Are Placental Blood Samples a Proxy for Infant Blood Samples When Comparing Lab

Neonatal anemia is a common problem faced by infants admitted to the NICU. Admission labs to the NICU typically required 3-4 mL of blood for diagnostic purposes. Blood losses from phlebotomy draws increases the likelihood of anemia in preterm infants less than 32 weeks gestation and may increase transfusion rates for neonates. Placental lab draws have been shown to decrease anemia in this patient population. Placental lab draw protocols are a standard of care throughout the Intermountain West region. A level III Newborn intensive care unit (NICU) in Ogden, Utah, was not using alternative sources for initial laboratory evaluation. Before this protocol could be implemented the laboratory required verification that the infant complete blood count (CBC) samples and placental CBC samples were equivalent. A retrospective chart review of NICU admissions was needed to assess for phlebotomy losses and anemia. An evidence based placental lab draw protocol was adapted and modified to meet the needs of the facility. An educational presentation was given to the key stake holders regarding the placental lab draw protocol and demonstration for obtaining paired samples was provided. Pre- and post-education surveys were completed by participants to first establish baseline knowledge of stake holders and acquired knowledge following educational sessions. Post implementation chart review was used to gather infant CBC and placental CBC information for comparison and analysis. Paired samples from the infant and its cord/placenta were obtained and sent to the institution's lab for analysis of equivalency using a paired samples t-test (p < 0.5). Retrospective chart reviews found that 100% of infants admitted to the NICU had a CBC drawn on admission. Of the 50 infants reviewed, three (6%) developed anemia and required blood transfusion. All key stake holders agreed that premature and extremely low birth weight (ELBW) infants were at higher risk for anemia and blood transfusion secondary to phlebotomy draws. During the four-month collection period 17 paired samples were obtained and evaluated. Statistical comparisons of the WBC, RBC, hematocrit and hemoglobin were conducted and significant differences between the infant and placental samples was found in all but HCT (p=0.60) and platelet (0.820) values, therefore sample equivalency for infant and placental CBCs could not be established. This project revealed system inefficiencies, barriers, communication failures and procedural problems with the initial protocol. With stakeholder input, the protocol was revised and approved. The institution will move forward with data collection slated to begin in April 2020.

Are Placental Blood Samples a Proxy for Infant Blood Samples When Comparing Lab Results? McKenna Vance The University of Utah College of Nursing In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 Abstract Background: Neonatal anemia is a common problem faced by infants admitted to the NICU. Admission labs to the NICU typically required 3-4 mL of blood for diagnostic purposes. Blood losses from phlebotomy draws increases the likelihood of anemia in preterm infants less than 32 weeks gestation and may increase transfusion rates for neonates. Placental lab draws have been shown to decrease anemia in this patient population. Placental lab draw protocols are a standard of care throughout the Intermountain West region. A level III Newborn intensive care unit (NICU) in Ogden, Utah, was not using alternative sources for initial laboratory evaluation. Before this protocol could be implemented the laboratory required verification that the infant complete blood count (CBC) samples and placental CBC samples were equivalent. Methods: A retrospective chart review of NICU admissions was needed to assess for phlebotomy losses and anemia. An evidence based placental lab draw protocol was adapted and modified to meet the needs of the facility. An educational presentation was given to the key stake holders regarding the placental lab draw protocol and demonstration for obtaining paired samples was provided. Pre- and post-education surveys were completed by participants to first establish baseline knowledge of stake holders and acquired knowledge following educational sessions. Post implementation chart review was used to gather infant CBC and placental CBC information for comparison and analysis. Paired samples from the infant and its cord/placenta were obtained and sent to the institution's lab for analysis of equivalency using a paired 2 samples t-test (p < 0.5). Results: Retrospective chart reviews found that 100% of infants admitted to the NICU had a CBC drawn on admission. Of the 50 infants reviewed, three (6%) developed anemia and required blood transfusion. All key stake holders agreed that premature and extremely low birth weight (ELBW) infants were at higher risk for anemia and blood transfusion secondary to phlebotomy draws. During the four-month collection period 17 paired samples were obtained and evaluated. Statistical comparisons of the WBC, RBC, hematocrit and hemoglobin were conducted and significant differences between the infant and placental samples was found in all but HCT (p=0.60) and platelet (0.820) values, therefore sample equivalency for infant and placental CBCs could not be established. Conclusion: This project revealed system inefficiencies, barriers, communication failures and procedural problems with the initial protocol. With stakeholder input, the protocol was revised and approved. The institution will move forward with data collection slated to begin in April 2020. 