Article Text

Achieving optimal cord management: a multidisciplinary quality improvement initiative
  1. Jessica Burgess-Shannon1,
  2. Rebecca Clarke1,
  3. Victoria Rowell1,
  4. Narendra Aladangady1,2
  1. 1Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK
  2. 2Queen Mary University of London, London, UK
  1. Correspondence to Dr Narendra Aladangady; n.aladangady{at}nhs.net

Abstract

Optimal cord management (OCM), defined as waiting at least 60 seconds (s) before clamping the umbilical cord after birth, is an evidence-based intervention that improves outcomes for both term and preterm babies. All major resuscitation councils recommend OCM for well newborns.

National Neonatal Audit Programme (NNAP) benchmarking data identified our tertiary neonatal unit as a negative outlier with regard to OCM practice with only 12.1% of infants receiving the recommended minimum of 60 s. This inspired a quality improvement project (QIP) to increase OCM rates of ≥ 60 s for infants <34 weeks. A multidisciplinary QIP team (Neonatal medical and nursing staff, Obstetricians, Midwives and Anaesthetic colleagues) was formed, and robust evidence-based quality improvement methodologies employed. Our aim was to increase OCM of ≥ 60 s for infants born at <34 weeks to at least 40%.

The percentage of infants <34 weeks receiving OCM increased from 32.4% at baseline (June–September 2022) to 73.6% in the 9 months following QIP commencement (October 2022–June 2023). The intervention period spanned two cohorts of rotational doctors, demonstrating its sustainability. Rates of admission normothermia were maintained following the routine adoption of OCM (89.2% vs 88.5%), which is a complication described by other neonatal units.

This project demonstrates the power of a multidisciplinary team approach to embedding an intervention that relies on collaboration between multiple departments. It also highlights the importance of national benchmarking data in allowing departments to focus QIP efforts to achieve long-lasting transformational service improvements.

  • Quality improvement
  • Quality improvement methodologies
  • Clinical Audit

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Waiting at least 60 s before clamping the umbilical cord after birth allows physiological transition to extra-uterine life and improves outcomes for new-born infants. Facilitating optimal cord management (OCM) is a key priority for neonatal professionals, reflected in national-benchmarking data that audits OCM rates.

WHAT THIS STUDY ADDS

  • This multidisciplinary quality improvement project (QIP) demonstrates the importance of national benchmarking data which is regularly fed-back to neonatal units to inform QI opportunities. It also demonstrates the importance of a collaborative approach and application of evidence-based QI methodologies to achieve sustainable improvements in practice for interventions that rely on engagement of a multidisciplinary team.

HOW MIGHT THIS STUDY AFFECT RESEARCH, PRACTICE OR POLICY

  • This QIP outlines a single unit’s experience of improving OCM rates through the development of a multidisciplinary QIP team, guideline and education sessions, all of which may inform strategies at other neonatal units looking to achieve similar sustainable practice changes.

Problem

Waiting at least 60 seconds (s) before clamping the umbilical cord, known as optimal cord management (OCM), supports physiological adaptation to extra-uterine life after birth and improves clinical outcomes for term and preterm babies.1–5 OCM is associated with a reduction in mortality, rates of intraventricular haemorrhage (IVH), necrotising enterocolitis and the need for blood transfusion and inotropes in preterm infants.1 3–5 Term babies receiving OCM benefit from a reduction in iron deficiency at 3–6 months.2 OCM is an evidence-based intervention supported by all major resuscitation councils for infants who are stable at birth.6–8

The National Neonatal Audit Programme (NNAP), which monitors benchmarking data on key clinical measures, identified our unit as a negative outlier with regard to OCM practice in August 2022 (based on 2021 performance). Only 12.1% of eligible infants were receiving OCM of at least 60 s compared with a national average of 43%.9

