制定单中心质量捆绑包以预防突然意外的产后崩溃。
Development of a single-center quality bundle to prevent sudden unexpected postnatal collapse.
机构信息
Division of Neonatology, Department of Pediatrics, Christiana Care Health System, Newark, DE, USA.
The Sidney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, PA, USA.
出版信息
J Perinatol. 2019 Jul;39(7):1008-1013. doi: 10.1038/s41372-019-0393-y. Epub 2019 May 14.
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.
背景
最近的报告表明，人们对产后突发意外性虚脱（SUPC）的认识有所提高。
当地问题
在 17 个月期间发生了 5 起 SUPC 事件。
方法
一个多学科团队采用质量改进方法来制定干预措施。明智的目标是制定一个捆绑式干预措施，以消除在皮肤接触护理期间发生在产房的 SUPC。
干预措施
捆绑式干预措施包括标准化评估工具和测量皮肤接触护理期间的氧饱和度水平，并对异常值规定了相应的反应。
结果
干预前，9143 例活产中有 5 例 SUPC 事件（发生率为 0.54/1000 活产），而干预后 13964 例活产中无 SUPC 事件，p=0.011。实施后达到特殊原因变异，当 SUPC 事件之间的分娩次数超过 3 个标准差时。
结论
在皮肤接触护理期间进行监测的捆绑式方法，包括测量氧饱和度，与没有发生额外的 SUPC 病例有关。
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