Embracing Change: A Quality Improvement Project to Introduce Deferred Cord Clamping Free

This quality improvement study was conducted in a large, tertiary level neonatal unit in the United Kingdom. Our unit manages infants from extremes of prematurity through to term infants with a range of medical, surgical, and neurosurgical complications. Our service delivers 13 000 infants per year alongside accepting transfers of infants from other hospitals for specialist intervention.¹⁴  Our neonatal and maternity staff are trained in the Newborn Life Support algorithm for management of the newborn at birth.¹⁵  This algorithm is issued by the Resuscitation Council, UK and reflects that deferred cord clamping should be routine care at birth.¹⁶  Before starting this project, we evaluated our in-house rates of deferred cord clamping. Although DCC rates were acceptable and improving in the term population because of a midwifery initiative in this population, the DCC rate in the preterm population (36 + 6 weeks or less) was poor, often 0% of preterm deliveries, and our shared goal was to address this.

We assembled a preliminary quality improvement (QI) team, initially composed of a neonatal resident and attending who met to identify key stakeholders from across perinatal services who would be impacted by implementing DCC for preterm infants. We then invited representatives from each of the key stakeholder professions and departments to meet and discuss the key issues that DCC implementation would pose for their individual teams. These meetings took place over a period of a several months (February–April 2019) and involved mapping out all the potential issues and pitfalls with DCC implementation and potential solutions. Our QI multidisciplinary discussions and mapping process allowed us to then identify that most of the issues and solutions were in relation to 3 key elements of care: equipment, staff, training, and governance. This then provided a frame that we used to assemble our driver diagram (Fig 1) in a clear and structured approach and provided targets for subsequent plan-do-study-act (PDSA) cycles. We focused first on governance, then education initiatives, for our initial PDSA cycles. This was to ensure there were safety mechanisms in place such as relevant guidelines and process flowcharts for staff to maximize DCC being performed safely. Subsequent PDSA cycles were then informed by data from the process control charts and staff feedback to guide the next PDSA cycle intervention.

Our quality improvement project team were keen to promote DCC in all preterm infants. To do so safely, provisions needed to be made for infants who required medical support during the stabilization process. Because of the configuration of the majority of our delivery rooms and theaters, it would not be possible to bring the resuscitaire alongside the mother to provide respiratory support to the infant if required. Instead, we devised a low-cost method to provide DCC to all preterm infants, which facilitated initial infant assessment and thermoregulation measures being performed while DCC was ongoing (Fig 3). In view of the limitation of not being able to provide respiratory support, our agreed QI goal was to increase rates of DCC in preterm infants (36 + 6 weeks or less) to 50% within 18 months.

We used a PDSA cycle approach to implement and progress this change in practice. PDSA cycle 1 focused on presenting the research basis for DCC to the wider clinical neonatal, obstetric, and midwifery teams for discussion (Figs 1 and 2). Once it was established that all 3 professional teams were in agreement to support the implementation of DCC, then a guideline for DCC covering all gestations and locations, both in delivery suite and in theater, was developed and subsequently approved.

Our quality improvement project (QIP) stipulated that deferred cord clamping should be for at least 60 seconds⁹  The QIP method for DCC was dependent on the infant’s gestational age. For infants >33 weeks’ gestation, the infant should be delivered onto the mother’s chest, dried, have a hat applied and assessed as per the NLS algorithm for color, tone, breathing and heart rate. In cases of infants born at <31 + 6 weeks or less, the infant should be delivered and placed into a NeoHeLP (Vygon)⁸  plastic bag on a platform of a Transwarmer wrapped in a towel and assessed as per NLS. If noninvasive breathing support is required, such as continuous positive airway pressure, this can be provided via the transport incubator at the mother’s bedside (Fig 3). In most cases, by the time the team had either dried and assessed, or placed the baby in the plastic bag, applied a hat, and assessed the infant, 60 seconds had passed, and the cord could be cut. We advised the clinical team that in cases of a significantly compromised infant, or if the team did not feel confident with DCC, the cord could be cut immediately and the infant brought to the resuscitaire.