Here we report a multidisciplinary quality improvement project (QIP) initiated to improve OCM rates at Homerton University Hospital. Homerton is one of the largest Neonatal Intensive Care Units (NICU) in London, and offers medical intensive, high-dependency and special care, retinal laser surgery and therapeutic hypothermia for term asphyxia in a population of high-risk babies from within Hackney and beyond. Tertiary neonatal care in North Central and North East (NC&NE) London is provided by three NICUs within the wider London Neonatal Operational Delivery Network. Homerton is one of three units providing the highest level of specialist care (level 3) within the NC&NE London Neonatal Network. This network has a total of 13 neonatal units which deliver different levels of care according to their designation and in line with the Department of Health Neonatal Toolkit (2009) and NICE Quality Standards for Neonatal Care (2010).10 11

Homerton treats around 950 infants per year, of which around 120 infants are born at or below 28 weeks of prematurity. Around 75% of extremely preterm (<28 weeks) babies are born to mothers from the local catchment area or in-utero transfers from network hospitals. The remaining infants are transferred ex-utero (after birth) from network hospitals and beyond. The hospital birth rate is around 5500 per year.

Our aim was to increase OCM of ≥60 s for infants<34 weeks born at Homerton to at least 40%, in line with the national average, over a 4 month period.

Background

A fall in pulmonary vascular resistance and increased blood flow through the lungs are normal physiological responses to transition after birth triggered by clearance of fetal lung fluid. Remaining attached to the placenta during transition means that this additional blood volume can be drawn from its reservoir, rather than redistribution of the infants own systemic blood supply. Studies suggest that OCM is associated with a significant increase in infant’s blood volume, and that this in turn translates to improved clinical outcomes.12

A Cochrane systematic review concluded that OCM for preterm infants reduces death before discharge compared with early cord clamping (ECC) (RR 0.73, 95% CI 0.54 to 0.98, data from 20 studies inclusive of 2680 infants).1 There was also a reduction in the rates of IVH (RR 0.83, 95% CI 0.70 to 0.99, 15 studies, 2333 infants), need for blood transfusion (RR 0.66, 95% CI 0.5 to 0.86, 2280 infants, 11 studies) and for inotropic support (RR 0.37, 95% CI 0.17 to 0.81, 250 patients, 5 studies).1 A further Cochrane review also found benefits for term infants with a reduced risk of iron deficiency at 3–6 months with OCM compared with ECC (RR 2.65, 95% CI 1.04 to 6.73, 1152 infants, 5 studies).2 Rates of jaundice requiring treatment were lower in term infants receiving ECC (RR 0.62 95% CI 0.41 to 0.96, 7 trials, 2324 infants); however, with phototherapy being a commonly available and safe treatment, the balance of risk benefit is felt to favour OCM in term infants that are well at birth.2 The overall number needed to treat with OCM to avoid one death is estimated at 30–50, and this may be much lower for the most preterm babies.13 The drive to embed OCM into routine neonatal practice is reflected in its inclusion into NNAP benchmarking standards.9

Situations in which OCM is not appropriate include when there is an immediate need for resuscitation of either the infant or mother, in which case this must be prioritised, or concerns regarding the integrity of the cord or placenta (such as lack of cord pulsation, cord snapping, placental abruption or separation).13 The safety profile of OCM in multiple births continues to be debated. Several studies support the practice in these infants, and national guidance suggests suitability should be assessed on a case-by-case basis rather than routine exclusion.13–15 However, in monochorionic twins where there is concern of placental vessel anastomoses (twin-to-twin transfusion syndrome or twin anaemia polycythaemia sequence), there is a risk of draining blood from one twin to the other during the procedure, thus these infants are often excluded from OCM.

The British Association of Perinatal Medicine (BAPM) published a ‘Quality Improvement Toolkit’ that supports OCM practice.13 Robust QIP methodologies that can be directly applied to improve OCM rates are highlighted, along with insights from successful projects.13 The importance of effective communication and team-working is emphasised; this is particularly pertinent in OCM which relies on collaboration between the whole perinatal team to be successful.13 Other key priorities in QIP design include supporting thermal regulation, lung aeration and parental involvement.13

Dunne et al described higher rates of admission hypothermia in preterm infants following the routine adoption of OCM in their unit from 6% to 54% in a recently published letter.16 Admission hypothermia is independently associated with a significant increased risk of death in preterm infants thus the importance of maintaining normothermia during OCM is essential.17

