Implementation of a Coarctation Watch Clinical Practice Guideline: An Evidence-Based Quality Improvement Project

Coarctation of the Aorta remains challenging to diagnose in the prenatal period. Coarctation of the Aorta (CoA) accounts for 5% of congenital heart disease in infants. Evidence shows that risk stratification and postnatal observation of infants with suspected Coarctation of the aorta improves the timely diagnosis of this disease. A Level III NICU in Utah has no guideline for the initial period of monitoring infants ³35 weeks gestation with prenatal suspicion of Coarctation of the Aorta, also known as Coarctation Watch. The lack of a standardized guideline has led to inconsistencies in clinical practice regarding the initial management of these infants. Methods: Pre- and post-intervention data were compared to evaluate the success of this quality improvement project. The surveys assessed staff practice and opinions before disseminating education and after implementing the Clinical Practice Guideline (CPG). Patient data was obtained with a retrospective chart review from January 2024 to October 2024 to look at clinical practice prior to implementation of the CPG. This quality improvement project involved the implementation of a clinical practice guideline created by key stakeholders in Neonatology and Fetal Cardiology. A literature review was conducted to review best practice. Patient data was obtained with a retrospective chart review from January 2024 to October 2024 to look at clinical practice prior to implementation of the CPG. A survey was distributed to NICU caregivers assessing current practice and knowledge before implementation of the CPG. Education was disseminated to NICU caregivers, and CPG was implemented. 2 PDSA cycles were completed post-implementation for rapid change. A postimplementation survey assessed caregiver thoughts on feasibility, usability, and acceptability. Key stakeholders with expert clinical opinion developed the clinical practice guideline. Approximately 200 caregivers received the surveys, with a 48% (n=96) pre-implementation response rate and a 16.5% (n=33) post-implementation response rate. 100% (n=33) of caregivers see the benefit of a standardized CPG for infants with suspected CoA. 77% (n=14) of providers report using this CPG in future clinical practice would be easy. And 83 % (n=15) see this CPG as useful in their continued practice. The identified barriers are that 21% (n=4) did not know there was a CPG, and 5.3% (n=1) could not locate the CPG. Although there was a low response rate to the post-implementation survey, most caregivers see the CPG as useable, feasible, and acceptable. The education and CPG are valuable resources for staff to improve the care of infants with prenatally suspected CoA. Following the interventions, ongoing collaboration with key stakeholders is crucial for successful implementation and sustainability.

1 Implementation of a Coarctation Watch clinical practice guideline: An Evidence Based Quality Improvement Project Madeline A. Park, Whitnee J. Hogan, Belinda Chan, Julieanne Schiefelbein College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III Spring 2025 2 Abstract Background Coarctation of the Aorta remains challenging to diagnose in the prenatal period. Coarctation of the Aorta (CoA) accounts for 5% of congenital heart disease in infants. Evidence shows that risk stratification and postnatal observation of infants with suspected Coarctation of the aorta improves the timely diagnosis of this disease. Local Problem A Level III NICU in Utah has no guideline for the initial period of monitoring infants ³35 weeks gestation with prenatal suspicion of Coarctation of the Aorta, also known as Coarctation Watch. The lack of a standardized guideline has led to inconsistencies in clinical practice regarding the initial management of these infants. Methods Pre- and post-intervention data were compared to evaluate the success of this quality improvement project. The surveys assessed staff practice and opinions before disseminating education and after implementing the Clinical Practice Guideline (CPG). Patient data was obtained with a retrospective chart review from January 2024 to October 2024 to look at clinical practice prior to implementation of the CPG. Interventions This quality improvement project involved the implementation of a clinical practice guideline created by key stakeholders in Neonatology and Fetal Cardiology. A literature review was conducted to review best practice. Patient data was obtained with a retrospective chart review from January 2024 to October 2024 to look at clinical practice prior to implementation of the CPG. A survey was distributed to NICU caregivers assessing current practice and knowledge 3 before implementation of the CPG. Education was disseminated to NICU caregivers, and CPG was implemented. 2 PDSA cycles were completed post-implementation for rapid change. A postimplementation survey assessed caregiver thoughts on feasibility, usability, and acceptability. Results Key stakeholders with expert clinical opinion developed the clinical practice guideline. Approximately 200 caregivers received the surveys, with a 48% (n=96) pre-implementation response rate and a 16.5% (n=33) post-implementation response rate. 100% (n=33) of caregivers see the benefit of a standardized CPG for infants with suspected CoA. 77% (n=14) of providers report using this CPG in future clinical practice would be easy. And 83 % (n=15) see this CPG as useful in their continued practice. The identified barriers are that 21% (n=4) did not know there was a CPG, and 5.3% (n=1) could not locate the CPG. Conclusion Although there was a low response rate to the post-implementation survey, most caregivers see the CPG as useable, feasible, and acceptable. The education and CPG are valuable resources for staff to improve the care of infants with prenatally suspected CoA. Following the interventions, ongoing collaboration with key stakeholders is crucial for successful implementation and sustainability. Keywords: Coarctation of the aorta, neonatal, newborn, neonatal intensive care unit, NICU, quality improvement, critical congenital heart disease, clinical practice guideline. 