3 Introduction Problem Statement Bloodwork obtained from newborns is needed for diagnostic purposes upon admission to the NICU. These specimens require 3-4 mL of blood in most instances (Carroll, Livingston, Baer, Karkula, & Christensen, 2018). Blood losses from specimens increase the likelihood of anemia in preterm infants less than 32 weeks gestation and may increase transfusion rates for neonates (Baer, Lambert, Carroll, Gerday, & Christensen, 2013; Carroll, 2015), (Baer et al., 2013), (Carroll & Christensen, 2015). A level III NICU in Ogden, Utah, that was not using alternative specimen sources for initial labs and wanted to implement a placental lab draw protocol to help reduce phlebotomy blood loss from the newborn and potential need for blood transfusions in neonates. In order to implement such a protocol, the laboratory at this hospital required demonstration that alternative specimen sources (e.g., placental specimens) were equivalent to newborn blood samples before institutional implementation of the protocol. A review of other institutional protocols was performed to provide guidance in the development of this health care facility's alternative blood specimen drawing protocol. A search for a similar protocol to serve as the underpinning procedural guideline for obtaining specimens for this project was conducted. A tested protocol was identified that had been implemented and used in similar NICU facilities in the Greater Salt Lake City, Utah, region as well as the broader United States. According to this protocol, placental lab draws were performed within 20 minutes of delivery of the neonate. After the placenta was delivered, it was placed in a sterile container and passed 4 to a member of the team who was specially trained to sterilize the placenta and obtain a sterile blood specimen from it. Blood obtained from the placenta was used in lieu of neonatal blood for the required admission labs. These included complete blood counts (CBC), blood cultures, blood gases, and transfusion type and screening specimens. The umbilical cord contains approximately 10 mL of blood plus more in the placenta. That is sufficient blood to obtain the necessary lab work without drawing labs from the neonate. Use of alternative blood samples was intended to reduce the incidence of anemia caused by unnecessary blood loss in premature infants less than 32 weeks gestation. Infants of this gestational age are at increased risk for incidental blood loss that is associated with anemia and by extension, at higher risk for blood transfusion (Carroll, Nankervis, Iams, & Kelleher, 2012), (Christensen et al., 2011), (Henry et al., 2015). Blood transfusions may result in increased risk of intraventricular hemorrhage, retinopathy of prematurity, adverse effects on neurodevelopment, and increase the need for vasopressors (Henry et al., 2015), (Wang et al., 2017). Implementation of a placental lab draw protocol will help to reduce avoidable blood loss. Review of the Literature A study conducted by Carroll, Nankervis, Iams, and Kelleher (2015) assessed the utilization of umbilical cord blood to reduce anemia in preterm infants. This study evaluated the use of umbilical cord blood for initial laboratory testing. Results confirmed that the use of umbilical cord blood was an effective measure that reduced the incidence of anemia in premature neonates and resulted in increased hemoglobin measures during the first week of life, a decrease in need for vasopressor administration, and a decrease in 5 need for packed red blood cell transfusions (Carroll et al., 2012). Another study examined clinical outcomes in a cohort of extremely low-birthweight infants who received red blood cell (RBC) transfusions at day of life 7, 30 and 60 days. Clinical endpoints of interest that were evaluated included retinopathy of prematurity, neurodevelopment outcomes, necrotizing enterocolitis, intraventricular hemorrhage, and in-hospital mortality. Researchers found that RBC transfusions had a significant negative impact on the survival of very low-birth-weight neonates in relation to the targeted clinical outcomes (Wang et al., 2017). Results from a meta-analysis of pooled data from similar studies revealed that labs obtained from the otherwise discarded fetal umbilical blood reduced phlebotomy losses in neonates. Researchers concluded that the complete blood