Measurement

Prior to QIP commencement, we conducted an updated baseline audit of OCM rates for infants <34 weeks in the preceding 4 months (June–September 2022). This threshold of prematurity was selected to be in line with NNAP audit standards. Only infants born at our unit were included, as we were the team responsible for management in the delivery room. Data were derived from ‘BadgerNet’, the electronic patient record that holds data for all infants admitted to UK neonatal units.18 We expect this to reliably reflect management for infants born below 34 weeks gestation as these patients are routinely admitted for further care and there is a dedicated place to record the timing of cord clamping at birth on the admission episode.

In total, 32.4% of infants <34 weeks received OCM of ≥60 s between June and September 2022 (n=12/37); 43.2% of infants had their cord clamped immediately after birth (n=16/37), 18.9% received <60 s of OCM (n=7/37) and cord clamping duration was unknown in 5.4% of cases (n=2/37).

In addition to the duration of deferred cord clamping, we recorded key demographic information, including gestation and mode of delivery, along with the reason for failed OCM where relevant and admission temperature. These same data were collected following QIP commencement and reviewed monthly. The first cycle of our audit completed at 4 months following initiation as planned. Review of this data informed ongoing follow-up to a total of 9 months to ensure OCM practice had fully embedded into unit practice.

Design

The provision of OCM relies on engagement and effective communication across the multiple specialties involved in the delivery of preterm infants. We therefore formed a multidisciplinary QIP team comprised of neonatologists, neonatal nurses, midwives, obstetricians and anaesthetists. As a team, we committed to employing robust, evidence-based methodologies in the design of our project; a multicycle ‘plan-do-study-act’ (PDSA) approach was utilised. In the planning phase, we circulated a survey to midwifery, obstetric, anaesthetic and neonatal staff to better understand barriers to OCM and explore change ideas. This informed a driver diagram (figure 1) and interventions which included the development of an OCM guideline, education sessions and sharing OCM rates with the whole perinatal team to encourage ownership and share successes.

Figure 1

Driver diagram and change ideas. MDT, multidisciplinary team; M&M, morbidity and mortality; MW, midwifery; NN, neonatal; OBS, obstetric; OCM, optimal cord management; QIP, quality improvement project.

Strategy

Our first PDSA cycle aimed to introduce our OCM guideline. This was developed by the multidisciplinary QIP team, presented and formally approved at a local clinical governance meeting. Multiple education sessions were held to support guideline introduction and compliance. This included a session at a morbidity and mortality meeting which is well attended by both obstetric and neonatal medical staff, and a dedicated midwife teaching session. These sessions were largely didactic in the form of a lecture presenting the evidence based for OCM and the practicalities of safely performing it. To engage different adult learning styles slides were combined with interactive discussions and a clinical video demonstrating OCM in practice for an extremely preterm infant. Monthly OCM rates were audited throughout this time and disseminated to the whole perinatal team by email.

Monthly review of our OCM rates meant that we were able to respond quickly to any real-time changes. The case notes of all babies<34 weeks were reviewed to derive these and provided an opportunity to reflect on and address any deviations from recommended practice. The learning points from this analysis could then be addressed in our monthly emails. We entered our second PDSA cycle when a drop in OCM rates correlating with a rotational change in junior staff was noted. Our aim here was to ensure that the new OCM guideline was truly embedded into routine practice. Repeat education sessions were initiated, including a dedicated session for new doctors which we plan to continue at further inductions. In addition to the previously designed largely didactic session, an extremely preterm delivery simulation scenario that included OCM was delivered early in the rotation. Posters were developed to reinforce key messages of the guideline and put up in theatre and labour rooms. Regular email communications on OCM rates continued throughout this time.

Results

We successfully improved OCM rates of ≥60 s for infants <34 weeks from 32.4% at baseline (n=12/37, June–September 2022) to an average of 80% over the 4 months following project initiation (n=28/35, October–January 2023) reflecting the first PDSA cycle (figure 2 and table 1).

