To Manny, Ido and Adina
CC Shmuel
Subj: Antenatal Steroid Use: Drilling down on the audit process
Date: May 30, 2019
Well this started out for me as a simple self-imposed task: how do our ANS use rates compare with others? And How do others conduct their audits to better understand the challenges of improving these rates. To my great delight and interest, I was pleased that others had pushed beyond the simple audit forms we first introduced 20 years ago and that some very creative thinking has been addressing this topic more recently. The headline for this report is that: THE GOAL POSTS HAVE BEEN MOVED! (Not sure how this American football saying gets best translated into the Hebrew context—maybe they have moved the basketball goal and made it higher!)
In particular:
- “Complete ANS” now is being transformed into ANS dosing >48 h and < 7d and, when appropriate, a “rescue” dose given.
- Audits and care planning aids should ideally identify and address the varied scenarios which confront the clinicians, e.g.
Levin et al: Major Findings: For the majority of women in this cohort, ACS timing was
suboptimal. In particular, two groups of women who ultimately
delivered preterm were unlikely to have optimally
timed steroids: (1) women who were asymptomatic but
received steroids for increased risk for spontaneous preterm
birth based on a positive fetal fibronectin, short ultrasound
cervical length or asymptomatic cervical dilation; and (2)
women presenting with abruption and/or vaginal bleeding.
Patients with hypertensive disorders were most likely to
receive optimally timed steroids, although this was not statistically
significant in the adjusted analysis. In addition to
optimal timing rates varying across different indications,
the timing of suboptimal administration —early or late—
was different across groups. Asymptomatic women at
increased risk for spontaneous preterm birth and women
with abruption/bleeding were much more likely to receive
steroids administered early, rather than late. Patients with
hypertensive disorders and preterm labour had a relatively
higher percentage of suboptimal timing cases due to late
administration (<24-hour interval to delivery) rather than
early administration (≥7 days).
How might this apply to the proposed breakout session? Several of these articles start from the raw material of hundreds of ANS audits, a situation we have not reached yet in our project work. Thus, you may want to pose two or three of these clinical scenarios to attendees as “how would you implement a “Plan/Do/Study/Act” cycle that would improve ANS preparation for patients presenting with each of these scenarios.
Oh by the way, below is the TABLE that compares “old” versus “new” ANS performance table.
Ref_au
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Ref_Journal
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Site
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Number
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NO ANS
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ANY ANS
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PARTIAL
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COMPLETE ANS
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"OLD"
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OPTIMAL
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<24 hr PTD
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2 DOSES OVER 24hr
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2 DOSES 1-7d PTD
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2 DOSES > 48 h < 7d PTD
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RESCUE DOSE > 7d
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Melamed
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ACOG_2015
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CANADA
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2126
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15.2
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85
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21.6
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63.1
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45.8
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17.3
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Travers
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AJOG 2018
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NICHD
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2282*
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6.6
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93.4
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22.7
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70.8
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na
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na
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na
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Levin
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BJPG 2015
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NEW YORK
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630
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7
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93
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?
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?
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na
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37.8
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13.8
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PMB Project
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Draft Report yr 01
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ISRAEL
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140
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12
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88
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22.5
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65.5
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7.7
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*24-28wksGA
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Ok , that’s it. My rough notes follow and the articles are also attached in the email.