4 Implementation of a Coarctation Watch clinical practice guideline: An Evidence-Based Quality Improvement Project Problem Description Coarctation of the aorta (CoA) is a ductus-dependent type of congenital heart defect (CHD) described by narrowing in the aortic isthmus (Thomas et al., 2024). CoA occurs in roughly 1 in every 1,800 babies born in the United States yearly, accounting for 5% of children with CHD (Bartolacelli, 2023; Thomas et al., 2024). CoA is a difficult diagnosis to make prenatally and most likely to go undetected on the pulse oximetry-based newborn critical congenital heart disease screen in the postnatal period (Thomas et al., 2024). Prenatal diagnosis of CoA is notoriously challenging, with a high rate of false positives on pulse oximetry and fetal echocardiography-based screening, leading to considerable anxiety for families and allocation of limited pediatric and neonatal resources to the admission and surveillance of neonates with equivocal findings (Raza, 2023). False positive rates range from 48% to 94% (Raza, 2023). When undetected CoA results in obstruction of blood flow, life-threatening cardiovascular failure may be the outcome, with a high burden of morbidity and mortality (Thomas et al., 2024). The ongoing challenge in the management of CoA is to find postnatal diagnostic parameters that flag neonates soon after birth so unnecessary care is minimized, and surgical management is expedited for those with true CoA (Thomas et al., 2024). The prenatal diagnosis and management of critical neonatal CDH have been shown to play an essential role in improving the outcomes of newborns with these conditions, allowing timely stabilization of the circulation before cardiac intervention or surgery, thus reducing the risk of perioperative morbidity and mortality (Donofrio, 2018). Standard hemodynamic 5 monitoring during ductus arteriosus closure (an "arch watch") can be utilized in infants with suspected fetal CoA. A Level III NICU in Utah has no standardized guideline for the initial period of monitoring infants ³35 weeks gestation with prenatal suspicion of CoA. This lack of a standardized guideline has led to inconsistencies in clinical practice regarding the initial care of these infants, including delayed feedings and increased length of stay. A standardized arch watch can be utilized to monitor infants while the ductus is closing, which allows for rapid recognition of a clinically significant CoA, and at the same time allows for progressing feedings and decreasing the length of hospital stay for infants in which CoA is ruled out. Available Knowledge Recent research has identified that a scoring system is feasible for fetal echocardiography and may be a simple tool for risk stratification for postnatal CoA (Contro et al., 2022; Vigneswaran et al., 2020; Villalain et al., 2024). This scoring tool is based on fetal echocardiography markers, ventricular disproportion, great vessels asymmetry, transverse aortic arch hypoplasia, flow turbulence, and Z-scores of the ascending aorta and the aortic isthmus (Contro et al., 2022). These markers can aid in determining the risk of true CoA and how closely monitored these infants should be in the postnatal period. However, no single or combination of measurements is entirely accurate; therefore, we cannot avoid the sequential observation of vital signs once the infant is born; this includes upper and lower extremity blood pressure, presence of a murmur, feeding tolerance, and respiratory rate (Vigneswaran et al., 2020). The early postnatal assessment of the size and morphology of the aortic arch can assist in risk stratification for the development of neonatal CoA (Vigneswaran et 6 al., 2020). Thus, obtaining postnatal echocardiograms is crucial for these infants with suspected CoA. Villalain et al. (2024) further highlight the importance of sonographic signs for detecting CoA: juxtaductal shelf, hypoplastic aortic arch, and downwardly displaced subclavian artery. These measures will be helpful in prenatal echocardiograms to help identify infant stratification risk. Wang et al. (2022) conducted a study on the use of a coarctation probability model incorporating prenatal cardiac sonographic markers to estimate the probability of an antenatal diagnosis of CoA. Findings revealed that the model performed well in predicting the need for surgical intervention in postpartum CoA and could be used to evaluate the risk stratification of postpartum CoA (Wang et al., 2022). Another recent study by Patel et al. (2024) found that the use of prenatal severity-based risk stratification for postnatal management was cost-effective and safe in achieving timely treatment of Coarctation in those who need it while reducing resource utilization in those who did not develop postnatal Coarctation. Recent literature has identified that postnatal monitoring should include serial evaluation of the upper-lower extremity blood pressure (BP) (gradient is a cornerstone of arch monitoring), the presence of a murmur, decreasing oral intake or feeding intolerance, or tachypnea are all nonspecific findings that may prompt further evaluation including an echocardiogram (Thomas et al., 2024). Thus, these assessments will be crucial in the clinical monitoring of infants with suspected CoA. Rationale This project used the Johns Hopkins Evidence-Based Practice (EBP) Model, which focuses on implementing a three-step process called PET: practice question, evidence, and 7 translation (Dang et al., 2022). The first step of this model is inquiry. This step included assessing staff knowledge and current clinical practice for CoA. The next step in the Johns Hopkin EBP model was a literature review with a PICO question to understand the evidence to support Coarctation watch risk stratification in the case of prenatally suspected CoA; PICO question: Does implementing an aortic coarctation (CoA) watch protocol improve outcomes compared to having no protocol? The next step is translation, which takes the evidence and implements a QI project based on evidence-based practice; a CoA watch guideline was developed and disseminated to the providers and bedside nurses in the NICU. The next step in the process will be to evaluate change in practice post-implementation and the guideline's feasibility, acceptability, and useability. Plan Do Study Act (PDSA) will be utilized to monitor and implement rapid changes as the evidence-based QI project progresses. Specific Aims This Doctor of Nursing (DNP) evidence-based quality improvement (QI) initiative aims to design and implement a systematic, evidence-based approach to the care of infants with prenatally suspected CoA through the