Figure 2

Percentage of infants <34 weeks achieving OCM of ≥60 s before and after the QIP commencement (indicated by the yellow arrow) in comparison to our target of 40% (indicated by the red line). A timeline of interventions is indicated. OCM, optimal cord management; QIP, quality improvement project.

Table 1

OCM rates and thermal care outcomes for <34 week infants born before and subsequent to QIP introduction

OCM rates fell to 38.5% (n=5/13) in March which corresponded to a change in rotational medical staff (figure 2). A second PDSA cycle, comprised of further education sessions and the development of posters (online supplemental figure 1), was initiated to respond to this. Average rates of successful OCM for the entire intervention period were 72.4% (n=63/87), and we completed the project with 84.6% (n=11/13) of infants <34 weeks receiving OCM for at least 60 s in June 2023 (figure 2).

Supplemental material

There were no major differences with regard to baseline demographic data for the two cohorts that were compared (before QIP and QIP cohort). There was a slightly higher proportion of the most vulnerable preterm infants (22+0–25+6 weeks) in the QIP cohort (online supplemental table 1).

Supplemental material

Rates of admission normothermia were maintained following the routine adoption of OCM (89.2% vs 88.5%), and there was a trend towards higher rates of normothermia in infants who received a full minute of OCM compared with those who required immediate clamping of the umbilical cord (table 1).

Patient notes were reviewed to delineate underlying reasons why OCM failed—this was defined as a lack of documented OCM of at least 1 min. Documentation of OCM status improved following project initiation (missing in 12.0% incidences in the before QIP cohort compared with 0% after, ameliorating any concern of missing data in this group) (online supplemental table 2). The most common reasons for failed OCM were in line with our local guideline (including immediate need for resuscitation and concerns around placental integrity). There were examples where a contraindication of OCM was recorded that was potentially clinically inappropriate—documented reasons included prematurity (n=1), infant size (n=1) and obstetric decision in the absence of either documented fetal or maternal concerns (n=4). Monthly case reviews highlighted these issues in real-time and informed the learning points disseminated in our monthly emails that aimed to overcome these obstacles. There may have been additional cases where OCM was inappropriately failed or truncated as the reason was not documented or clear from the notes. There was one case of an extremely preterm infant born unexpectedly in a bathroom without any equipment to perform OCM safely, thus this case was recorded as other.

Lessons and limitations

There are several important lessons to be learnt from this QIP which saw a dramatic improvement in OCM rates following its initiation. The benefit of using evidence-based methodologies when designing projects is clearly demonstrated. Exploration of barriers and change ideas offered by the whole team an contextualised in a driver diagram informed a multifaceted QIP with interventions that focused on education and effective team-working. We achieved our initial aim of improving OCM rates of ≥60 s for infants <34 weeks to >40% within our first PDSA cycle. Ongoing audit however demonstrated a fall in OCM rates correlating to a change in rotational medical staff and highlighted the need for a further PDSA cycle.

This project also demonstrates the power of an MDT approach to successfully embed an intervention that relies on the collaboration of multiple departments. We formed a multidisciplinary QIP team to appreciate barriers from all perspectives and champion the project among all staff groups. We shared OCM rates monthly with the wider perinatal team to encourage ownership and celebrate successes. The importance of national benchmarking data is also highlighted. NNAP monitoring of key performance indicators allows units to focus their QIP efforts and achieve transformational service improvements.

There were several specific concerns that colleagues raised towards OCM prior to the project, awareness of which was raised through our staff survey and OCM QIP MDT discussions. These included a fear that OCM would increase hypothermia rates and impair the need for immediate resuscitation when needed. We made sure to embed the continuation of thermal control measures, and how to identify babies who need immediate resuscitation within our guideline and education sessions that supported project commencement. Our obstetric colleagues pressed the importance of joint assessment for the baby while maintaining sterility in caesarean sections, thus it was agreed to routinely offer a member of the neonatal team to scrub and provide immediate assessment at the operation table.