David
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DW on preliminary inquiry of ANS results in Israel—
1st cut of unverified Isr entries to PMB dataset showed 144 records in which ANS status was noted. (3 without). Of these, 130 (90% showed “ANY ANS”, 93 reported as “complete” courses (73%) and 32 (25%) “as incomplete”
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t participating centers of the National Institute of Child Health and Human
Development Neonatal Research Network between January 2006 and December 2011
Re-iterates importance of ANS—not relevant here
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Association of Neurodevelopmental Outcomes
and Neonatal Morbidities of Extremely Premature Infants
With Differential Exposure to Antenatal Steroids
Sanjay Chawla JAMA peds 2016
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Among the no, partial, and complete ANS groups, there were significant differences in the rates of mortality (43.1%, 29.6%, and 25.2%, respectively), severe intracranial hemorrhage among survivors (23.3%, 19.1%, and 11.7%), death or necrotizing enterocolitis (48.1%, 37.1%, and 32.5%), and death or bronchopulmonary dysplasia (74.9%, 68.9%, and 65.5%). Additionally, death or neurodevelopmental impairment occurred in 68.1%, 54.4%, and 48.1% of patients in the no, partial, and complete ANS groups, respectively
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Results
Between 2006 and 2011, 8847 infants with a GA of 27 weeks
or less were born at NRN centers. Of these, 700 infants died
within 12 hours without receiving aggressive neonatal care. A
total of 2026 infants were not eligible for follow-up; 79 had
weights greater than 1000 g, 1574 had Gas more than 26 weeksfor infants born after 2007, 372 were outborn, and 1 had an unknown status. Follow-up data were available for 3892 of 4284eligible extremely low GA neonates (90.8%) (Figure)
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24 0/7 and 33 6/7
weeks of gestation and admitted to tertiary neonatal
units in Canada during 2010–2012 were obtained from
the Canadian Neonatal Network
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Melamed Lee Canadian Network ACOG 2015
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No Antenatal
Corticosteroids
324
Gestational age 28 wk or less
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ANS
Less Than 24 Hours
460
Gestational age 28 wk or less
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ANS
1–7 Days
974
Gestational age 28 wk or less
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ANS
Greater Than 7
Days
368
Gestational age 28 wk or less
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Of 6,870 eligible neonates, 1,378 (20%)
received no antenatal corticosteroids; 1,473 (21%) received partial antenatal corticosteroids; 2,721 (40%) received antenatal corticosteroids 1–7 days before
birth; and 1,298 (19%) received antenatal corticosteroids greater than 7 days before birth
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CANADA--2010-2012
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No Corticosteroids
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Less Than 24 Hours
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1–7 Days
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Greater Than 7 d
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15.2%
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21.6%
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45.8%
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17.3%
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Non-Optimal
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OptimaL
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54.2%
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45.8%
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Mortality and pulmonary outcomes of extremely preterm infants exposed to antenatal corticosteroids.
Travers NICHD Am J Obstet Gynecol. 2018
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1,022 infants 22 0/7 to 28 6/7 weeks' gestational age with a birthweight of ≥401 g born from Jan. 1, 2006, through Dec. 31, 2014, were analyzed
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Infants exposed to any antenatal corticosteroids had a lower rate of death (2193/9670 [22.7%]) compared to infants without exposure (540/1302 [41.5%]) (adjusted relative risk, 0.71; 95% confidence interval, 0.65-0.76; P < .0001). Infants exposed to a partial course of antenatal corticosteroids also had a lower rate of death (654/2520 [26.0%]) compared to infants without exposure (540/1302 [41.5%]); (adjusted relative risk, 0.77; 95% confidence interval, 0.70-0.85; P < .0001)…
This study was
also designed to determine if exposure to
a partial or a complete course of
antenatal corticosteroids is associated
with improved survival and pulmonary
outcomes in extremely preterm infants
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Variability of Very Low Birth Weight
Infant Outcome and Practice in
Swiss and US Neonatal Units
Mark Adam peds 2018
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Has vlbw inf and crude percentage .. not really useful
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We observed a wide variability in
some of the obstetric, DR, NICU, and
nutritional practices between the SNN
and US-VON. After adjustment for
case mix and indirect standardization
using US-VON infants as reference,
the SNN had a higher than expected
use of antenatal steroids, a practice
well-known to improve outcome.
33
In the DR, stabilization on continuous
positive airway pressure rather than
intubation was higher in the SNN, for
which recent large trials reveal a lower
risk of CLD or death.
34 On the ward,
the SNN also used less
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WONG Antenatal corticosteroids administration: are we giving them
at the right time? Arch on GYN 2018
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Overall, our antenatal corticosteroids administration
rate is comparable to that attained by centres in other
developed countries. It is difficult but important to discriminate
women who will benefit from this timely intervention
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24 Levin HI, Ananth CV, Benjamin-Boamah C, Siddiq Z, Son M,
Friedman AM (2016) Clinical indication and timing of antenatal
corticosteroid administration at a single centre. BJOG
123(3):409–414
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Amongst the preterm deliveries, 50.3% women had presented
at gestation age ≤ 34+6 to the delivery suite triage
unit. Of these, 85.9% had received at least one dose of
antenatal corticosteroids, as shown in Fig. 1. Only 22.1%
had delivered within the window of efficacy (≥ 48 h to
≤ 7 days after the first dose of antenatal corticosteroids).
