New findings show that the practice of delayed cord clamping varies widely across hospitals in California. A total of 52 California Perinatal Quality Care Collaborative (CPQCC) member hospitals submitted data on delayed cord clamping (DCC) in 2016, and hospital rates of DCC were found to range from 0 to 74.5 percent. Overall, infants <32 weeks or with a birth weight of <1500 grams were more likely to receive DCC, though many hospitals reported significant gaps in data collection.
Delaying cutting the umbilical cord by one to three minutes after birth has been demonstrated to provide multiple health benefits to babies, and especially preemies. It may improve hematologic status and iron stores and decrease the need for blood transfusions, mechanical ventilation, and surfactant.
It remains largely unknown with what frequency hospitals practice DCC in the delivery room. This is one of the first multicenter studies to address adoption of DCC and hospital- and patient-level factors that may predict the likelihood of receiving DCC.
During 2016, data were collected on a total of 5,332 CPQCC-eligible infants, and 1,555 (29 percent) received DCC. The majority of infants who received DCC experienced a delay between 30 and 60 seconds (65 percent). Lower rates of DCC were associated with infants born by C-section, and those of Hispanic race as compared to White race. Hospitals with less than 50 neonatal intensive care unit (NICU) beds were more likely to practice DCC, whereas Level 3 American Academy of Pediatrics NICUs, non-profit hospitals, and teaching institutions were less likely to practice DCC.
Preterm infants were more likely to receive DCC compared to term infants, though data were collected only on CPQCC-eligible infants who were admitted into the NICU and/or required intensive care. Given the sample represented sicker babies and excluded healthier babies, overall rates of DCC in the general population may not be fully reflected in this study.
A paper discussing the study’s findings was published online on March 21 in the American Journal of Perinatology. Henry C. Lee, MD, a neonatologist who serves as the Chief Medical Officer for CPQCC and is an Associate Professor of Pediatrics at Stanford University, is the senior author; former CPQCC intern Chinh L. Tran is the lead author. Tran is now a medical student at the University of California, Irvine.
From recommendation to adoption
In 2012, the American College of Obstetricians and Gynecologists recommended DCC for at least 30 to 60 seconds for preterm infants, and in January 2017 they updated the recommendation to include healthy, term infants. The World Health Organization, American Academy of Pediatrics, Neonatal Resuscitation Program, and American College of Nurses and Midwives also endorse DCC.
While the benefit of DCC has been suggested for some time by advocates, the alignment of professional societies and groups that review and endorse evidence-based guidelines on a consensus on this topic is relatively recent. According to Dr. Lee, use of antenatal steroids prior to preterm delivery may offer a rough estimate of how long it has taken in the past for widespread adoption of a multi-disciplinary perinatal recommendation. “It took a long time to get people to adopt, and we are still working toward universal implementation since CPQCC started more than 20 years ago,” says Dr. Lee.
The implementation of DCC is still new for some hospitals, and gaps exist in providing support for providers to practice DCC and track progress.
Because CPQCC primarily collects NICU data, collecting data on a procedure that happens in the delivery room presented a unique challenge. Janella Parucha who managed the project explains, “We wanted to see how feasible it was for hospitals to starting collecting data on delayed cord clamping. The first hurdle for us was trying to figure out how we were going to get our people this information and submit the data.”
Santa Clara Valley (SCV) Medical Center served as a reference point for participating hospitals; co-author, neonatologist, and member of the Perinatal Quality Improvement Panel of CPQCC Priya Jegatheesan, MD, was a champion of the DCC project at SCV. The hospital had been practicing DCC and had been collecting data for more than three years prior to when the study began. Developing a collection process using the Epic electronic medical record, SCV staff were able to offer advice to other units on what had worked for them.
Throughout the project, Parucha conducted quarterly webinars with participating hospitals to assess the collection process. During the webinars, participating centers shared their experiences and tips, giving presentations on their progress. This sharing of ideas facilitated a collaborative learning environment. Based on the thoughts and information provided by participants at community, intermediate, and regional hospitals, Parucha helped create tip sheets about DCC data collection that have now been distributed to all 140 CPQCC member hospitals.
Tips have focused on bringing together leadership from obstetrics and neonatology and disseminating information on why delayed cord clamping is important. “A lot of the hospitals, once they realized this is something that is recommended by ACOG and WHO, we got a lot more buy in,” says Parucha.
Rates of delayed cord clamping increased over the course of the year, from an average of 21 percent in January 2016 to 37 percent in December 2016.
Future support for hospitals
Data collection revealed that non-teaching hospitals were more likely to practice DCC, with 75 percent of infants who received DCC being delivered at non-teaching hospitals.
While this study did not attempt to identify further differences between the 52 participating NICUs, the authors infer that it is less likely for DCC to be practiced at teaching hospitals for a variety of reasons including high delivery volume, staffing, and factors associated with high-risk deliveries. Parucha learned from the project that having the necessary support structure is often key to DCC adoption, and CPQCC may target future quality improvement initiatives to help improve workflow at teaching hospitals to optimize DCC.
CPQCC is continuing to understand more about how DCC is being implemented throughout the state. In January 2018, the organization began collecting data on DCC for all 140 CPQCC member hospitals. Dr. Lee says future quality improvement initiatives may “involve improving data quality amongst hospitals and then helping people to engage a multi-disciplinary team in order to adopt the practice, and standardizing policies for patients.”
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By: Laura Hedli
Laura Hedli is a writer for the Division of Neonatal and Developmental Medicine at Stanford University School of Medicine. You can reach her at lhedli@stanford.edu.