count (CBC) specimens from neonates and placental blood sources were found to be equivalent (Christensen, Carroll, & Josephson, 2014). Rationale The theoretical framework used to implement the project is the Donabedian model. This model is used to evaluate quality and find ways for improvement by using structure, process and outcome. This model is appropriate because structure measures influence process measures, which in turn affect outcomes. The structure is focused on the setting of the project, what will be implemented, and who will be involved in the project. The structure for this quality improvement project is a level III NICU with skilled registered nurses, nurse practitioners and neonatologists who will assist in the project's implementation. The process of this framework focusses on what will be 6 accomplished and how it will be presented. The outcome evaluates what will be measured, assessed or reviewed. The process involves determining the frequency of complete blood counts obtained from neonates upon admission to the NICU. A process was put in place to compare the laboratory results of blood specimens obtained from the placenta to those obtained from neonates. The comparative analysis of neonatal blood samples and umbilical or placental blood samples was needed to evaluate whether they were equivalent and could be used to reduce blood loss in these infants. Reducing blood loss and the need for blood transfusion were the core outcomes. "Outcome measures are known as the ultimate validators because they show the effectiveness and quality of a project" (NHS Improvement, n.d.) Specific Aims The overarching purpose of this project was to reduce unnecessary blood loss in neonates that may lead to the need for blood transfusion and other adverse health outcomes. The primary aim was to compare complete blood count (CBC) results taken from placental specimens to samples taken from the neonate in order to determine if placental samples are an equivalent substitute for neonatal sample Methods Context This quality improvement project was implemented at a regional medical center in Ogden, Utah, in the level III NICU. The medical center is located in a suburban/urban area, with a diverse population of neonates and their families. Racial composition of patients served by this facility is primarily Caucasian (84%). This medical facility draws 7 patients from surrounding smaller towns and rural communities in northern Utah. Families are encouraged to actively participate in the care of their infants, and they are also included in the decision-making process for their child. The clinical providers include two neonatologists, four nurse practitioners, approximately 60 registered nurses and 10 respiratory therapists. This facility is also a teaching hospital. Interventions The first objective in this project was to identify the number of labs drawn on infants for NICU admission. Determination of the number, type and volume of the blood specimens required for NICU admission was accomplished through a review of charts from September 2019 to March 2020. Information from the pre-implementation chart review were used to demonstrate the extent of the problem. The second objective was to implement simultaneous lab draws from infants and their placentas. Education regarding the protocol for drawing specimens from the placenta was provided to the neonatologists, nurse practitioners, registered nurses, critical care techs, and respiratory therapists prior to the start of the intervention. Samples were labeled with patient information specifically and designated as infant source or placental source on the label. Both specimens were sent to the lab together to complete the comparative analysis. The third objective was to compare lab results from the infant and placenta sources. Statistical analyses were completed by a statistician to determine if there were any significant differences in results between the two samples. The results were compiled and assessed for equivalence. In addition, neonates who developed anemia, received a 8 transfusion, or experienced a poor outcome related to blood loss were tracked. The fourth and final objective was to develop a formal institutional protocol for obtaining placental lab specimens. The protocol would then need be reviewed by the appropriate approval body for integration into the institution's policies. Feedback regarding the procedure was elicited from participants and used to refine the protocol. Study of the Intervention In order to assess if blood loss is a significant risk to infants, a retrospective chart review of the infant's charts is necessary to provide evidence that phlebotomy losses are associated with anemia. Inclusion and exclusion criteria were clearly identified to control confounding factors to prevent them from influencing the outcome. The placental lab draw protocol was developed using evidence-based protocols that have already been established and that are utilized in other hospital throughout the Intermountain