393 - Risk-Stratified De-Medicalization of Delivery Plans for Infants with Ductal-Dependent Congenital Heart Disease Supports Family Centered Care

Poster Number: 393
Publication Number: 393.2215

Background: Infants with prenatally diagnosed ductal-dependent congenital heart disease (DDCHD) born at our center were historically delivered in the obstetric operating room (OB-OR) regardless of mode of delivery to facilitate immediate evaluation and care. Many infants with DDCHD do not require immediate stabilization as the ductus arteriosus remains open.

Objective: We sought to de-medicalize these deliveries, to support parent-infant bonding and reduce the use of limited OB-ORs, by implementing a risk stratifying delivery coordination tool.

Design/Methods: Building on prior work that reduced unnecessary postnatal respiratory intervention using standardized documentation of anticipated initial clinical presentation, a multidisciplinary team developed the “CHD MINT” (Congenital Heart Disease Michigan Initial Neonatal Treatment) tool for infants with prenatally diagnosed CDH. Most DDCHD babies without non-cardiac risk factors were in the “Orange” category (Fig 1). Baseline data were collected prior to implementation (November 2019). Process measure: presence of standardized notes with a preliminary delivery plan in the gestational parent’s chart. Outcome measure: % of vaginal deliveries in the OB-OR, percentage of families with parental-infant bonding time in the first 2 hours of life. Balancing measure: unplanned respiratory support needs in the first 2 hours of life. Data were collected for 3 years following implementation.

Results: In the first 3 years, 141 infants met criteria for the “Orange” CHD MINT category. Initial compliance with standardized wording in consultation notes was high (90%) and remained so. Compliance with creating distinct delivery planning note was initially low at 55% but increased to >90% by 8 months, with sustained compliance; interventions to improve compliance included education, prompts in note templates and personalized notification with cardiologists of compliance rates compared to anonymized peers. Use of OB-ORs for all deliveries decreased after implementation of CHD MINT, primarily driven by a decrease in vaginal deliveries in OB-ORs (Fig 2). Rates of parent-infant bonding in the first hour of life increased (Fig 3) especially among neonates who did not receive respiratory support. There was no change in respiratory support provided with PPV or with prolonged CPAP or intubation in the pre-MINT cohort (N=160) vs the MINT cohort (PPV: 10% pre vs 8% post; CPAP or Intubation: 10% pre vs 10% post).

Conclusion(s): Structured risk stratification with standardized documentation can safely support family centered care and efficient resource utilization.