golden hour part i: delivery room management update
TRANSCRIPT
Golden Hour Part I: Delivery Room Management update
Maya Balakrishnan, MD
Assistant Professor of Pediatrics
USF College of Medicine
FPQC Neonatal-Focused Meeting
September 30, 2014
Objectives
Provide project overview
Discuss initiative-wide results
Team work
Thermoregulation
Oxygen administration
Delayed cord clamping
Discuss opportunities for improvement
Selection of Pilot Hospitals
Participate in FPQC
Deliver babies with
GA≤30 6/7 wks
Anticipated BW≤1500g
Expressed interest in participation
Looked for variety in:
# births
extent of existing quality infrastructure
Selection of Pilot Hospitals
ACADEMIC
USF/TGH
ACH/Johns Hopkins
NON-ACADEMIC
St. Joseph’s Hospital
Florida Hospital Tampa
Sarasota Memorial Hospital
Baptist Hospital Miami
South Miami Hospital
Broward Health Systems
Plantation Hospital
Table 1. Mean birth weight and gestational age
General Descriptive Statistics Data to 7/31/2014
Variable N Missing Mean Std Dev Minimum Maximum
Birth weight in grams 671 0 1089 347 410 2722
Gestational age in weeks 671 2 28 3 23 38
Delivery Type Frequency Percent
Vaginal 134 21%
C-section 488 78%
Missing 6 1%
Apgar Scores
< 7 159 25%
≥ 7 464 74%
Missing 5 1%
Table 2. Frequencies of delivery type, Apgar scores, and resuscitation requirements
Chest Compression in
DR* Frequency Percent
Yes 43 8%
No 459 86%
Missing 40 6%
Epinephrine in the DR*
Yes 44 7%
No 464 86%
Missing 41 7% Hospital 5
*n=565 in prospective database (i.e., after 10/1/2014) In 2012 ~2,250 VLBW infants in VON’s FPQC database From 10/2013-7/2014=9 months Estimate ~1,688 VLBW infants
Our efforts affected the care of ~33% of these infants
*DR: Delivery Room
Evidence-Based Measures
in DR Management
1 . TEAMWORK
2. THERMOREGULATION
3. OXYGEN ADMINISTRATION
4. DELAYED CORD CLAMPING
Initiative-Wide Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
en
t ach
ieve
d
Month of birth
Delivery Team Briefing Prior toAnticipated Delivery
Equipment Check Prior to Delivery
Radiant Warmer Turned to 100% HeatPrior to Delivery
DR Debriefing within 4 hrs
Goal
Readiness bundle: Pre-delivery DR preparation & DR debriefing
Goal: ≥80% of DR team debriefings w/in 4 hours of delivery
Initiative-Wide Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
en
t ach
ieve
d
Month of birth
Airway
Circulation
Team Leader
Scribe
Goal
Exclusive DR team roles Goal: ≥90% of DR teams having exclusive DR roles
Opportunities for improvement
Advantage of debriefings
Goal: 1-3 documented opportunities for each
delivery
Total # opportunities to date: 201 (for 565 deliveries)
Pareto principle or the “80-20 rule”
80% of output is created by 20% of input
Opportunities grouped into general themes
Helps highlight important areas to direct focused efforts
92
35 33 29
12
46%
63%
80%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
Teamwork Respiratory care Delayed cordclamping
IV fluids or access Thermoregulation
Op
po
rtu
nit
es
General themes
Opportunities for improvement (n=201)
38
19 17 16
9 8 7 4
32%
48%
63%
76%
84%
91%
97%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
20
40
60
80
100
Op
po
rtu
nit
ies
General themes
Teamwork opportunities for improvement (n=118)
12
8 7
2
41%
69%
93%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5
10
15
20
25
Obtaining access Hypoglycemia IV fluid prepared Other
Op
po
rtu
nit
ies
General themes
IV fluids & access opportunities for improvement (n=29)
Opportunities Airway Circulation Team Lead Scribe Briefing EquipmentRadiantWarmer
Debriefing
high 49% 66% 64% 66% 56% 67% 73% 73% 52%
low 22% 83% 42% 48% 39% 43% 54% 55% 29%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% c
om
pli
an
ce p
er
# o
f b