West. The protocol was adapted and modified to meet the needs of the facility due to use of different supplies. The protocol was otherwise similar and lab obtainment is the same. Education was provided to key stakeholders through PowerPoint presentation regarding the protocol. This information was presented in staff meetings and through email. Demonstration of the proper technique was provided on previously delivered placentas and on placentas delivered within 20 minutes of delivery. Pre- and post- implementation surveys were utilized to first show that increased education is needed to decrease phlebotomy losses to infants is necessary to reduce anemia. Pre-implementation surveys were also used to establish a baseline of understanding. A post-implementation protocol survey was used to establish 9 understanding of the protocol and if any adjustments needed to be made to the protocol to increase compliance. Post-protocol chart review was an appropriate approach to gather infant CBC and placental CBC information for comparison and analysis. Measures A retrospective chart review of 50 charts was performed to determine the extent of the problem with infant specimens in terms of adverse effects. The chart review evaluated patients admitted to the NICU during the four-month evaluation. The PI evaluated demographic information that was further broken down into gestational age, weight, race, ethnicity, and gender, initial labs obtained, the timeframe of obtaining the labs, and whether the infant developed anemia or any other adverse outcome related to blood loss. An evaluation of the number of blood transfusions that occurred in the fourmonth implementation process and if these infants were included in the process was included in the chart review. An 11-question survey was developed and administered to stakeholders to collect demographic information that included gender, race, age, ethnicity, number of years as a clinician, and highest level of education. This survey also evaluated stakeholders' understanding of placental lab draws and risk factors for anemia and blood transfusions in neonates. The same survey was given to key stakeholders following the educational session to evaluate learning. Surveys were anonymous and coded with a unique identifying number to pair preand post-surveys; pre-surveys had a letter designation of "A" and post-surveys had a 10 letter designation of "B". These surveys were made available in electronic format. Respondents were given one week to complete the survey. Reminders were sent via text message to increase response rates. A post implementation chart review was performed on the 17 infants that participated in the study. The chart review obtained variables of interest regarding the participants gestational age, gender, and date of birth and reviewed the CBC from the infant and alternative source and the time that they were drawn. The five key components of the CBCs that were evaluated and compared included, white blood cells (WBC), red blood cells (RBC), hemoglobin (HGB), hematocrit (HCT) and platelets (PLT). Analysis Descriptive statistics were used to analyze demographic data of participants in the project, the data was organized into frequency tables to compare groups to determine if there was a significant change from pre-education of placental lab draw procedures and after presentation of the education. A paired sample t-test was performed to see if there was a statistical difference between the infants CBC and the cord CBC. A Wilcoxon signed-rank test was performed to assess whether the distributions of the CBCs were similar. The level of significance was set at p < 0.05. Ethical Considerations No conflicts of interest were identified during the implementation and completion of this project. This project was established as a quality improvement project by the University of Utah Institutional Review Board. All data were de-identified and findings were reported in aggregate format. Data were stored on a password-protected computer to 11 which only the PI and other team members involved in the project had access. Results A retrospective chart review of 50 neonatal charts was conducted to determine the frequency of blood draws and whether the infant developed anemia or any other adverse outcome related to phlebotomy blood losses. Results from the chart review provided evidence that 100% of infants admitted to the NICU had a CBC drawn on admission, including infants who were direct admits and non-direct admits. Of the 50 infants, 3 (6%) of them were diagnosed with anemia and required a blood transfusion (Table 1). Prior to implementation of the placenta lab draw protocol, a pre-education survey was provided to the key stakeholders that focused evaluating stakeholders' understanding of placental lab draws and risk factors for anemia and blood transfusions in neonates. Response rate for the stakeholders was 30% (n = 18). Survey responses indicated that all of the key stake holders believed that premature and ELBW infants are