Improving cord management in preterm neonates at birth.
Abstract
Background
Umbilical cord management is a critical aspect of neonatal care, impacting both immediate and long-term health outcomes for newborns. The timing of cord clamping and the methods used can significantly influence the infant's adaptation to extra-uterine life, affecting parameters such as blood volume, iron status, and respiratory transition. Current guidelines and practices vary widely, necessitating optimizing these procedures based on the latest evidence.
Description of the Project
Our setting is the University of California San Diego NICU, a 52 bed Level 3 NICU with a birthing center that delivers approximately 40 infants with gestational age < 30 weeks per year. Recently, our unit adopted an innovative approach involving trolley deliveries (Figure 2) for delayed cord clamping (DCC) of 90 seconds as part of a multicenter randomized clinical trial. This method facilitates the initiation of ventilation while the infant remains attached to the umbilical cord.
Lessons Learned/Expected Outcomes
Recent CPQCC data show that DCC > 60 seconds improved in 2024 after initiation of the trolley. It increased from annual averages of 10-15% to 36.5%. However, we seek to impact more of our < 30 weeks infant population. We are initiating a QI project with the aim to increase the duration of delayed cord clamping (DCC) to 90 seconds in preterm infants (<30 weeks gestational age) by 20% within six months, from May 2025 to October 2025. Process measures of tracking trolley use and neonatal provider involvement at DCC will allow us to follow adherence to our proposed guidelines. Balancing measures will track intubation rates and initial hypothermia on admission to the NICU in the setting of DCC.
Recommendations/Next Steps
We are establishing a multidisciplinary team comprised of members from both the obstetrics and neonatal teams. Key drivers (Figure 1) have been identified to develop targeted interventions to enhance DCC rates. Baseline monthly data from 2022-2024 is being collected and will be analyzed on a statistical process control chart. DCC process will be further explored and discussed with our multidisciplinary team through fishbone diagrams and process mapping. We anticipate that these measures will result in us achieving our aim and primary outcome measure of increasing the duration of DCC to 90 seconds in infants < 30 weeks with a global aim of improving health outcomes for our smallest infants.