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.