at higher risk of anemia then term infants. All participants agreed that premature infants and ELBW infants are at greater risk of a transfusion related injury (Table 2). The drafted placental lab draw protocol was implemented on 17 patients during a four-month period starting in October 2019 and continuing through January 2020. Patients who were directly admitted to the NICU during this time and who required initial lab work shortly after birth had a CBC obtained from the infant and placenta within 20 minutes of birth. Infants who were not admitted directly following birth were excluded due to lack of comparative placental CBC. The mean gestational age at the time 12 labs were obtained was 33 4/7 weeks. The gestational age was similar to the implementation group. Initial education was provided to the staff September 2019 and sample collection began October 2019. Collection of samples was supervised by the primary investigator (PI) in the initial phase of implementation and was later supervised by two assigned registered nurses. In January 2020, the PI was evaluating CBC data from the 17 infants that were included during the project, when it was discovered that the umbilical cord CBC results were not resulted into the patient chart. Communication with the laboratory was initiated to inquire about and obtain the umbilical sample results. The lab was initially resistant to provide the results from the umbilical samples to the PI for analysis. Continued communication occurred with the laboratory and concern from the laboratory was raised regarding the samples. The laboratory ran initial analyses of the comparative CBC specimens in January of 2020 and determined that the samples were not equivalent. During the month of February 2020, the PI was told to cease the collection of comparative specimens until further review and approval of a protocol from the Director of the facility's lab. A collaborative meeting was held with key stakeholders to discuss the findings of the paired CBC specimens. Discussion in the meeting resulted in a plan to reevaluate the lab collection protocol being implemented, re-educate participating staff regarding the collection procedure and specimen handling/labeling, provide ongoing communication with the lab director, and attend weekly meetings with key stakeholders during collection of specimens. The PI was required to re-educate the staff regarding the revised protocol 13 approved by the stakeholder group which was not accomplished within the timeframe for project implementation. Specimen labeling and handling was systematized and the alternative source for infant blood samples was designated to be the cord of the placenta for consistency. Results from analysis of the specimens that were already collected indicated that the CBCs obtained from the infant and the placenta were not comparable on three of the five components of interest in the CBC (see Tables 4 & 5). A statistical comparison of the infant and placenta WBC, RBC, HCT and HGB values was conducted using a paired t-test (see Table 4). It was found that the placental samples were significantly different from their paired infant samples for WBC, RBC, and HGB (p < 0.5), and could therefore not be used as proxies for infant samples for CBC analyses. Analyses of platelets (p= 0.820) and HCT (p=0.6) from the paired samples were not found to be significantly different (see Table 4). Data were insufficient for meaningful analysis due to the small number of samples procured for the study. A power analysis is needed to determine the number of samples needed to power the study adequately. The time constraints over which the project was able to be accomplished did not allow for resuming sample collection due to the system problems that arose during the course of the project that delayed further sample collection by nearly a month. Discussion Summary Neonatal anemia is a real concern for infants admitted to the NICU. Blood loss 14 from specimens collected upon admission increases the likelihood of anemia in preterm infants who are less than 32 weeks gestation and may increase transfusion rates for neonates. The aim of this project was to assess the adequacy of alternative blood specimen sources (e.g., placental specimens) to serve as proxy for newborn blood samples in an effort to reduce phlebotomy blood losses of NICU infants. Results of this project established that all infants admitted to the NICU had a CBC obtained on admission and 6% developed anemia that required blood transfusion. This implies that by reducing the amount of blood that is obtained on admission from the infant by obtaining the needed blood from an alternative source, that phlebotomy blood losses can be significantly reduced. The goal to provide evidence that alternative blood sources (e.g., placental specimens) are equivalent to newborn blood samples was not accomplished. Interpretation Collecting initial blood from a discarded source, has been found to significantly improve neonatal outcomes in the first week