Reviewing cases monthly to identify missed opportunities for OCM was incredibly valuable in highlighting and addressing obstacles quickly. Documented reasons that were deemed clinically inappropriate included prematurity and infant size; we were therefore able to address the importance of OCM for these infants in our monthly communications to avoid further issues.

During our project, there was a case of monochorionic diamniotic (MCDA) twins who appropriately received OCM in line with our guideline. Twin 1 had a low haemoglobin after birth followed by a difficult neonatal course, and they sadly died. This triggered anxiety about the appropriateness of OCM in MCDA twins even though the historic concerns around OCM in the context of anastomotic vessels would typically lead to blood draining from twin 2 into twin 1 (born first therefore drop in blood pressure occurs sooner facilitating the gradient that then drives polycytheamia in twin 1 and anaemia in twin 2). A literature search and review of established practice in other units was undertaken to inform our recommendations. A meeting was held to discuss the evidence base that informs the practice of OCM in MCDA twins and agreement made to continue this as long as there were no specific antenatal concerns of twin-to-twin transfusion syndrome or twin anaemia polycythemia sequence. The wording of our guideline was then changed to ensure this was absolutely clear.

The regular evaluation of monthly OCM rates was important in informing our decision to move to a second PDSA cycle as the decline was identified to occur around the time of a change in rotational staff. We therefore changed our aim from ‘guideline introduction’ to sustained integration into clinical practice, with specific thought given not only to how we could educate this group of rotational clinicians but also those joining in the future. A session designed to be delivered at induction was therefore developed.

We acknowledge the limitations of our project. We do not know the exact reason for failed OCM in many cases (32.0% in the before group, and 16.7% in the QIP cohort). The classification of reasons for failed OCM was somewhat subjective due to recording which was mainly deduced from the delivery room narrative. Similarly, the cases of ‘obstetric decision’ which were recorded as potentially inappropriate only took account of the neonatal notes where neither a maternal or neonatal reason was documented. We have not collected data on the seniority of staff members present at delivery, thus are not able to conclude if senior oversight would be an important priority in a further PDSA cycle.

Conclusion

In summary, we achieved our aim of increasing OCM of ≥60 s for infants <34 weeks to >40% following a multiple PDSA cycle QIP. National benchmarking data highlighted the acute need to improve OCM and we are now achieving rates that greatly exceed the most recently published national average of 43%.9 The success of our project relied on engagement from all members of the perinatal team. The formation of a multidisciplinary QIP team, open survey to explore barriers and change ideas and regular MDT staff members teachings and correspondence sharing OCM rates facilitated this engagement.

Ongoing monitoring to ensure that there is not a further drop in OCM rates with the next rotation of trainee medical staff would be important. There is a plan for ongoing education sessions at induction to protect against this. Given the previously reported concerns about hypothermia following the introduction of OCM by others, we were delighted that thermal outcomes were maintained in our cohort.16 The established benefits of OCM for preterm infants means that its introduction into routine practice is a priority. Our experience, which demonstrates that this can be done safely will hopefully support others to undertake their own OCM QIP. We place infants born vaginally into plastic bags and apply a hat at the perineum and encourage the use of sterile plastic bags at caesarean section to support thermal control. Effective communication between the whole perinatal team is essential to facilitate these interventions occurring concurrently to OCM.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • X @JessBS

  • Collaborators Authors would like to acknowledge the support of the entire OCM team: Georgia Ekitzidou, Mina Wanti, Sistine Briones, Beena Yeldo, Tena Cizmesija, Bijaya Chowdhury, Ade Kojeku, Gitty Blum, Iliana Baragan, Lyndsay McNeill, Bonita Lowe, Lynda Imessaoudene, Tabitha Tanqueray and Claire Howarth. We are grateful to all the neonatal, midwifery, obstetric and anaesthetic teams at Homerton University Hospital for their support in delivering OCM.

  • Contributors JB-S, NA, RC and VR were all involved in delivering the optimal cord management QIP and collection of the data that informs our results section. JB-S, NA, RC and VR were all involved in drafting and reviewing the manuscript for submission. NA is the guarantor of this submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.