implementation of the clinical practice guideline (CPG) and assess feasibility, usability, and clinical satisfaction of the guideline. Methods Context This project was conducted in a Level III 48-bed NICU in Salt Lake City, Utah. A Level III NICU cares for critically ill infants with gestational ages ranging from 22 to 40 weeks. This NICU is adjacent to a children's hospital with surgical capabilities. The participants comprise approximately 200 clinicians, including neonatologists, fellows, nurse practitioners, and registered nurses. The assessment included current processes and caregiver understanding of 8 CoA. Approximately 200 NICU caregivers received the pre-implementation survey, (Appendix A). The participants included a voluntary sample of caregivers who work in this NICU. The PDSA was implemented to make rapid cycle changes as needed. A post-implementation survey was also shared with approximately 200 of the same clinicians to assess feasibility, usability, satisfaction, guideline uptake, and understanding (Appendix B). The focused chart review component included gestational age, length of stay, time of initial echocardiograms, time to full feeding, need for transfer to a higher level of care (Level IV or CICU), and necrotizing enterocolitis (NEC). From January 2024 to October 2024, there were eight patients with prenatal suspicion (Table 1). Intervention(s) The first step of the quality improvement (QI) project was to create a stakeholder team within the healthcare system. A team was formed, and members were recruited (a NICU medical director, a fetal cardiologist, a pediatric cardiologist, and one nurse practitioner). The goal of creating this team was to establish the objectives of the QI and design a practice question to guide the usability and feasibility of a Coarctation Watch CPG in the NICU. The QI team created and implemented a Coarctation watch CPG, the guideline consisted of a flowchart based on risk stratification and subsequent clinical care. Infants with moderate suspicion for CoA based on fetal echocardiogram were categorized as needing coarctation watch. Coarctation watch infants were to be admitted to the NICU and to follow the flowchart (Appendix D), with initial resuscitation after birth, sequential blood pressure monitoring and peripheral pulse checks, and obtaining an echocardiogram. The next step was to gather evidence surrounding the current coarctation management. A literature search was conducted to review the current practices associated with CoA. A chart 9 review of retrospective data was conducted to assess patient outcomes pre-CPG implementation, (Table 1). The retrospective data included charts of the infants discharged with CoA at the University of Utah Hospital pre-implementation of the CPG from January 2024 to October 2024. Data collection included administering a pre-implementation survey to all participants to understand their current practice, perceptions, and attitudes about a practice change. The survey was created using the Research Electronic Database Capture (REDCap) tool. It was distributed to the participants via email, and their responses were voluntary. Stakeholder meetings were conducted to discuss progress and continuation of the project goals. (Appendix A). Educational materials were disseminated before the implementation of the guideline, and they involved a PowerPoint presentation to review the pathophysiology of the CoA and explain the guideline, (Appendix C). The guideline flowchart was distributed via email and posted on the unit, (Appendix D). Two PDSA cycles occurred after implementing the guideline to identify barriers and other adjustments. Upon the first PDSA cycle, feedback revealed that caregivers required clarification that this guideline is for the 24 hours of life and that total fluids/feedings should be advanced as clinically indicated under the direction of neonatology and input from cardiology after the initial echocardiogram has been performed. Also, the guideline was uploaded to a central location for the providers to easily access. Upon the second PDSA cycle, feedback showed that the guideline would be more appropriate for providers to utilize, and the focus for RNs was redirected to education on clinical assessment of CoA and awareness of a new CPG. After implementing the guideline, a follow-up survey was distributed to caregivers to assess changes in knowledge of CoA, use of the guideline, feasibility, usability, and satisfaction of the guideline. 10 Study of the Intervention(s) This QI project consisted of a retrospective chart review and utilized two surveys to follow pre- and post-implementation (Appendix A and B). A chart review of retrospective data was conducted to assess patient outcomes pre-CPG implementation (Table 1). The retrospective data included charts of the infants discharged with CoA at the hospital pre-implementation of the CPG from January 2024 to October 2024. A pre-intervention survey was designed to understand the need to standardize CoA watch in neonates and assess current practices. Two PDSA cycles occurred after implementing the guideline to identify barriers and other adjustments. A postintervention survey was used for this project to evaluate clinicians' perceived feasibility, usability, and acceptability of the guideline. The project lead created surveys, which were reviewed, discussed, and approved by the project team. Data was collected using the REDCap tool hosted at the hospital. The survey was distributed by email and QR code to the participants, with anonymous responses. The data was imported from REDCap to EXCEL for analysis. The project lead analyzed the raw data, and the project sponsor endorsed the data being reviewed; this data was also imported into EXCEL for analysis. Measures The focused chart review component included gestational age, length of stay, time of initial ECHO, time to full feeding, need for transfer to a higher level of care (Level IV or CICU), and necrotizing enterocolitis (NEC) (Table1). The pre-implementation survey consisted of 10 questions, displayed in Appendix A. The first two questions established demographic data: years of experience and role. The following questions used a 3-point Likert scale ranging from no experience/not confident to familiar/confident, and/or yes/no/unsure questions to determine current practice, knowledge, and 11 the need for standardization. The last two were free-text questions about the benefits