irth
s
Measures of team work
Effects of level of engagement on team work
Evidence-Based Measures
in DR Management
1 . TEAMWORK
2. THERMOREGULATION
3. OXYGEN ADMINISTRATION
4. DELAYED CORD CLAMPING
Admission Temperature
Goal temperature: 36.5-37.5° C
~50% of VLBWs
have abnormal
admission
temperature
*FPQC data is similar to
VON network data
FPQC 2012 Data (n=2,294)
>37.5° C 5%
36.5-37.5° C 50% 36.0-36.5° C
25%
32-35.9° C 20%
2012 VON FPQC data, n=2,399 infants
Initiative-Wide Data
60% 62% 60% 67%
55%
71% 70% 73% 71% 70% 64%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
en
t o
f in
fan
ts w
ith
in t
em
pera
ture
ran
ge
Month of Birth
Data Points Goal
NICU admission temperature Goal: ≥80% with NICU admission temperature of 36.5°-37.5°C
NICU admission temperature
Initiative-Wide Data
UCL 38.5 38.3
CL 36.7 36.8
LCL 34.9
35.3
34.5
35.0
35.5
36.0
36.5
37.0
37.5
38.0
38.5
39.0
Tem
pera
ture
in
deg
rees
Cels
ius
July 2013 → February 2014 : March 2014 → July 2014
12 11
8
2
36%
70%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5
10
15
20
25
30
Thermoregulationmethods
Equipment check Ambient temperature Other
Op
po
rtu
nit
ies
General themes
Thermoregulation opportunities for improvement (n=33)
Evidence-Based Measures
in DR Management
1 . TEAMWORK
2. THERMOREGULATION
3. OXYGEN ADMINISTRATION
4. DELAYED CORD CLAMPING
Initiative-Wide Data
Pre-ductal oxygen saturation at 10 minutes Goal: ≥80% compliance with NRP oxygen targets (85-95%) at 10 min
The following infants are excluded –
1. Infants with SPO2 >95% despite receiving FiO2 of 21% and 2. Infants with SPO2 <85% despite receiving FiO2 100%
78% 81%
74%
66%
72% 72% 74%
81%
72%
78%
71%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
en
t o
f in
fan
ts w
ith
in
ox
ygen
satu
rati
on
go
al
ran
ge
Month of Birth
Data points with excluded infants Goal
Pre-ductal oxygen saturation at 10 minutes Note: The following infants are excluded –
1. Infants with SPO2 >95% despite receiving FiO2 of 21% 2. Infants with SPO2 <85% despite receiving FiO2 100%
Initiative-Wide Data
CL 90 91
LCL 69
76
55
60
65
70
75
80
85
90
95
100
Perc
en
tag
e P
re-D
ucta
l O
xyg
en
Satu
rati
on
at
10 M
inu
tes
of
Lif
e
July 2013 → February 2014 : March 2014 → July 2014
Initiative-Wide Data
45% 41% 50%
79%
57% 55%
40%
59% 62%
79%
60% 70%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
en
t
Month of Birth
Missing
Out of Range
Within Range
Pre-ductal oxygen saturation at 10 minutes
11
9
5 5
3 2
31%
57%
71%
86%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5
10
15
20
25
30
35
Equipmentcheck
Pulse ox Surfactant CPAP Intubationdifficulty
Other
Op
po
rtu
nit
ies
General themes
Respiratory care opportunities for improvement (n=35)
Evidence-Based Measures
in DR Management
1 . TEAMWORK
2. THERMOREGULATION
3. OXYGEN ADMINISTRATION
4. DELAYED CORD CLAMPING
Initiative-Wide Data
50% 44%
20% 13%
21% 29%
34%
43%
51%
70%
55%
66% 71%
65% 58%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Perc
en
t ach
ieve
d
Month of Birth
All hospitals Original 6 hospitals Goal
Delayed Umbilical Cord Clamping Goal: ≥80% compliance with delayed cord clamping for 30-60 seconds
6
4
3
1
43%
71%
93%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
2
4
6
8
10
12
14
Communication w/OB Process to perform DCC Clear contraindications Other
Op
po
rtu
nit
ies
General themes
Delayed cord clamping opportunities for improvement (n=14)
Some final thoughts…
Our efforts are affecting the care of a significant
number of VLBWs delivered in FL
Engage your team members & share how well your site
is doing with them!
There is always room for improvement – keep working
through your PDSA cycles.
Start developing strategies to sustain your gains.