of life. Neonatal anemia is a common diagnosis of infants admitted to the NICU. Initial blood loss from phlebotomy procedures upon admission increases the likelihood of anemia in preterm infants. Neonatal anemia often results in blood transfusions, even with conservative transfusion guidelines, and increases transfusion associated risks to the infant. When performing retrospective chart reviews, the PI found that 100% of infants admitted to the NICU had initial laboratory work obtained for diagnostic purposes. Pre-education and post-education surveys indicated that all of key stakeholders who participated in the survey agreed that 15 premature and ELBW infants are at the highest risk for anemia and transfusion related injuries. The surveys also indicated that utilizing techniques to decrease phlebotomy blood losses can be beneficial in risk for anemia in premature and ELBW infants. Current literature provides evidence that implementation of a placental lab draw protocol can be an effective measure in reducing initial anemia in the premature and ELBW population. A study conducted by Carroll, Nankervis, Iams, and Kelleher (2015) found that when this process was utilized, infants maintained an acceptable hemoglobin level in the first week of life which reduced the need for a packed red blood cell transfusion (Carroll et al., 2012). Packed red blood cell transfusions have been found to increase incidence of retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, in-hospital mortality and poorer neurodevelopmental outcomes to ELBW and premature infants. Researchers found that RBC transfusions had a significant negative impact on the survival of very low-birth-weight neonates in relation to the targeted clinical outcomes (Wang et al., 2017). Reduction in initial phlebotomy losses to the neonate is crucial to reduce transfusion related injuries. A study conducted by Christensen, Carroll and Josephson (2014) provided clear evidence that CBC specimens from the neonate and placental blood sources were found to be equivalent. Although this study did not show specimen equivalency of the paired samples, results from an appropriately powered study may have resulted in very different outcomes. There was a positive incidental finding. A 28 4/7 weeks gestation infant, participated in the study and had initial laboratory work obtained from the placenta. This 16 infant did not develop anemia in the first week of life but did develop anemia on day of life 15. The infant required a blood transfusion on day of life 15. This infant was able to avoid a blood transfusion in the first week of life, reducing a potential transfusion related injury during this crucial time period. Limitations There were multiple limitations of this project. Data obtained from the preimplementation chart review were helpful in assessing barriers and facilitators to be addressed prior to implementation of the protocol. The main barrier to the implementation of a placental lab draw protocol in this facility was the laboratory requiring prior verification that a CBC drawn from the placenta could serve as a proxy for the infant sample, supported by objective data analyses. Although use of a placental lab draw protocols are standard practice throughout the Intermountain West and is supported by multiple research studies, the facility in question will not approve proxy specimens without data to support the practice at their institution. There were time constraints that limited the number of samples that could be obtained for comparison to provide a large enough sample size to provide sufficient power for analysis of the results. Due to problematic communication with the laboratory Director and his concerns regarding non-equivalency of paired samples, he requested that sample collection be stopped until April 1, 2020. This led to delays with the project's implementation timeline which inhibited collection of samples for final analysis. The lab Director stipulated a number of criteria to be met in order for the project to resume. Among these changes were reevaluation of the process, re-education to key stake holders, 17 and weekly meetings for increased communication. Unfortunately, the COVID-19 pandemic also caused changes in clinical student rotations that prohibited the PI from continuing with the required clinical presence to conduct further educational sessions with staff and attend weekly meetings with the lab Director and other stakeholders. The revised paired sample collection protocol was established to eliminate confounding factors identified in stakeholder discussions. Confounding factors included location from which the samples were drawn, timing of the sample draws, and the processing of the sample in the lab. The revised protocol was distributed to the laboratory manager, head pathologist, NICU manager, and neonatologist before reeducation was started. The process standardized collection of the paired samples to be drawn from the alternative source and infant within 20 minutes of birth and