通过质量改进方法促进极早产儿延迟脐带结扎实施  

Promoting the implementation of delayed cord clamping in very preterm infants by quality improvement method

作　　者：宋思捷[1,2,3] 欧姜凤 秦诺 朱叶芳 吴艳[1,2,3] 龚华[1,2,3] 陈文[1,2,3] 叶俊英 钟晓云[1,2,3] Song Sijie;Ou Jiangfeng;Qin Nuo;Zhu Yefang;Wu Yan;Gong Hua;Chen Wen;Ye Junying;Zhong Xiaoyun(Department of Pediatrics,Women and Children's Hospital of Chongqing Medical University,Chongqing 401147,China;Department of Neonatology,Women and Children's Hospital of Chongqing Medical University,Chongqing 401147,China;Perinatal Medical Center,Chongqing Health Center for Women and Children,Chongqing 401147,China)

机构地区：[1]重庆医科大学附属妇女儿童医院儿科,重庆401147 [2]重庆医科大学附属妇女儿童医院新生儿科,重庆401147 [3]重庆市妇幼保健院围产医学中心,重庆401147

出　　处：《中华围产医学杂志》2024年第6期490-498,共9页Chinese Journal of Perinatal Medicine

基　　金：重庆市科卫联合医学科研项目重点项目(2022ZDXM035);重庆市科卫联合医学科研项目面上项目(2021MSXM116,2021MSXM239)。

摘　　要：目的探讨质量改进(quality improvement,QI)促进极早产儿实施延迟脐带结扎(delayed cord clamping,DCC)的作用。方法回顾性收集2017年1月至2021年1月重庆医科大学附属妇女儿童医院出生并转入新生儿科的极早产儿的基本资料和QI评价指标。QI评价指标包括(1)过程指标:DCC实施率及时间;(2)结局指标:血红蛋白和红细胞压积等;(3)平衡指标:产房内气管插管比例、胸外按压比例、Apgar评分以及入院时体温和血气pH值等。评价指标分析时分为4个阶段,分别为QI实施前期(2017年1~12月)、QI实施期(2018年1~12月)、QI实施后期(2019年1~12月),以及持续QI期(2020年1月至2021年1月)。QI项目自2018年8月起实施。通过绘制控制图或采用统计检验[包括单变量方差分析、Mann-Whitney U检验及χ^(2)检验(或Fisher精确概率法)]进行分析。结果(1)过程指标:实施QI项目后,DCC平均实施率及平均实施时间从0分别逐渐增加至82.2%和47.1 s。(2)结局指标:血红蛋白水平在QI实施期、QI实施后期及持续QI期均明显高于QI实施前期[分别为(202.22±28.84)、(210.10±33.52)、(210.52±32.27)与(187.94±35.29)g/L,F=8.61,P<0.001]。QI实施后期和持续QI期极早产儿的红细胞压积明显高于QI实施前期[(58.99±8.71)%、(60.18±8.06)%与(55.41±9.17)%,χ^(2)=5.13,P=0.002],其余指标差异无统计学意义。(3)平衡指标:QI实施后期和持续QI期产房内气管插管比例低于QI实施前期[16.0%(19/119)和13.2%(25/191)与42.3%(30/71),χ^(2)=29.08,P<0.001],入院时体温逐渐上升[QI实施前期、实施期、实施后期和持续QI期分别为35.3℃(34.5~36.1℃)、36.0℃(34.0~37.7℃)、36.0℃(35.6~37.4℃)和37.0℃(35.9~38.1℃),H=277.88,P<0.001]。持续QI期入院时血气pH值为7.32(6.85~7.50),高于其余3个时期[7.26(7.07~7.46)、7.26(7.04~7.43)与7.25(6.91~7.49),H=34.46,P<0.001]。结论该QI项目提高了极早产儿DCC实施率,延长了DCC时间。Objective To investigate the effect of quality improvement(QI)project on delayed cord clamping(DCC)implementation in very preterm infants.Methods This study retrospectively collected the clinical data and assessed the QI indices of very preterm infants born in the Women and Children's Hospital of Chongqing Medical University and transferred to the Neonatology Department from January 2017 to January 2021.The indices for QI assessment included three types:(1)process indices:the implementation rate and timing of DCC;(2)outcome indices:hemoglobin level and hematocrit,etc;(3)balancing indices:the proportion of neonates requiring endotracheal intubation in the delivery room and chest compressions,Apgar score body temperature,and blood pH value on admission,etc.There were four phases for the implementation of QI,the pre-QI period(January to December of 2017),the QI period(January to December of 2018),the post-QI period(January to December of 2019),and the sustained-QI period(January 2020 to January 2021).The QI project was performed since August 2018.Control charts or statistical tests were used for statistical analysis.Results(1)Process indices:After the implementation of the QI project,the practice of DCC increased from 0 to 82.2%,and the timing of umbilical cord clamping was from 0 s to a delay of 47.1 s.(2)Outcome indices:The levels of hemoglobin in the QI period,the post-QI period,and the sustained-QI period were significantly higher than those in the pre-QI period[(202.22±28.84),(210.10±33.52),(210.52±32.27)g/L vs.(187.94±35.29)g/L;F=8.61,P<0.001].The hematocrit values in the post-QI period and the sustained-QI period were significantly higher than those in the pre-QI period[(58.99±8.71)%,(60.18±8.06)%vs.(55.41±9.17)%;χ^(2)=5.13,P=0.002].The other indices showed no statistical differences in different phases.(3)Balancing indices:The proportions of neonates receiving endotracheal intubation in the delivery room in the post-QI period and the sustained-QI period were significantly lower than those in the pre-

关 键 词：质量改进 结扎术 脐带 婴儿 极度早产 新生儿护理 

分 类 号：R722.6[医药卫生—儿科]