of implementing a CPG for CoA watch and identifying potential barriers to implementing a CPG. Another method used to assess needed changes were PDSA cycles. PSDA cycles identified rapid changes that were needed during the implementation phase. The post-implementation survey consisted of 5 to 10 questions, depending on the participant's role in the NICU, displayed in Appendix B. The first two questions established demographic data: role and years of experience. The following two questions used a Likert scale: agree/somewhat agree/neutral/disagree/I did not know there were educational presentations to assess the perception of the disseminated educational material. The following four questions assessed the guideline's usability, feasibility, and acceptability. The following questions assessed barriers to using the CPG. The last question was free text, asking for improvements and suggestions to make it better. Analysis This DNP project used quantitative descriptive analysis for pre-implementation and postimplementation surveys. The data sets were analyzed using EXCEL. Short-answer responses were qualitatively analyzed. PDSA was utilized for making needed changes. Chart Review The focused chart review component included retrospective patient charts (n=8) and utilized descriptive statistics. Data from the chart review were summarized using descriptive statistics to create a table for gestational age, length of stay, time of initial ECHO, time to full feeding, need for transfer to a higher level of care (Level IV or CICU), and necrotizing enterocolitis (NEC)(Table 1). Surveys 12 Data was analyzed using descriptive statistics. Demographic data was summarized using descriptive statistics. We summarized participant demographics using frequency counts and central tendencies. Participants were organized by role (physician, fellow, nurse practitioner, registered nurse). Years of experience were grouped into categories (less than 1 year, 1-5 years, 6-10 years, and more than ten years). Short-answer responses were qualitatively analyzed. First, I reviewed the responses. The project lead then coded all the responses. The codes were then examined by the team and combined into overarching themes. Ethical Considerations This project was a quality improvement initiative and did not require Institutional Review Board approval deemed by the University of Utah. There were no conflicts of interest or compensation for participants' time. Results Retrospective Chart Review Eight medical records were reviewed from January 2024 to October 2024, with prenatal suspicion of CoA. The gestation ages ranged from 32 weeks to 38 weeks. Time to initial echo was within 12 hours for all patients. The time to rule in or out ranged from less than one day 0% (0), 2 to 5 days 62.5% (6), 6-10 days 25% (2), 11-15 days 0% (0), and greater than 16 days 12.5% (1). None of the patients were diagnosed. The length of hospital stay ranged from 0-5 days 25% (2), 6-10 days 0% (0), 11-15 days 25% (2), and greater than 16 days 50% (4). The time to initial feeding ranged from less than 4 hours 0% (0), 4-11 hours 25% (2), 12-24 hours 50% (4), and greater than 24 hours 25% (2). Time to full feedings ranged from less than 2 days 0% (0), two to five days 25% (2), six to ten days 50% (4), and greater than ten days 25% (2). No 13 patients needed to be transferred to a higher level of care. There was no occurrence of necrotizing enterocolitis. (Table 1). Pre-implementation Survey Approximately 200 NICU Caregivers received the pre-implementation survey, (Appendix A). 96 surveys were returned, a 48% response rate. The respondents comprised 9.4% (n=9) <1 year of experience, 25% (n=24) 1-5 years of experience, 14.6% (n=14) 6-10 years of experience, and 51% (n=49) >10 years of experience (Table 2). The roles of the participants included 12.5% (n12) attendings, 1% (1) Fellows, 24% (n=23) NNPs, and 62.5% (n=60) RNs (Table 2). Regarding familiarity with the pathophysiology of CoA, 2.1% (n=2) expressed no experience, 45.3% (n=43) expressed somewhat familiarity, and 52.6% (n=50) expressed familiarity with the pathophysiology of CoA (Table 3). When asked if the CCHD screen catches all cases of CoA, 4.3% (n=4) responded yes, 79.8% (n=75) responded no, and 16% (n=15) responded unsurely (Table 3). The RNs responded to the question how confident are you in assessing signs of symptomatic infants with CoA? 16.6% (n=1) responded not confident, 56.6% (n=34) responded somewhat confident, and 26.6% (n=16) responded confident (Table 4). The providers responded to the question: How confident are you in determining the severity of Coarctation based on the fetal or first echo? 33.3% (n=12) responded not confident, 52.8% (n=19) responded somewhat confident, and 13.9% (n=5) responded confident (Table 5). All caregivers were asked if there are current variations in practice related to Coarctation watch; 67.7% (n=65) responded yes, 1% (n=1) responded no, and 31.3% (n=30) responded unsure (Table 6). When asked if the NICU has a standardized CPG for Coarctation watch infants, 19.8% (n=19) responded yes, 46.5% (n=45) responded no, and 33.3% (n=32) responded unsure (Table 6). Common themes for potential benefits of implementing a CPG for infants with a suspected 14 coarctation were consistency, earlier detection and treatment, decreasing length of stay, feeding faster, improved staff knowledge, reduced errors, reuniting families sooner, and clear orders for bedside RNs (Table 7). Common themes for barriers to implementing a CPG were buy-in, lack of education, ease of locating the guideline, collaboration with specialists, implementation, compliance, and increased workload to follow CPG (Table 7). After the educational presentations, the implementation phase began. Two PDSA cycles occurring after implementing the guideline to identify barriers and other adjustments. Upon the first PDSA cycle, feedback revealed that caregivers required clarification that this guideline is for the 24 hours of life and that total fluids/feedings should be advanced as clinically indicated under the direction of neonatology and input from cardiology after the initial echocardiogram has been performed. Also, the guideline was uploaded to a central location for the providers to easily access. Upon the second PDSA cycle, feedback showed that the guideline would be more appropriate for providers to utilize, and the focus for RNs was redirected to education on clinical assessment of