ABSTRACT
Objective: Routine maternal oxygen supplementation for category 2 intrapartum fetal heart rate tracings has not been shown to reduce fetal acidemia in prospective studies. We aim to validate that de-implementing this intervention did not increase the risk of neonatal acidemia in a real-world setting. Study Design: This is a retrospective, single-institution study of laboring patients with category 2 intrapartum tracings from January 2019 - June 30, 2021. In March 2020, secondary to the COVID pandemic, routine maternal oxygen supplementation for such tracings was abandoned per hospital guidelines, providing the opportunity to compare pre- and post-de-implementation cohorts. Laboring patients with singleton or twin pregnancies between 23-42 weeks of gestational age with persistent category 2 tracings, as identified by a previously described external safety monitoring system, were evaluated. Major fetal anomalies, contraindications to labor and maternal indication for O2 supplementation were excluded. The primary outcome was fetal acidemia, defined as umbilical cord pH < 7.2. Secondary outcomes included severe acidemia (pH < 7.0), 5-minute Apgar score < 4 and neonatal intensive care unit admission. Regression analyses controlling for known variables associated with neonatal acidemia generated adjusted odds ratios. Result(s): Out of the 9088 deliveries during the study period, 1162 tracings were flagged as category 2, including 681 (59%) in the post-intervention group. The two cohorts had comparable baseline characteristics (Table 1). No difference in neonatal acidemia was observed between the pre- and post-de-implementation group (15.4% vs 13.8%, aOR 0.89, 95% CI 0.63-1.22, Table 2). Severe acidemia, 5-minute Apgar < 4 and NICU admission were not increased in the post-de-implementation group. Conclusion(s): De-implementation of routine maternal oxygen supplementation for category 2 intrapartum fetal tracings did not increase risk for neonatal acidemia in a real-world setting, validating the lack of effectiveness for the intervention. [Formula presented] [Formula presented] Copyright © 2022
ABSTRACT
Purpose: Beyond patient symptom management during treatment, patient reported outcomes (PRO) play a critical role in oncology survivorship. Although considered standard of care, PRO collection and use is challenging for radiotherapy (RT) centres lacking electronic PRO (ePRO) infrastructure. This work outlines facilitators and barriers to the implementation of an ePRO program across a multicentre radiation oncology department. Material(s) and Method(s): Dalhousie University's Department of Radiation Oncology (DRO) is composed of four RT centres across three provinces. Department-wide implementation of ePRO was precipitated by several key events: In 2009, a Canadian Partnership Against Cancer (CPAC) grant enabled 2 centres to begin paper-based PRO using the Canadian Problem Checklist (CPC) and Edmonton Symptom Assessment System (ESASr). In 2015, the Department's research retreat set ePRO as a priority. In 2017, Accreditation Canada mandated routine evaluation of patient outcomes and in 2018, the Canadian Partnership for Quality Radiotherapy (CPQR) identified Dalhousie's DRO as an early adopter within the pan-Canadian PRO initiative. In 2019, three DRO centres were awarded CPAC funding to launch ePROs. The fourth centre now hopes to use lessons learned in order to facilitate their ePRO implementation. Result(s): ePRO was launched in September 2021 with a phased approach across centres and tumour sites so that user feedback can inform the roll out. Clinic workflows now includes ePRO at consultation, first and last RT review as well as follow-up. Within the ePRO application (Noona), CPQR-endorsed PRO tools include CPC, ESASr, and the Brief Pain Inventory (BPI), with use of other tumour-site specific questionnaires planned. Project charter included needs assessments (human resource, staff /patient education) and change management strategies required to obtain buy-in from front line staff. Although coordination of such a large-scale initiative was challenged by COVID restrictions, project priority was escalated with ePRO recognized as a powerful tool to assess patient symptoms in clinic or remotely. Research unit support was invaluable to navigate IT project complexities including vendor/collaborator contracts, processes of Privacy Impact Assessments and IT architectural reviews. From the advisory board to PRO working groups, mullti-stakeholder feedback and collaboration has been key, including representatives of patients, cancer program leadership, project managers/principle investigators, administrative staff, nurses, radiation therapists, radiation oncologists, industry, IT and legal. Conclusion(s): Multi-centre implementation of an ePRO program has been feasible but complex and time intensive. It is hoped that our lessons learned may benefit those RT centres aiming to transition from paper-based to ePRO systems. With critical electronic infrastructure now in place, we await data to analyze ePRO amongst other patient outcomes in ongoing RT Big Data initiatives. Copyright © 2022 Elsevier Ireland Ltd. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).