 1400
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Severe IVH (VON, 2012)
Birth Weight
< 501
501-600
601-700
701-800
801-900
901-1000
1001-
1100
1101-
1200
1201-
1300
1301-
1400
> 1400
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
NEC (VON, 2012)
Birth Weight
Severe IVH = Grade III + Grade IV
• Grade III– Blood in ventricle– Enlarged ventricle
• Grade IV– Blood in brain– (Not germinal matrix)
Cranial Ultrasound – Grade III
Grade III
Normal
Cranial Ultrasound – Grade IV
Normal
Grade IV
Prognosis of Grade III IVH
Five year follow up:
• ¼ Normal• ¼ Mild Neurological Symptoms• ¼ Moderate Handicap or Retardation• ¼ Severe Handicap or Severe Retardation
Resch B Childs Nerv Syst 1996 Jan;12(1):27-33 N = 40
Prognosis of Grade III & IV IVH
Two year follow up:
• Developmental delay (DQ < 70) 17.5% • Cerebral Palsy
30.0%• Deafness 8.6%• Blindness 2.2%
Bolisetty, S et al Pediatrics. 2014 Jan;133(1):55-62.N = 93
Cord Clamping, Then and Now
• 1950’s “Early Clamping” – If before 60 sec“Late Clamping” – If after 5 minutes.
• Now “Immediate Clamping” • Usually 15 – 20 seconds after delivery
“Delayed Clamping” – 30 to 60 sec.
Timed Cord Clamping
Transfer of 15 mL/Kg of blood after 1 minute from placenta to baby.• Increase blood volume
from 70 to 85 ml/kg at birth by not immediately clamping the cord.
Transfer of 20 mL/Kg of blood after 3 minutes.
Quality Improvement
Involves a change in behavior.Involves measurement.
William Edwards Deming
• 1900 – 1993• "PDSA" (Plan-Do-Study-Act). • A number of Japanese
manufacturers applied his techniques widely and experienced heretofore unheard-of levels of quality and productivity.
Quality Improvement (QI)
…requires measurements.
Research v. QI
• Research– Fixed study design– Focus on one question– May not produce result– May not lead to quality
improvement
• Quality Improvement– Focus on outcome
measurements– Flexible study design– Focus of study may shift– PDSA cycles designed to
lead to improvement
PDSA
Series of Large Projects Each Project Has Many Steps
ACOG & AAP Agree - December 2012 Placental Transfusion Reduces IVH
Benefits for premature– Reduce IVH by 50%– Improved transitional
circulation– Improved blood volume– Decreased need for
transfusions
Placental Transfusion Reduces NEC
• AUTHORS' CONCLUSIONS:
• Providing additional placental blood to the preterm baby by delaying cord clamping for 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion, better circulatory stability, less intraventricular hemorrhage (all grades) and lower risk for necrotizing enterocolitis.
Cochrane Database Syst Rev. 2012 Aug 15;8:CD003248. doi:10.1002/14651858.CD003248.pub3.
Present TWH NICU QI Project
Placental Transfusion ProjectPTP
A transfusion of blood from the placenta to the premature infant at delivery reduces the
incidence of severe IVH and NEC.---
Implementation of ACOG-AAP Consensus
Placental Transfusion Project
Timeline– May 2013 Presentation of ACOG/AAP opinion
statement at Soc. for Ped. Research– June 2013 Circulate supporting references at
TWH to Neo and Perinatal staffs. Begin Neo/Perinatal project meetings.
Began informal cord milking (no data).– July 2013 Introduce placental transfusion to
IVON QC as potential new project.• Potential for multiple site involvement in QI
Placental Transfusion Project
• Fundamentally different from earlier projects– Multiple departments• OBs and Peds
– Data set not captured by NeoData (NICU EMR)• Need new form of data capture and tracking
Placental Transfusion Project
Timeline– Aug. 2013 First draft of NICU audit tool.
• Ped/OB collaboration on cord clamping & milking• OBs: We thought you wanted the baby ASAP…
– Nov. 2013 Grant proposal submitted to Indiana Department of Health for I-VON QC
– Nov. 2013 TWH NICU data collection begins.• Project staff meetings begin in earnest.
– Dec. 2013 TWH OB protocol, parallel to IU.– Jan. 2014 Begin monthly data reporting to OB’s
• Continue PDSA cycles, create “run charts”, etc…
“Huddle Board”
Placental Transfusion ProjectTimeline– Feb. 2014 “Huddle Board” poster for NICU
(Monthly data reporting continued.)
– Mar. 2014 Dept. of Health approved $100,000grant for IVON QC project.
– May 2014 IU IRB approved IVON QC project.(8 participating NICUs)
– Sept. 2014 TWH data now statistically significant– Oct. 2014 TWH data presentation – “internal”.– Nov. 2014 TWH data – “external” report to state
“Infant Mortality Summit”.
Tracking Data• Data collection is part of QI• Data quality is important• Data trends are important
Labor Audit Tool
Labor Audit Tool
NICU Audit Tool
NICU Audit Tool
# NICU Audit Tools Submitted Audit Tool Submission Rate (%)
Placental Transfusion Procedures
Severe IVH
No Severe IVH• Last IVH event was in May 2013,
before starting our project…• The reduction in IVH in 2013 + 2014
is statistically significant, P<.05, but… …could it just be by chance?
Improvement v. Random Event
• Weakness of relatively sample sizes– Just “lucky” so far…?– Gather more data slowly• Years of data necessary for infrequent events
• Gather larger sample size quickly– Placental Transfusion Project at 8 sites– Multiple NICU participation yields more data• Project data gathering begins October 2014
Multiple Site Data Collection
• Multiple participating NICUs• REDCap data collection– Remote Electronic Data Capture software• Timed cord clamping• Cord milking• Exchange transfusion
Including 8 IU IRB Sites
REDCap Data Gathering Begins
Questions?
Thank you to Dr. Kenneth Herrmann for your help with this presentation.