CoA and awareness of a new CPG. Post-implementation Survey Approximately 200 NICU caregivers received the post-implementation survey, see Appendix B. The respondents comprised 24.2% (n=8) Attendings, 3% (n=1) Fellow, 30.3% (n=10) NNPs, and 42.2% (n=14) RNs (Table 8). Their experience ranged from 6.1% (n=2) <1 year of experience, 21% (n=7) 1-5 years of experience, 18% (n=6) 6-10 years of experience, and 54.5 % (n=18) >10 years of experience (Table 8). When asked if the educational presentation increased my confidence in understanding the pathophysiology of CoA, respondents answered 51.5% (n=17) "agree," 12.1% (n=4) "somewhat 15 agree," 15.2% (n=5) "neutral," 0 (n=0) "disagree," and 21% (n=7) "did not know there were educational presentations" (Table 9). When the RNs were asked if the educational presentation increased their confidence in assessing signs of symptomatic infants with CoA, 57.1% (n=8) agreed, 14.3% (n=2) somewhat agreed, 14.2% (n=2) neutral, 0% (n=0) disagreed, and 14% (n=2) did not know there were educational presentations (Table 10). Feedback for increasing confidence for the RNs included having an accessible reference for signs and symptoms either online or in a reference binder (Table 10). Acceptability was assessed by asking, "Do you see a benefit of a standardized Coarctation Watch CPG?" 84.8% (n=28) responded "agree," 15.2% (n=5) responded "somewhat agree," 0% (n=0) responded "neutral," and 0% (n=0) responded "disagree" (Table 11). The providers (Attendings, Fellows and NNPs) were asked, "What proportion of patients with a prenatal suspicion for CoA did you utilize the Coarctation Watch CPG since its implementation in November 2024?" 5.3% (n=1) said none, 10.5% (n=2) said some, 52.6% (n=10) said all, and 31.6% (n=6) said I have not cared for any patients with prenatal suspicion of CoA since the implementation of the CPG (Table 12). Usability was assessed next. Providers were asked if it was easy to find the information they needed on the Coarctation Watch CPG: 61.1% (n=11) agree, 5.6% (n=1) somewhat agree, 33.3% (n=6) neutral, and 0% (n=0) disagree (Table 13). When asked if it was easy to integrate the Coarctation Watch CPG into practice (or I foresee it being easy to integrate into practice), 55.6% (n=10) answered "agree," 22.2% (n=4) answered "somewhat agree," 22.2% (n=4) answered "neutral," and 0% (n=0) answered, "disagree" (Table 14). 16 Feasibility was assessed by asking the providers if they see the CPG as useful in their continued practice. 77% (n=14) stated they agree, 5.6% (n=1), 16.7 5% (n=3) stated they were neutral, and 0% (n=0) stated they disagree (Table 14). The next section of the post implementation survey assessed barriers. Surveyors were asked if there any barriers to using the Coarctation Watch CPG; 21.1% (n=4) did not know there was a new CPG, 5.3% (n=1) could not locate the CPG, 0% (n=0) did not understand how to use the guideline, 0% (n=0) not enough education on the guideline, 26.3% (n=5) other, 47.7% (n=9) none (Table 15). When asked how we could make it better and what improved would you suggest, suggestions included continuing to fine-tune the CPG with cardiology, clear identification of risk stratification in the patient's chart from the last fetal clinic note, improved communication on implementation of the guideline (sending out multiple emails/lines of communication to reinforce the guideline, more RN education, and having a central known location for accessing the guideline (Table 16). Discussion Summary The Coarctation Watch CPG was implemented to standardize the initial care of infants with a suspected CoA, with 100% of surveyed caregivers seeing the benefit of a Coarctation Watch CPG. The education before implementation increased confidence in caring for infants with CoA. This guideline has helped to standardize the initial care of infants with CoA, but better distribution of the guideline, clear risk stratification, and more education would improve buy-in. 17 Interpretation The retrospective chart review showed one consistency: all patients received their first echocardiogram within the first 12 hours of life. Otherwise, the chart review revealed variances in the clinical practice of infants with prenatal suspicion of CoA. With the main controllable factor being time to initial feeding. The time to initial feeding varied with 0% in the first 4 hours of life, 25% in 4 to 11 hours of life, 50% in 12 to 24 hours of life, and 25% after 24 hours of life. Most Patients received their initial feed within 24 hours of life. When assessing current practices of caring for infants with suspected CoA, 67.7% of caregivers responded that there were variances in practice. This helped identify the need for a CPG. Caregivers identified potential benefits of implementing a CPG for infants with suspected Coarctation; common themes included consistency, earlier detection, and treatment, decreased length of stay, feeding faster, preventing NEC, improved staff knowledge, reduced errors, reuniting families sooner, clear orders for bedside RNs. 84.8% of caregivers said the guideline benefits infants with suspicion of CoA. 63.1 % of providers said they utilized the guideline when caring for infants suspected of CoA, indicating adequate uptake of the guideline. 77% of caregivers consider the CPG useful in their continued practice. Indicating feasibility and usability. No providers disagreed with the CPG’s feasibility, usability, and acceptability. However, improvements can be made to make the guideline more useable. Barriers that were identified to using the CPG include 21.1 % (n=4) did not know there was a new CPG, 5.3% (n=1) could not locate the CPG and 26.3 % (n=5) stated other. Suggested improvements include continuing to fine-tune the CPG with cardiology, clear identification of risk stratification in patients' chart from last fetal clinic note, improved communication on implementation of the 18 guideline (sending out multiple emails/lines of communication to reinforce the guideline, more RN education, and having a central known location for accessing the guideline. The data may reflect that improved distribution of the guideline may increase uptake of the guideline in the future. In addition, resources for the RNs may improve RN satisfaction with the CPG. Limitations Limitations include a response rate of 48% for the pre-implementation survey and only a 16.5% response rate for the post-implementation survey. The post-implementation