Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse

Area of Science:

• Neonatal care
• Quality improvement in healthcare
• Infant safety protocols

Background:

• Sudden unexpected postnatal collapse (SUPC) is a growing concern in neonatal care.
• Previous reports indicate an increasing awareness of SUPC events.
• A local problem of five SUPC events over 17 months necessitated intervention.

Purpose of the Study:

• To develop and implement a bundled intervention aimed at eliminating SUPC during skin-to-skin care in the delivery room.
• To improve infant safety by addressing the risks associated with postnatal collapse.

Main Methods:

• A multidisciplinary team employed a quality-improvement approach.
• A bundled intervention was created, including a standardized assessment tool and oxygen saturation monitoring.
• Prescribed responses to abnormal oxygen saturation values were established for skin-to-skin care.

Main Results:

• The incidence of SUPC decreased from 0.54 per 1000 live births pre-intervention to zero post-intervention.
• No SUPC events occurred in 13,964 live births after the intervention's implementation (p=0.011).
• Statistical analysis showed special cause variation, indicating the intervention's effectiveness.

Conclusions:

• A bundled monitoring approach during skin-to-skin care, incorporating oxygen saturation measurement, was associated with the elimination of SUPC.
• This quality improvement initiative successfully enhanced infant safety in the delivery room.
• Standardized protocols for monitoring newborns during skin-to-skin care are crucial for preventing adverse events.