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  • Quality Improvement Article
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Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse

Journal of Perinatology volume 39, pages 1008–1013 (2019)Cite this article

Subjects

Abstract

Background

Recent reports suggest a rising awareness of sudden unexpected postnatal collapse (SUPC).

Local problem

Five SUPC events during a 17-month period.

Methods

A multidisciplinary team used a quality-improvement approach to develop the intervention. The smart aim was to develop a bundled intervention to eliminate SUPC from occurring in the delivery room during skin-to-skin care.

Intervention

A bundled intervention included a standardized assessment tool and measurement of oxygen saturation levels, with prescribed responses to abnormal values, during skin-to-skin care in the delivery room.

Results

Pre-intervention, there were five SUPC events/9143 live births (incidence 0.54/1000 live births) compared with 0 SUPC events/13,964 live births post intervention, p = 0.011. Special cause variation was achieved after implementation when the number of deliveries between SUPC events exceeded 3-sigma.

Conclusion

A bundled approach to monitoring during skin-to-skin care, including measurement of oxygen saturation, was associated with no additional cases of SUPC.

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References

  1. Poets A, Steinfeldt R, Poets CF. Sudden deaths and severe apparent life-threatening events in term infants within 24 h of birth. Pediatrics. 2011;127:e869–73.

    Article  Google Scholar 

  2. Lehtonen L, Gimeno A, Parra-llorca A. Early neonatal death: a challenge worldwide. Semin Fetal Neonatal Med. 2017;22:153–60.

    Article  Google Scholar 

  3. Ludington-Hoe SM, Morgan K. Infant assessment and reduction of sudden unexpected postnatal collapse risk during skin-to-skin contact. Newborn Infant Nurs Rev. 2014;14:28–33.

    Article  Google Scholar 

  4. Feldman-Winter L, Goldsmith JP. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics . 2016;138:e20161889.

    Article  Google Scholar 

  5. Lutz TL, Elliott EJ, Jeffery HE. Sudden unexplained early neonatal death or collapse: a national surveillance study. Pediatr Res. 2016;80:493–8.

    Article  Google Scholar 

  6. Pejovic NJ, Herlenius E. Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment. Acta Paediatr Int J Paediatr. 2013;102:680–8.

    Article  Google Scholar 

  7. Becher J-C, Bhushan SS, Lyon AJ. Unexpected collapse in apparently healthy newborns--a prospective national study of a missing cohort of neonatal deaths and near-death events. Arch Dis Child Fetal Neonatal Ed. 2012;97:F30–34.

    Article  Google Scholar 

  8. Andres V, Garcia P, Rimet Y, Nicaise C, Simeoni U. Apparent life-threatening events in presumably healthy newborns during early skin-to-skin contact. Pediatrics. 2011;127:e1073–1076.

    Article  Google Scholar 

  9. Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks, and preventive measures. Transl Stroke Res. 2013;4:236–47.

    Article  Google Scholar 

  10. Thach BT. Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards. J Perinatol. 2014;34:275–9.

    Article  CAS  Google Scholar 

  11. Neuburger J, Walker K, Sherlaw-Johnson C, Van Der Meulen J, Cromwell DA. Comparison of control charts for monitoring clinical performance using binary data. BMJ Qual Saf. 2017;26:919–28.

    Article  Google Scholar 

  12. Feldman-Winter L. Evidence-based interventions to support breastfeeding. Pediatr Clin North Am. 2013;60:169–87.

    Article  Google Scholar 

  13. Policy Statement. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–e841.

    Article  Google Scholar 

  14. ACOG Committee Opinion. Optimizing support for breastfeeding as part of obstetric Practice. Committee opinion 756. Obstet Gynecol. 2018;132:e187–e196.

    Article  Google Scholar 

  15. Meek JY, Noble L. Implementation of the ten steps to successful breastfeeding saves lives. JAMA Pediatr. 2016;170:925–6.

    Article  Google Scholar 

  16. Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr. 2016;170:923–4.

    Article  Google Scholar 

  17. Garofalo NA, Pellerite M, Goodstein M, Paul DA, Hageman JR. Sudden unexpected postnatal collapse (SUPC): one neonatal death is one death too many. Current concepts. Neonatol Today. 2019;14:55–58.

    Google Scholar 

  18. Garofalo NA, Pellerite M, Goodstein M, Paul DA, Hageman JR. Sudden unexpected postnatal collapse (SUPC): one neonatal death is one too many Part 2: Collaborative Quality Initiatives. 2019;14:4–6.

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Funding

The project was completed with no specific financial support.

Author information

Authors and Affiliations

  1. Division of Neonatology, Department of Pediatrics, Christiana Care Health System, Newark, DE, USA

    David A. Paul, Neal D. Goldstein & Stephen A. Pearlman

  2. The Sidney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, PA, USA

    David A. Paul & Stephen A. Pearlman

  3. Department of Nursing, Women and Children’s Services, Christiana Care Health System, Newark, DE, USA

    Dawn Johnson

Authors
  1. David A. Paul
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  2. Dawn Johnson
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  3. Neal D. Goldstein
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  4. Stephen A. Pearlman
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Corresponding author

Correspondence to David A. Paul.

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The authors declare that they have no conflict of interest.

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Paul, D.A., Johnson, D., Goldstein, N.D. et al. Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse. J Perinatol 39, 1008–1013 (2019). https://doi.org/10.1038/s41372-019-0393-y

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  • DOI: https://doi.org/10.1038/s41372-019-0393-y

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