response rate was less than the pre-response rate, partly due to communication, with minimal reminders to fill out the survey and only email format for notification of the survey. A lower response rate of RNs responded to the post-implementation survey. Time was also a limiting factor, and this may have affected the ability to mitigate the response rate of the post-implementation survey. Another limitation is the QI project's implementation duration; caregivers had minimal opportunities to utilize the CPG before the post-implementation survey was distributed to them. The implementation phase was reduced due to the time constraints of the academic semester, and thus, no post-implementation chart review was conducted to compare with the retrospective chart review. Conclusions This QI project successfully implemented an evidenced-based Coarctation Watch CPG. Most caregivers reported utilizing the CPG with all or some of the patients they cared for with suspicion of CoA. Most respondents expressed the guideline's usability, feasibility, and acceptability and saw the benefit for infants. 19 Acknowledgments I want to thank my project chair Julieanne Schiefelbein, DNP, MAppSc, MA (ED), NNP, PNP, my content expert Whitnee Hogan, MD, my project sponsor Belinda Chan, MD, and Specialty Track Director Kim Friddle PhD, NNP-BC, APRN for all their expertise, guidance and continual support throughout this DNP project. I would also like to thank Ashley Mantle, DNP, NNP-BC, APRN for her time and support with this QI project. 20 References Contro, E., Cattani, L., Balducci, A., Prandstraller, D., Perolo, A., Larcher, L., Reggiani, M. L. B., Farina, A., Donti, A., Gargiulo, G. D., & Pilu, G. (2022). Prediction of neonatal Coarctation of the aorta at fetal echocardiography: a scoring system. 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J., Durand, I., Slodki, M., Respondek-Liberska, M., Patel, C., Kawamura, H., Rizzo, G., Pagani, G., … Galindo, A. (2024). Diagnostic accuracy of prenatal ultrasound in Coarctation of aorta: systematic review and individual participant data meta-analysis. Ultrasound in obstetrics & gynecology: the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, 63(4), 446–456. https://doi.org/10.1002/uog.27576 Vigneswaran, T. V., Bellsham-Revell, H. R., Chubb, H., & Simpson, J. M. (2020). Early Postnatal Echocardiography in Neonates with a Prenatal Suspicion of Coarctation of the Aorta. Pediatric cardiology, 41(4), 772–780. https://doi.org/10.1007/s00246-020-02310-5 Wang, H. H., Wang, X. M., Zhu, M., Liang, H., Feng, J., Zhang, N., Wang, Y. M., Yu, Y. H., & Wang, A. B. (2022). A clinical prediction model to estimate the risk for Coarctation of the aorta: From fetal to newborn life. The journal of obstetrics and gynaecology research, 48(9), 2304–2313. https://doi.org/10.1111/jog.15341 22 Tables Table 1 Retrospective Chart Data January 2024-October 2024 Demographics Gestational age 32-33 weeks 33-34 weeks 34-35 weeks 35-36 weeks 36-37 weeks 37-38 weeks 38-39 weeks ³39 Gender Female Male Clinical Measures Time of initial echo Within 12 hours Greater than 12 hours Time of rule in/out of CoA Less than 1 day 2-5 days 6-10 days 11-15 ³16 days Diagnosis of CoA Yes Length of Hospital Stay 0-5 days 6-10 days 11-15 days ³16 Time of initial feed < 4 hours 4-11 hours 12 -24 hours > 24 hours Time to full feedings < 2 days 2-5 days 6-10 days >10 days N=8 1 (12.5%) 0 (0%) 1 (12.5%) 0 (0%) 3 (37.5%) 1 (12.5%) 2 (25%) 0 (0%) 2 (25%) 6 (75%) 8 (100%) 0 (0%) 0 (0%) 5 (62.5%) 2 (25%) 0 (0%) 1 (12.5%) 0 (0%) 2 (25%) 0 (0%) 2 (25%) 4 (50%) 0 (0%) 2 (25%) 4 (50%) 2 (25%) 0 (0%) 2 (25%) 4 (50%) 2 (25%) 23 Transfer to Higher level of care yes Necrotizing enterocolitis Yes 0 (0%) 0 (0%) 24 Table 2 Demographics of Pre-implementation Survey Participants N (%) Years of Experience • <1 9 (9.4%) • 1-5 24 (25.0%) • 6-10 14 (14.6%) • >10 49 (52.0%) Position in NICU • Attending 12 (12.5) • Fellow 1 (1.0%) • NNP 23 (24%) • RN 60 (62.5%) 25 Table 3 Knowledge assessment On a scale of 1-3, how familiar are you with the pathophysiology of Coarctation of the Aorta? • No experience N (%) 2 (2.1 %) • Somewhat familiar 43 (45.3%) • Familiar 50 (52.6 %) Does the CCHD screening catch all cases of Coarctation of the Aorta? • Yes 4 (4.3%) • No 75 (79.8%) • Unsure 15 (16%) 26 Table 4 RN Knowledge assessment How confident are you in assessing signs of symptomatic infants with Coarctation of the Aorta? N (%) • Not confident 10 (16.6%) • Somewhat Confident 34 (56.6% • Confident 16 (26.6%) 27 Table 5 Assessing provider confidence (Attendings, Fellows, and NNPs) How confident are you in determining the severity of Coarctation based on the fetal echo or first echo? N (%) • Not confident 12 (33.3%) • Somewhat Confident 19 (52.8%) • Confident 5 (13.9 %) 28 Table 6 Assessment of current practice Are there variations on practice related to Coarctation watch? N (%) • Yes 65 (67.7%) • No 1 (1.0 %) • Unsure 30 (31.3) Does the NICU have a standardized clinical practice guideline for Coarctation Watch infants? • Yes 19 (19.8 %) • No 45 (46.9%) • Unsure 32 (33.3%) 29 Table 7 Benefits and Barriers – Free text What are some potential benefits of implementing a clinical practice guideline for infants with suspected Coarctation? What, if any, barriers do you see in implementing a clinical practice guideline? Common themes: consistency, earlier detection and treatment, decreased length of stay, feeding faster, preventing NEC (x1), improved staff knowledge, reduced errors, reuniting families sooner, clear orders for bedside RNs Common themes: buy-in, lack of education, ease of locating the guideline, collaboration with specialists, implementation, compliance, increased workload to follow CPG 30 Table 8 Demographics of Post-implementation Survey Participants Role N (%) Attending 8 (24.2%) Fellow 1 (3.0%) NNP 10(30.3%) RN 14 (42.4%) Years of Experience Less than 1 year 2 (6.1) Between 1-5 years 7 (21%) Between 6-10 years 6 (18%) Greater than 10 years 18 (54.5%) 31 Table 9 Assessing confidence - All The educational presentation increased my confidence in understanding the pathophysiology of Coarctation of the Aorta. N (%) Agree 17 (51.5%) Somewhat Agree 4 (12.1%) Neutral 5 (15.2%) Disagree 0 I did not know there were educational presentations 7 (21%) 32 Table 10 Assessing confidence - RNs The educational presentation increased my confidence in assessing signs of symptomatic infants with Coarctation of the Aorta. N (%) Agree 