It was essential that other aspects of good quality neonatal care were not impacted in pursuit of implementing deferred cord clamping. A risk area identified early by the QIP team was the potential for infants, particularly the preterm cohort, to become hypothermic while DCC was ongoing at the mother’s bedside. We consulted the literature before commencing our QIP and found that other centers had also experienced concerns regarding hypothermia with DCC.¹⁷  These centers had incorporated use of specialized thermal regulation equipment, such as the NeoHeLP wrap,¹⁸  to ensure normothermia while DCC was ongoing.

Our team opted to include a specific focus on thermoregulation within the DCC guideline and education package. Our DCC guideline recommends use of the NeoHeLP wrap for all preterm infants 32 weeks’ or less gestation. The NeoHeLP wrap is a plastic poncho-style wrap specifically designed for neonatal patients. It fits well around the infant and includes an adjustable hood to maximize coverage and promote effective conservation of heat within the wrap. The wrap includes soft adjustable fastening along the front which allows monitoring wires and/or umbilical lines to emerge from the wrap without creating a gap in the seal of the wrap and compromising thermoregulation. Our DCC protocol stipulated that for all births there should be an assigned member of the neonatal team who was responsible for thermoregulation and would be regularly checking the temperature every few minutes and making adjustments as necessary. Our DCC guideline stipulated that the NeoHeLP bag was to be used as standard in conjunction with the Transwarmer mattress (Draeger)¹⁹  for infants 32 weeks’ or less gestation. Regular temperature checks would ensure infants did not overheat; if their temperature was consistently rising, the Transwarmer should be removed.

The newborn service in which this QIP took place is a large tertiary-level medical and surgical unit with a preexisting, positive simulation culture with twice weekly, multidisciplinary, in-situ simulations. Simulation sessions were essential in allowing the QIP team to develop and refine the process for DCC within our center. Simulation was subsequently used in regular training sessions with the wider clinical team to allow the staff to explore and embed the process of DCC for preterm infants. In addition, the QIP team used simulation to develop a process map and educational training package for preterm DCC in theater. This was developed through multidisciplinary simulation with the neonatal, obstetric, midwifery, anesthetic, and theater teams. Although simulation may not be a familiar teaching, training, or safety testing modality to some clinicians, it can be used in simple and very effective ways to ensure safe and robust patient care and staff safety; for example, by using low fidelity simulation to ‘walk through’ proposed changes in practice and develop new process flow maps. This is vital, because the first time a system or flow process is tested should not be with a real patient.

To avoid spread of the coronavirus disease 2019, many face-to-face mandatory and educational courses and conferences were cancelled during 2020. In response to these restrictions, the QIP team developed videos covering theoretical and research basis for DCC alongside the practical aspects of how to provide DCC safely. The prerecorded videos ensured that content was consistently delivered by a member of the QIP team and approved by the whole QIP team. The videos could be accessed via staff intranet or E-mail and have been downloaded onto education team computers and tablets for ease of use (BitLy link to the practical provision of DCC: https://bit.ly/3apHide), allowing socially distanced and remotely accessible learning.

Statistical process control charts (p charts) were used to track monthly QIP data, allowing the QIP team to monitor progress and the impact of successive PDSA cycles. After 2 consecutive above average months, the DCC p chart would be rebased, increasing to a higher average. Statistical analysis was performed using comparative percentage analysis for the p chart data. Two-tailed t test was used for parametric variables, such as gestational age and temperature. For categorical variables, such as delivery modality, the χ² test for independence was applied.

Staff feedback was gathered in relation to deliveries where DCC was not performed. We identified eligible infants who had not received DCC from the electronic patient record. A designated member of the QI team then sent targeted individual emails to members of the clinical team involved in the infant’s delivery requesting details as to why DCC had not been performed. Feedback was requested via E-mail initially. If there was no response to E-mail, the designated QIP member would seek out verbal feedback from staff and collate this for themes in an anonymized spreadsheet.

The authors sought guidance from the Trust Research and Audit department and were advised that because this was a quality improvement project, approval from an ethics panel was not indicated.

Over the QIP period, rates of deferred cord clamping for preterm infants increased from zero to 45%. This increase in provision of preterm DCC has been sustained over time indicating that this aspect of preterm care is being embedded successfully within our team.