placenta delivery. Placental samples were standardized to be drawn from the umbilical cord and not from the placenta to improve sample quality. Infant samples were standardized to be drawn from a peripheral intravenous (PIV) site. If a PIV blood sample could not be obtained, a heel stick CBC sample would be accepted but the sample was required to be labeled accordingly. Samples were to be labeled with the patient's identifying information and the time of the sample draw was to be recorded on the patient ID label as well. A second color coded sticker was to be added after collection to identify the sample collection site. Cord collection stickers were coded pink, PIV collection stickers were codded green and heel collection stickers were coded yellow. The color-coded stickers created visual cues to improve sample identification when received by the lab personnel. Collection of paired blood samples was slated to restart on April 1, 2020. 18 Conclusions Although the project did not achieve all of its intended objectives, it did serve as a pilot study for instituting a protocol to reduce phlebotomy losses from ELBW and premature infants admitted to the NICU. Stakeholders involved in the initial implementation of the project before it was halted had come to a consensus that a protocol needed to be put in place to reduce harm to these infants. This project revealed system inefficiencies, barriers, communication failures and procedural problems with the initial protocol. Recognition of these problems will help to improve system functions, facilitate collection of samples for analysis, and provide the evidence necessary to support a protocol for alternative sources for necessary admission labs; all of which will reduce phlebotomy losses in infants at high risk for anemia and RBC transfusions and their attendant risks. Acknowledgments I would like to acknowledge the efforts of Pamela Phares, PhD, APRN, CNM; Robert Christensen, MD; Alysha Jenkins, APRN, NNP-BC; and Kimberly Friddle, PhD, APRN, NNP-BC. As project chair, content experts and program director they all provided invaluable guidance, advice and mentorship. 19 References Baer, V. L., Lambert, D. K., Carroll, P. D., Gerday, E., & Christensen, R. D. (2013). Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions. J Perinatol, 33(5), 363-365. doi:10.1038/jp.2012.127 Carroll, P. D. (2015). Umbilical Cord Blood-An Untapped Resource: Strategies to Decrease Early Red Blood Cell Transfusions and Improve Neonatal Outcomes. Clin Perinatol, 42(3), 541-556. doi:10.1016/j.clp.2015.04.017 20 Carroll, P. D., & Christensen, R. D. (2015). New and underutilized uses of umbilical cord blood in neonatal care. Matern Health Neonatol Perinatol, 1, 16. doi:10.1186/s40748-015-0017-2 Carroll, P. D., Livingston, E., Baer, V. L., Karkula, K., & Christensen, R. D. (2018). Evaluating Otherwise-Discarded Umbilical Cord Blood as a Source for a Neonate's Complete Blood Cell Count at Various Time Points. Neonatology, 114(1), 82-86. doi:10.1159/000488024 Carroll, P. D., Nankervis, C. A., Iams, J., & Kelleher, K. (2012). Umbilical cord blood as a replacement source for admission complete blood count in premature infants. J Perinatol, 32(2), 97-102. doi:10.1038/jp.2011.60 Christensen, R. D., Carroll, P. D., & Josephson, C. D. (2014). Evidence-based advances in transfusion practice in neonatal intensive care units. Neonatology, 106(3), 245-253. doi:10.1159/000365135 Christensen, R. D., Lambert, D. K., Baer, V. L., Montgomery, D. P., Barney, C. K., Coulter, D. M., . . . Bennett, S. T. (2011). Postponing or eliminating red blood cell transfusions of very low birth weight neonates by obtaining all baseline laboratory blood tests from otherwise discarded fetal blood in the placenta. Transfusion, 51(2), 253-258. doi:10.1111/j.1537-2995.2010.02827.x Henry, E., Christensen, R. D., Sheffield, M. J., Eggert, L. D., Carroll, P. D., Minton, S. D., . . . Ilstrup, S. J. (2015). Why do four NICUs using identical RBC transfusion guidelines have different gestational age-adjusted RBC transfusion rates? J Perinatol, 35(2), 132-136. doi:10.1038/jp.2014.171 21 Wang, Y. C., Chan, O. W., Chiang, M. C., Yang, P. H., Chu, S. M., Hsu, J. F., . . . Lien, R. (2017). Red Blood Cell Transfusion and Clinical Outcomes in Extremely Low Birth Weight Preterm Infants. Pediatr Neonatol, 58(3), 216-222. doi:10.1016/j.pedneo.2016.03.009 Table 1 Retrospective Chart Review Findings Mean Gestational Age (weeks) 33 4/7 Weight (gm) Race/Ethnicity Gender Initial Labs Anemia 730-4235 53% Caucasian 37% Hispanic/Latino 10% other 52% Male 48% Female 100% CBC 6% n=50 22 Table 2 Pre-education survey Role Key stake holder n= 18 ELBW Premature Risk for anemia 50% 50% Risk for *Preventative Transfusion measures 30% 100% 70% **Side effects from transfusion 100% Note: *Preventative measures include: Placental lab draws, minimizing phlebotomy losses, use of erythropoiesis stimulating factors. **Side effects from transfusion include retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage. Table 