8 (57.1%) Somewhat Agree 2 (14.3%) Neutral 2 (14.3%) Disagree 0 I did not know there were educational presentations 2 (14.3) What would help increase your confidence in assessing signs of symptomatic infants with Coarctation of the Aorta? Common themes: having something tangible to reference re signs and symptoms, online, in a unit binder etc.. and Practice caring for infants with suspected CoA 33 Table 11 Assessing Acceptability Do you see a benefit of a standardized Coarctation Watch Clinical Practice Guideline? N (%) Agree 28 (84.8%) Somewhat agree 5 (15.2%) Neutral 0 Disagree 0 34 Table 12 Assessing feasibility What proportion of patients with a prenatal suspicion for Coarctation of the Aorta did you utilize the Coarctation Watch Clinical Practice Guideline since its implementation in November 2024? N (%) None 1 (5.3%) Some 2 (10.5%) All 10 (52.6%) I have not cared for any patients with prenatal suspicion of Coarctation of the Aorta since the implementation of the Clinical Practice Guideline 6 (31.6%) 35 Table 13 Assessing usability It was easy to find the information you needed on the Coarctation Watch Clinical Practice Guideline N (%) Agree 11 (61.1%) Somewhat Agree 1 (5.6%) Neutral 6 (33.3%) Disagree 0 36 Table 14 Assessing acceptability It was easy to integrate the Coarctation Watch Clinical Practice Guideline into practice (or I foresee it being easy to integrate into practice) N (%) Agree 10 (55.6%) Somewhat Agree 4 (22.2%) Neutral 4 (22.2%) Disagree 0 (0%) Do you see the clinical practice guideline being useful in your continued practice? Agree 14 (77.8%) Somewhat Agree 1 (5.6%) Neutral 3 (16.7%) Disagree 0 37 Table 15 Assessing Barriers Are there any barriers to using the Coarctation Watch Clinical Practice Guideline? N (%) Did not know there was a new Clinical Practice Guideline 4 (21.1%) Could not locate the Clinical Practice Guideline (1, 5.3%) Did not understand how to use guideline 0 (0.0%) Not enough education on the guideline 0 (0.0%) Personal preference 0 (0.0%) Other 5 (26.3%) None 9 (47.4%) 38 Table 16 Improvements and suggestions How can we make it better, what improvements would you suggest? Common themes: collaboration with cardiology colleagues. Clear identification of risk stratification in fetal clinic note. Share the guideline and reminders multiple times to reinforce change and the guideline. More RN education 39 Appendix A Pre-Implementation Survey 2+'8+ )5362+9+ 9.+ 8:7;+> (+25< ".'41 >5: 5< 254- .';+ >5: <571+* /4 9.+ # >+'7 >+'78 >+'78 >+'78 $.'9 /8 >5:7 658/9/54 99+4*/4 +225< 4 ' 8)'2+ 5, .5< ,'3/2/'7 '7+ >5: </9. 9.+ 6'9.56.>8/525-> 5, 5'7)9'9/54 5, 9.+ 579' 5 +=6+7/+4)+ !53+<.'9 ,'3/2/'7 '3/2/'7 5+8 9.+ 8)7++4/4- )'9). '22 )'8+8 5, 5'7)9'9/54 5, 9.+ 579' %+8 5 #48:7+ 57 8 .5< )54,/*+49 '7+ >5: /4 '88+88/4- 8/-48 5, 8>36953'9/) /4,'498 </9. )5'7)9'9/54 5, 9.+ 579' 59 )54,/*+49 !53+<.'9 )54,/*+49 54,/*+49 '3 675;/*+7 57 75;/*+78 +5 +225<8 5< )54,/*+49 '7+ >5: /4 *+9+73/4/4- 9.+ 8+;+7/9> 5, 5'7)9'9/54 ('8+* 54 9.+ ,+9'2 +).5 57 ,/789 +).5 59 )54,/*+49 !53+<.'9 )54,/*+49 54,/*+49 7+ 9.+7+ ;'7/'9/548 /4 67')9/)+ 7+2'9+* 95 5'7)9'9/54 <'9). %+8 5 #48:7+ 5+8 9.+ # .';+ ' 89'4*'7*/?+* )2/4/)'2 67')9/)+ -:/*+2/4+ ,57 5'7)9'9/54 $'9). /4,'498 %+8 5 #48:7+ $.'9 '7+ 853+ 659+49/'2 (+4+,/98 5, /362+3+49/4- ' )2/4/)'2 67')9/)+ -:/*+2/4+ ,57 /4,'498 </9. 8:86+)9+* )5'7)9'9/54 $.'9 /, '4> ('77/+78 *5 >5: 8++ /4 /362+3+49/4- ' )2/4/)'2 67')9/)+ -:/*+2/4+ 63 &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 6750+)97+*)'6 57- 40 Appendix B Post-implementation Survey 41 42 Appendix C Educational PPT What is Coarctation of the Aorta? Coarctation of the Aorta DNP-QI Project Madeline Park BSN, RN, DNP-S • CoA is a discrete narrowing of the descending aorta, usually distal to the origin of the subclavian artery and adjacent to the Ductus Arteriosus (DA), this portion of the descending aorta is called the aortic isthmus. • CoA occurs 1 in 1800 infants in the US. • More commonly seen in males than in females • The incidence of CoA in Turners syndrome (which only affects females) is 30%. • Maternal health influences include preexisting diabetes mellitus (Thomas et al., 2024; Karlson & Cowley, 2021). Coarctation of the aorta cont. • Ductal tissue often extends into the area of the coarctation and with ductal closure, the narrowing may be significant enough to impair systemic perfusion. • In severe cases, the left ventricle may be unable to pump blood beyond the narrowing and the infant will develop congestive heart failure and cardiogenetic shock • The transverse aortic arch and isthmus may also be hypoplastic, associated cardiac defects include a bicuspid aortic valve (50% of cases) and VSD (Hoffman et al., 2019) Postnatal evolution of aortic arch anatomy with ductal restriction and closure. Obstructive Systemic Outflow Tract Clinical Presentation Early signs of shock • “Comfortable” tachypnea • Poor feeding • Low urine output • Change in level of consciousness • Progressive loss of femoral pulses Advanced signs of shock • increased respiratory distress • Loss of consciousness • Weak pulses • Tachycardia, hypotension • Poor perfusion and tissue oxygenation → Severe metabolic acidosis 43 • Serial evaluation of upper and lower extremity blood pressure • blood pressure (systolic, diastolic and mean) will be higher in the pre-stenotic aorta and extremities than in the post-stenotic aorta and extremities due to impaired pulse propagation beyond the narrowed isthmus. BP gradient of ≥20(?)is concerning What is ARCH WATCH • Physical exam: • Sublet and non-specific • Gray-appearing skin, delayed capillary refill (late findings) • Pulses: weak femoral pulses may indicate delayed pulse propagation and reduced descending aorta flow • Presence of a murmur • Decreasing oral intake/feeding intolerance • Tachypnea • Oliguria (and increasing serum creatinine trends are concerning) Echocardiogram findings • Diagnosis of neonatal CoA in the presence of PDA is difficult. The aortic isthmus ≤3 mm without PDA or the isthmus ≤4 mm in the presence of PDA may be diagnostic of neonatal COA. • The ratio of the aortic isthmus to the descending aorta at the diaphragm <0.64 is also a reliable sign of COA in the presence of PDA. • Presence or absence of a posterior “ridge” or “shelf” or “ledge” in the juxtaductal region of aortic arch • Varying degrees of isthmic hypoplasia and hypoplasia of the transverse aortic arch may be present. Poststenotic dilatation of the descending