Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment.

OBJECTIVE: This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. STUDY DESIGN: A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. RESULTS: The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. CONCLUSION: Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. KEY POINTS: · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..

Using quality improvement (QI) to improve video consultations in community paediatrics during the COVID-19 pandemic

BackgroundOur community paediatrics service serves a diverse inner-city population of approximately 70,000 children and young people, with high rates of deprivation. During the COVID-19 pandemic, we shifted rapidly from face-to-face assessments to video assessments, with unknown implications on quality of care. Lack of guidelines and preventable technical problems led to incomplete assessments and precious time wasted. This could lead to adverse health, developmental, educational and long-term social outcomes.ObjectivesBy June 2020, to reduce avoidable technical problems with video clinics from 100% to less than 20%, in order to minimise time wasted, improve quality of video assessments, patient safety and satisfaction.MethodsAll staff were trained to use video consultations by virtual workshops, online demonstration, one-to-one troubleshooting and practice runs (NHS England Attend Anywhere platform, 2020). We engaged stakeholders through regular online Skype Huddles, email and Whatsapp updates to ensure ongoing dynamic learning, ensure clear communication and discuss improvement strategies.Our primary measure was the number of preventable technical problems (e.g. patient not receiving instructions, child moving camera, interpreter not booked). Outcome measures included patient outcomes following video consultations (discharge or follow up required), qualitative patient satisfaction feedback and clinician reported quality of consultation – satisfactory (yes/partly/no). The number of ‘Did not Attend’ episodes (DNAs) was a balancing measure.ResultsTeam Skype meetings and plan-do-study-act (PDSA) cycles shared learning from video consultations. In April 2020, we reviewed 188 patients (69% by video, 31% by telephone), increasing to 267 (82% by video, 18% by telephone) in May 2020, showing a sustained increase in number of video consultations. Avoidable technical problems reduced from 100% to 20% from March to mid-April, which was sustained. We were able to discharge 44% of patients following their initial video consultation, the others requiring follow up in specialty clinics or face-to-face follow-up to complete the assessment. Clinician feedback was encouraging;55% of consultations were fully satisfactory, 35% partly (unable to examine child, poor internet connection, time consuming) and 10% were not satisfactory. Over 2/3 of patients preferred having a video consultation to face-to-face and the majority were thankful for contact, discussion and plans made. Qualitative patient feedback included: ‘This conversation is amazing, we were able to address a lot of issues despite being a video consultation.’ Some patients who forgot about the appointment were still contactable by phone and able to engage with the video consultation, due to the flexibility conferred by remote consultations. However, the overall rate of DNAs doubled from 7% in April/May 2019 to 14% in April/May 2020. This is likely due to initial challenges with instructions and accessibility of video consultations to our high number of vulnerable families, experiencing digital poverty, learning difficulties or language barriers.ConclusionsThe pandemic has brought dramatic changes to all our lives and accelerated the need for development in video consultations, which will remain an integral part of our service. Quality improvement is effective in optimising video consultation compared to telephone. Further work is required to better understand and manage accessibility and risk of video consultations, as well as virtual multidisciplinary working.

Fifteen-minute consultation: How to undertake an effective video consultation for children, young people and their families.

The COVID-19 pandemic has changed how we work in paediatrics with increasing use of virtual consultations. When optimised, a great deal can be achieved through video consultation compared with telephone, but accessibility and clinical risk need to be carefully considered and managed. This article aims to provide a structured approach with top tips for planning and delivering video consultations effectively in paediatrics.