The Use of Placental Blood on Admission to

The Use of Placental Blood on Admission to the NICU Copyright Monet Nicole Birthing Stories Denver, CO Audrey Nervig DNP, NNP Lori Rubarth, Ph. D, APRN, NNP-BC Creighton University

Disclosure • The author declares that she has no relevant or material financial interests that relate to the evidence based practice implementation described in this presentation

Background / Significance • Phlebotomy = Poor patient Outcomes • Pain 7, 8, 12, 18 • Blood Loss 1 • Anemia 19 • Early Blood Transfusion 4, 19 • Intraventricular Hemorrhage (IVH) 4 • Historical Misconceptions 5, 9, 16 • False results • Correlates with maternal labs • Not feasible or sustainable

Purpose • To implement and assess the feasibility and efficacy of drawing initial laboratory specimens for all infants upon admission to the NICU from the otherwise discarded placenta, eliminating the need for heel lance, venous sticks, and arterial draws. • Doctorate of Nursing Practice Project

Supporting Research Evidence • Correlation 2, 3, 9, 10, 11, 15, 16 • Complete Blood Count with Differential • Blood Culture • Feasibility and Sustainability 1, 5 • Benefits of Placental Draws 1, 5 • Higher Hemoglobin • Decreased Blood Transfusion • Elimination or Decrease in Severity of IVH

Setting and Sample • Midwest Level III 35 bed NICU • All infants admitted to NICU will have initial phlebotomy drawn from placenta • Evaluate infants < 1500 grams pre- and postimplementation • Non eligible infants: • Admitted to NICU from outside hospital or newborn nursery • Placental abruption • Cord blood banking • RN unable to draw useable specimen from placenta

Implementation 1. CBC with differential Comparison (N=20) 2. Trained NICU staff RNs to draw placental blood 3. Policy and Practice Change 4. Retrospective Chart Review 5. Analysis and Interpretation

Materials for Drawing Blood from the Placenta

Results

Results

Results

Results Intraventricular Hemorrhage Intraventricular Incidence and Grade Hemorrhage Pre-Implementation (N=2) Grade 3 -4 IVH Post-Implementation (N=1) Grade 1 IVH

Results Intraventricular Feasibility and Sustainability Hemorrhage • Placental Blood Draw Success Rate (N=12) • 56% for CBCs • 75% for Blood Cultures • No contaminated specimens • Genetic Screening (Karyotype and Microarray) • Incorporated into standard of practice • RN Staff • No increased cost to the unit

Limitations and Opportunities • EBP implementation project, could not control for variables • Resistance to change • Learned skill

Further Outcome Evaluations • Continued evaluation • Process Improvement • Development of RN skill expertise • Newborn Metabolic Screening • Standardized reference range for CBC indices drawn from placental blood

Take Home Message • Drawing admission lab specimens from the placenta for VLBW infants • May increase hematocrit levels • May delay early blood transfusions • May decrease incidence and/or severity of IVH • Is a feasible and sustainable procedure • Has additional clinical benefits • Additional Evaluation is needed

Acknowledgements • Lori Rubarth, Ph. D, APRN-NP, NNP-BC • Brenda Wallingford, DNP, APRN-NP, NNP-BC • Molly Schlegel, DNP, APRN-NP, NNP-BC • Tracy Meyers, RN, BSN • Terrance Zach, M. D. • John Schmidt, M. D. • Harold Kaftan, M. D. • Brenda Horton, MT(ASCP) • Craig Stacey, MBA, MT(ASCP) • RN Staff of CHI Health Bergan Mercy Medical Center • Tom Rubarth, Graphic Design

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Questions? Copyright Emma Jean Photography Brisbane, Queensland, Australia

Additional Slides for Questions Copyright Emma Jean Photography Brisbane, Queensland, Australia

Correlation – Research Evidence • Blood Culture • • Copyright Emma Jean Photography Brisbane, Queensland, Australia Low contamination rate 2, Low false positive rate, 9, 15 High specificity, sensitivity, and positive predictive value 11 Detects more pathogens than peripheral samples 10, 11 • CBC with Differential • • • Moderate to high statistically significant correlation between WBC 3, 9 High correlation between I: T ratios No statistical difference in false positives 3, 9 A significant high correlation for Hct and Hgb 3, 9 and High correlation for platelets 9 • Overall infant values are independent of maternal values 16