aorta is usually imaged. • Aortic measurements more than 2 standard deviations below the mean for the patients body size ( z-score < -2) 44 (Leo et al., 2023) References • Hoffman, J. , Thompson-Bowie, N., & Jnah, A. (2019). The Cardiovascular System. In etal and Neonatal Physiology for the Advanced Practice Nurse. Springer Publishing LLC. https://online.vitalsource.com/books/9780826157454 • Karlson, K. & Cowley, C. (2021). S.T.A.B.L.E. –Cardiac Module. (2nd Ed.). S.T.A.B.L.E., Inc. • Leo, I., Sabatino, J., Avesani, M., Moscatelli, S., Bianco, F., Borrelli, N., De Sarro, R., Leonardi, B., Calcaterra, G., Surkova, E., Di Salvo, G., & On Behalf Of The Working Group On Congenital Heart Disease Cardiovascular Prevention In Paediatric Age Of The Italian Society Of Cardiology Sic (2023). Non-Invasive Imaging Assessment in Patients with Aortic Coarctation: A Contemporary Review. Journal of clinical medicine, 13(1), 28. https://doiorg.ezproxy.lib.utah.edu/10.3390/jcm13010028 • Park, M. K. (2014). Park's The Pediatric Cardiology Handbook (5th ed.). Elsevier Health Sciences (US). https://online.vitalsource.com/books/9780323371025 • Thomas, A. R., Levy, P. T., Sperotto, F., Braudis, N., Valencia, E., DiNardo, J. A., Friedman, K., & Kheir, J. N. (2024). Arch watch: current approaches and opportunities for improvement. Journal of perinatology: official journal of the California Perinatal Association, 44(3), 325–332. https://doi.org/10.1038/s41372-023-01854-7 45 Appendix D Coarctation Watch Clinical Practice Guideline 46 References: 1. Berseth, CL, et al. (2003). Prolonging Small Feeding Volumes Early in Life Decreased the Incidence of Necrotizing Enterocolitis in Very Low Birth Weight Infants. Pediatrics, 111; 529-534. 2. Carlo WF, Kimball TR, Michelfelder EC, Border WL. (2007). Persistent diastolic flow reversal in abdominal aortic Doppler-flow profiles is associated with an increased risk of necrotizing enterocolitis in term infants with congenital heart disease. Pediatrics, 119 (2): 330-5. 3. Kamitsuka MD, et al. (2000). The Incidence of Necrotizing Enterocolitis After Introducing Standardized Feeding Schedules for Infants Between 1250-2500 Grams and Less Than 35 Weeks of Gestation. Pediatrics, 105(2):379-384. 4. Lambert DK, Christensen RD, Henry E, et al. (2007). Necrotizing enterocolitis in term neonates: data from a multihospital health-care system. Journal of Perinatology, 27, 437-433. 5. Luca AC, Miron IC, Mindru ED, et al. (2022). Optimal Nutrition Parameters for Neonates and infants with Congenital Heart Disease. Nutrients, 14 (8): 1671. 6. McElhinney DB, Hedrick HL, Bush DM, et al (2000). Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: Risk Factors and Outcomes. Pediatrics, 106 (5): 1080-1087. 7. McNeill, S., Gatenby, J., McElroy, S., & Engelhardt, B. (2011). Normal cerebral, renal and abdominal regional oxygen saturations using near-infrared spectroscopy in preterm infants. Journal of Perinatology, 51-57. 8. Mecarini, F, Comitini, F, Bardanzellu, F, et al. (2020). Neonatal supraventricular tachycardia and necrotizing enterocolitis: case report and literature review. Italian Journal of Pediatrics, 46 (1): 117. 9. Mills KI, Kim JH, Fogg K. (2022). Nutrition Considerations for the Neonate With Congenital Heart Disease. Pediatrics, 150 (Suppl 2). 10. Nakib G, Sajwani S, Abusalah Z, et al. (2018). Recurrent supraventricular tachycardia and necrotizing enterocolitis: A causative role or simple association? A case report and literature review. Pediatric Reports, 10 (3): 736. 11. Patel, A., Lazar, D., Burrin, D., Smith, O., Magliaro, T., Stark, A., . . . Olutoye, O. (2014). Abdominal Near-Infrared Spectroscopy Measurements Are Lower in Preterm Infants at Risk for Necrotizing Enterocolitis. Pediatric Critical Care Medicine, 735-741. 12. Scahill CJ, Graham EC, Atz AM, et al. (2017). Preoperative feeding and necrotizing enterocolitis: Is the fear justified?. World J Pediatr Congenit Hear Surg, 8 (1): 62-68. 13. Won Jeon, G. (2019). Clinical Application of Near-Infrared Spectroscopy in Neonates. Neonatal Medicine, 121-127 47 Appendix E Executive Summary Summary A level III Newborn Intensive Care Unit (NICU) in Utah had no guideline for initial care of infants with suspicion of Coarctation of the Aorta (CoA). This led to inconsistencies in management of infants with suspicion of CoA. This Doctor of Nursing Quality Improvement Project created and implemented a Coarctation Watch Guideline for infants ³ 35 weeks gestation. Background Coarctation of the Aorta remains challenging to diagnosis in the prenatal period. Coarctation of the Aorta is accounts for 5% of congenital heart disease in infants. Evidence shows that having risk stratification and postnatal observation of infants with suspected Coarctation of the Aorta improves diagnosis of this disease. Intervention This quality improvement project involved the implementation of a clinical practice guideline created by key stakeholders in Neonatology and Fetal Cardiology. A literature review was conducted to review best practice. A survey was distributed to NICU caregivers assessing current practice and knowledge prior to implementation of the CPG. Education was disseminated to NICU caregivers, and then CPG was then implemented. 2 PDSA cycles were completed post implementation for rapid change. A post-implementation survey assessed caregiver thoughts on feasibility, usability and acceptability. Results The clinical practice guideline was developed by key stakeholders with expert clinical opinion. Approximately 200 caregivers received the surveys, with a 48% (n=96) pre-implementation 48 response rate and a 16.5% post-implementation response rate. 100% (n=33) of caregivers see the benefit of a standardized CPG for infants with suspected CoA. 77% (n=14) of providers report it would be easy to use this CPG in future clinical practice. And 83 % (n=15) see this CPG being useful in their continued practice. Barriers that were identified are 21% (n=4) did not know there was a CPG, 5.3% (n=1) could not locate the CPG. Recommendations Although there was low response rate to the post-implementation survey, the majority of caregivers see the CPG as useable, feasible and acceptable. The education and CPG appear to be valuable resources for staff to improve the care of infants with suspicion of CoA. Following the interventions, ongoing collaboration with key stakeholders is crucial for successful implementation and sustainability.