A large proportion of preterm deliveries who presented
at gestation age ≤ 34+6 (45.7%) did not receive adequate
exposure to antenatal corticosteroids before birth (either
Arch Gynecol Obstet (2018) 297:373–379 375
1 3
not given or delivered less than 48 h after the first dose of
corticosteroid). No repeat courses of antenatal corticosteroids
were administered.
Based on our KKH regime, an additional of 38 women
who had presented between 35+
0 and 36+
0 weeks’ gestation
received antenatal corticosteroids (12.8% of all
preterm deliveries). Out of these 38 women, 16.1% had
delivered within the window of efficacy.
Amongst the term deliveries, 5.42% had received a
course of antenatal corticosteroids at preterm gestations.
Overall, 1 in 2.2 antenatal corticosteroids courses had been
administered to women who eventually delivered at term.
The top indications for antenatal corticosteroids for the
preterm deliveries in our centre were spontaneous preterm
labour (PTL) (38.9%), preterm premature rupture of
membranes (PPROM) (25.7%) and hypertensive disorders,
where early delivery was indicated (13.9%) (Table 1
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In our study, we found that gestational
age at presentation, the presence of regular uterine
activity on tocography and cervical change is associated
with delivery within 1 week
Such models may be adapted for validation in our centre
and form the basis of a protocol to aid doctors in decisionmaking.
The New York Centre [24], who reported the best
optimal timing of corticosteroids so far in 40% of their
women, had a defined policy and procedures for corticosteroid
administration.
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LEVIN BJOG. 2016 Feb;123(3):409-14. doi: 10.1111/1471-0528.13730. Epub 2015 Oct 20.
Clinical indication and timing of antenatal corticosteroid administration at a single centre. Levin HI1, Ananth CV1,2, Benjamin-Boamah C1, Siddiq Z1, Son M1, Friedman AM1.
Columbia NEW YORK
MOVES ANS SURVEILLENCE FROM ANY ANS PRIOR TO PRETERM BIRTH
TO OPTIMAL TIMING OF PRETERM BIRTH
NOTES THAT A SIX YEAR EFFORT WAS NEEDED TO MOVE RESCUE DOSING FROM 40% TO 80%
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Of 630 women who delivered preterm, 589 (93%) received ACS prior to delivery. ACS timing was optimal in 40% (238 of 589) of cases. Women with hypertensive disorders were most likely to have steroids optimally timed (62%). Asymptomatic women at increased risk for preterm delivery were less likely to receive optimally timed ACS (12%). The majority of women who received steroids >2 weeks prior to delivery (57%) received a second course
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versus
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Antenatal corticosteroid timing: accuracy after the introduction of a rescue course protocol
N K Makhija
American journal of obstetrics and gynecology. , 2016, Vol.214(1), p.1200-6
PROSPECTIVE TOOL—DEVELOPMENT
Seattle
A cautionary tale : b/c of how the difficulty of predicting preterm delivery and its effect on ordering ANS appropriately
No usable data
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The opportunity for a second course of antenatal
corticosteroid did not improve the number of women who delivered within
any optimal antenatal corticosteroid window. Administration timing was
similar for the initial course and the rescue course, with approximately
one-quarter of women delivering within the optimal antenatal corticosteroid window. These findings likely reflect the few circumstances in which
rescue antenatal corticosteroid is useful and the poor predictability of
preterm birth. Future focus should be aimed at tools to predict the timing of
preterm birth to optimize antenatal corticosteroid administration
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Antenatal corticosteroids administration: are we giving them
at the right time?
Tifany Tuck Chin Wong arch ob gyn 2018
good discussion of audit and analysis but definitions are enough differrent as to make it difficult to combine into a summary table so I omitted from the table
very practical approach (I think but then again I am not an OB!
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Results 85.9% of women who delivered at gestational
age ≤ 34+6 received at least one dose. 22.1% had delivered
within the window of efcacy. Gestational age > 32 weeks
at presentation, uterine activity on tocography and cervical dilation with efacement were associated with preterm
delivery within 1 week of presentation.
Conclusion Overall, our antenatal corticosteroids administration rate is comparable to that attained by centres in other
developed countries. It is difcult but important to discriminate women who will beneft from this timely intervention.
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