3 Post-Education Survey Role Key stake holder ELBW Premature Risk for anemia 80% 20% Risk for *Preventative Transfusion measures 80% 100% 20% **Side effects from transfusion 100% n= 22 Note: *Preventative measures include: Placental lab draws, minimizing phlebotomy losses, use of erythropoiesis stimulating factors. **Side effects from transfusion include retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage. Table 4 Comparative CBC Samples Test Statistic Standard Error Standardized Test Statistic WBC 147 21.125 3.337 23 RBC 143.5 21.122 3.172 HGB 8.5 19.329 -3.078 HCT 135 21.122 2.77 PLT 56 17.603 -0.227 p value 0.001 0.002 0.02 0.06 0.82 ______________________________________________________________________ Table 5 Descriptive Statistics of Comparative CBC Samples Minimum Maximum Mean Std Deviation WBC-I 2.8 18.2 9.4 5.07 WBC-P 5.1 19.3 11.9 4.38 RBC-I 3.1 4.8 3.9 0.49 RBC-P 4 5.9 4.5 0.53 HGB-I 14.3 22.7 17.1 2.17 HGB-P 11.3 18.3 14.9 2 HCT-I 34.1 54.1 44.7 5.56 HCT-P 42.1 64.8 50.1 5.99 PLT-I 56 474 244.5 103.33 PLT-P 144 409 243.8 71.28 ____________________________________________________________ Note: I= Infant, P= Placenta/Proxy Appendix A Umbilical cord blood Collection Protocol Purpose/Overall Goal: ⦁ ⦁ ⦁ Key Stake Holders: ⦁ ⦁ ⦁ Decrease initial phlebotomy loss upon admission to infants upon admission to the NICU. Reduce anemia in neonate population and reduce blood transfusion Provide evidence that umbilical cord blood can be used as a proxy infant blood NICU, Family birthplace, Laboratory. Designate who will be obtaining labs from the umbilical cord/placenta and who will be drawing labs from the infant. Coordination and communication is key! 24 Clinical Process: ⦁ ⦁ ⦁ Inform the OB and family birthplace staff that you would like to obtain initial clinical labs from the placenta or umbilical cord. Ask OB to leave the umbilical cord attached to the placenta. A cord clamp is preferred for clamping. The cord clamp needs to b placed at the furthest away point from the placenta. In the case of multiples request that 1 clamp is used for baby A and 2 clamps are used for baby B, and so on. Ask the Doctor if they would like the placenta sent to pathology an they would like to check the placenta. Prepare your work area: ⦁ ⦁ ⦁ ⦁ Place the chux over your work area Open the gauze and alcohol wipes. Have lavender CBC tubes available on work area Attach 18-gauge needle to 10 mL syringe and maintain clean technique with syringe and needle. After receiving the placenta: ⦁ Blood needs to be obtained within 20 minutes following delivery! Don PPE Receive the placenta in a basin, from family birthplace following delivery Arrange the umbilical cord/placenta on your work area Clean umbilical cord site from blood with gauze. Apply alcohol to the umbilical cord and allow to dry. Insert the needle bevel down and lift up with the needle to prevent collapse of the vessel. Draw back on the syringe to withdraw as much blood as possible. ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ 25 After umbilical blood collection: ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ Infant sample collection: ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ ⦁ Dispose: Fill CBC tube with 0.5 mL of blood Label the tube with a patient sticker and correlating colored sticker Umbilical (yellow). Date, time of collection and initial on patient label Optional and only if enough blood is obtained: A second CBC tub can be filled with 0.5 mL of blood. Label the second tube with patient sticker and correlating colored sticker: Umbilical (yellow). Label the 2 CBCs as A and B. Date, time of collection and initial on patient label Place samples in proper specimen bag and ensure that it is ordered Simultaneous umbilical sample obtainment and infant obtainm needs to occur or within 20 minutes! The sample needs to be peripheral (e.g, IV). Fill the CBC tube with 0.5 mL of blood Label the tube with a patient sticker and correlating colored sticker Peripheral (pink). Date, time of collection and initial on patient label If a peripheral (e.g., IV) sample was not able to be obtained a heel stick sample can be used. Fill the CBC tube with 0.5 L of blood Label the tube with a patient sticker and correlating colored sticker heel (red). Date, time of collection and initial on patient label Place samples in proper specimen bag and ensure that it is ordered Dispose of sharps in proper bin. Placenta disposed of properly or taken to L&D staff. 26 Needed Equipment: Umbilical blood draw kit: 10 mL Syringe 18 gauge needle 2 lavender microtainers 2 Alcohol wipes Gauze Yellow umbilical stickers Biohazard bag Infant blood draw kit: IV start supplies 1 lavender microtainer 2 Alcohol wipes Pink: Peripheral IV sticker Red: Heel sticker Biohazard bag Chux CBC blood draw kit Infant blood draw kit Yellow Gown Face bask with shield or glasses Sterile gloves Infant labels Sample specific colored labels: ⦁ Umbilical blood (pink) ⦁ Peripheral IV (green) ⦁ Heel (yellow) (Author: McKenna Vance, 2020) 27