Our QIP data showed no statistically significant differences between infants receiving DCC and those who did not for gestational age (P value .808) or birth weight (P value .948). For those that received DCC, the mean gestation was 33 + 3 weeks (range 24 + 0–36 + 5 weeks) and the mean birth weight was 1977 g (range 676–2910 g). This is similar to those who did not receive DCC during the QIP period, in which the mean gestation was 32 + 2 weeks (range 24 + 3–36 + 4 weeks) with a mean birth weight of 1960 g (range 666–3490 g). Of note, there was a statistically significant difference between the delivery modalities between the 2 groups (P value <.00001). For those infants who received DCC, 63% were delivered via vaginal delivery. In contrast, 70% of infants who did not receive DCC were delivered via LSCS. This may represent logistical issues providing DCC in theaters. Our DCC guideline and education package does cover provision of DCC in theater; therefore, this finding may instead reflect that the indication for the lower segment caesarian section, such as fetal distress, may result in these infants being born in poor condition and, hence, not receiving DCC. Provision of DCC to the compromised preterm infant will be a target for improvement for the next phase of our QIP (cycle 6) with the implementation of the LifeStart trollies, which are able to provide respiratory support while DCC is ongoing.

Admission temperature was monitored for each infant throughout the QIP. There was no significant difference in mean or temperature range for the pre- and post-QIP infant cohorts (Fig 5). The average admission temperature in the pre-QIP cohort (March 2019) was 36.8°Celsius with a range of 35.5° to 37.7°C. The post-QIP cohort (Feb 2021) were divided into those infants who had received DCC and those who had not. For those that did receive DCC the mean admission temperature was 36.5 C with a range of 35.6° to 37.7°C. For those that did not receive DCC, the mean was 36.8°C with a range of 35.5° to 38.2°C. There was no statistically significant difference between the mean admission temperatures pre-QIP and post-QIP (P value .093) and no statistically significant difference within the post-QIP cohort of infants who received DCC versus those who did not (P value .109).

After persistently low rates of DCC between April and September 2019, the QIP team tracked all admissions in which DCC had not been performed over the next 3 months (October–December 2019) and collected feedback from staff at the delivery as to the reason DCC had not been performed. Feedback indicated that common reasons for not performing DCC were respiratory or cardiovascular compromise of the infant (50%) and lack of time to prepare for DCC before the infant delivered (50%). This staff feedback enabled the QIP team to target the midwifery and obstetric teams to encourage them to call the neonatal team earlier in the case of preterm delivery. This facilitated time for the neonatal team to discuss and agree performing DCC with the maternity team and parents, and to prepare the NeoHeLP bag and Transwarmer for those infants 32 weeks’ or less gestation. This was implemented in PDSA cycle 3, and progressive improvements in DCC rates were then seen going forward.

Our QIP has created a significant and sustained change in practice with deferred cord clamping now being considered a routine part of neonatal care at our center. This QIP shows that DCC can be implemented for preterm infants with simple, readily accessible techniques. We are proud of the significant progress we have made in being able to provide DCC to preterm infants who are not cardiovascularly compromised at birth and increasing our preterm DCC rate from 0% to 45%.

An additional strength of our QIP is our focus on length of time for DCC. Large scale studies show improved outcomes for preterm infants when cord clamping was deferred for at least 60 seconds.²⁰  Therefore, our QIP required the infant to have received at least 60 seconds of DCC for this to be counted as deferred cord clamping. Within our QIP cohort, some infants received 30 to 40 seconds of DCC (<60 seconds) and, therefore, were categorized as not receiving DCC in our analysis. Comparison of our data with other studies shows that there are several QIP publications that cite higher and more rapid improvements in DCC practice than we were able to achieve in our center.^21,22  There are several potential reasons for this finding. Most pertinent is the individual QIP definition for deferred cord clamping. Other publications report including infants as receiving DCC even if the cord was clamped after 30 seconds. This definition is within the scope of the American College of Obstetricians guidelines, which recommend DCC for 30 to 60 seconds.²³  Although using this shorter time duration (> 30 seconds) would have improved our reported rates of achieved DCC, this is not the definition provided by WHO, the British Association of Perinatal Medicine, or National Institute of Clinical Excellence.^24–26  Therefore, for our QIP, we stipulated that DCC must be for at least 60 seconds.

The size of our center is another relevant factor likely to have an impact on the rapidity of uptake of DCC provision. The Pauley et al QIP cites increased rates of DCC to 96% after 6 weeks in a center that delivers 2600 infants per year.²²  This finding is impressive and is to be commended. The rate of change in our QIP was significantly slower. This may be influenced by the fact that our QIP was conducted in a maternity service that delivers 13 000 infants per year.¹⁴  Larger centers have increased numbers of staff, and this increases the complexity of QIP training for staff and staff reaction to the QIP change in practice. In our experience of conducting this QIP, the reaction from the wider clinical team was highly variable, with some staff being reluctant to embrace DCC and the change in working practices at birth that safe provision of DCC necessitates.

Poor staff acceptance and lack of engagement with a change project is the commonest cause for project failure²⁷  Resistance to change must be accounted for in the project planning, and strategies to provide a clearly articulated ‘why’ behind the project are essential to maximize staff engagement and, therefore, increase likelihood of project success.^28,29  In relation to our QIP, we had preexisting experience of successful deferred cord clamping in other neonatal units and were able to draw on this experience in education sessions with staff. Sharing stories of successful DCC in practice and the positive impact this had clinically and emotionally for families was helpful in providing an engaging narrative with which staff could understand and connect. These discussions with staff took place through a series of education sessions, including nursing mandatory training and simulation sessions, and facilitated greater acceptance of this change in practice. Acknowledging the difficulties with implementing a new practice in a busy center is important to allow staff to feel that their concerns have been heard. Our approach to gaining staff feedback in cases in which DCC had not been performed was another avenue to allow staff to express the difficulties they were facing in delivering DCC and allowed our QIP team to address these issues through subsequent PDSA cycles (Fig 2). For example, some neonatal staff felt apprehensive about working so close to the mother in her personal space and were concerned about being in the way of the obstetricians. These concerns were addressed by discussing how and where the neonatal team needed to be situated for DCC, for example, at the side of the mother and, therefore, not obstructing the obstetrician or compromising the mother’s care. Our education sessions stipulated that the neonatal team are responsible for the infant once it is born so neonatal staff should be present at the mother’s bedside, especially for preterm infants, to assess the infant and decide if DCC is appropriate. Neonatal team presence in this context is likely to be reassuring for the parents and midwifery staff. This type of staff discussion during the training sessions allowed our QIP team to address staff concerns and present them with the evidence basis behind DCC and the distinct benefits it confers for preterm infants. These sessions allowed us to provide the ‘why’ behind the need for preterm DCC. As seen by the increased DCC rates after increased education initiatives, such as in November 2020, addressing the ‘why’ behind QI is a vital component for success.

Our next goal for this QIP is to address the safe provision of respiratory support for compromised infants while performing DCC. This would allow us to increase our target and aim for DCC in a higher percentage of preterm infants. To achieve this our QIP team have produced a business case for the acquisition of LifeStart trollies. The LifeStart trolley is a piece of medical equipment which is small, portable, and can be easily maneuvered to be next to the mother at delivery and provides a stable, warmed surface, enabling the neonatal team to provide interventions, such as airway support, while DCC is ongoing. Our business case has been approved, and we look forward to using our QIP methodology to implement this next phase of change. Our revised goal will be to increase preterm DCC to 80% over the 12 months after introduction of the LifeStart trolley.

Deferred cord clamping should be considered a standard part of delivery room care and preterm stabilization. Implementing a significant, sustained change in practice is time-consuming and requires coordinated multidisciplinary input. The QIP team must be conscious that change can be an intimidating prospect for the wider clinical team and, therefore, must be done sensitively with a clear rationale and techniques for making the ‘why’ behind the change accessible. This allows emotional engagement between staff and the project. Without this, the QIP is unlikely to be successful in the long term.

The authors acknowledge the contribution of the following members of the quality improvement project team who have helped pushed the project forwards: Stephanie Dow, Penelope Heap, Alison Smith, Victoria Beech, Stella Adiru, Katy McKie, Karim Zuberi, Helen Porte, Ellie Hunter, Reem Ghalib, Rebecca Ollerenshaw, Nishita Das, and Reuben Gibbons.