Background: Prenatal detection of coarctation of the aorta (CoAo) is challenging, mainly due to a high false-positive rate. Neonatal hospitalization of patients with low suspicion of CoAo can have a significant impact, including increased healthcare costs and the social burden of mother-baby separation. A less interventionist approach to these patients could improve quality of care while mitigating these effects. Objective: We aimed to reduce unnecessary interventions by 50% within one year in neonates admitted to the NICU with prenatal suspicion of CoAo (psCoAo) by implementing prenatal risk stratification and a risk-specific postnatal management approach. Design/Methods: This quality improvement project was conducted in a tertiary neonatal unit in Montreal, Canada. A multidisciplinary team stratified psCoAo into low, intermediate, and high risk categories and developed individualized management plans for each. The study consisted of three phases: pre-intervention (January 2022-January 2023), intervention (February 2023), and post-intervention (July 2023-July 2024). Results: Fourteen patients were identified; one was excluded post-intervention due to transposition of the great arteries. Demographics were similar except for a higher rate of postnatal CoAo confirmation in the pre-intervention group. Pre-intervention, no patient received PGE1 on admission, whereas one patient in the post-intervention group did.
After the intervention, three low-risk, one moderate-risk, and two high-risk patients were identified, with CoAo confirmed in only one of the high-risk patients. The protocol was used in three of six patients, resulting in a decrease in the frequency of laboratory testing and vital sign monitoring. There were no changes in medications, labs, or monitoring orders in the first 24 hours of life for these three patients. Median length of stay (LOS) was slightly reduced in the post-intervention period (7 vs. 5 days), as was NICU LOS (1.8 vs. 0.8 days). There were no reported complications in either group. In addition, while four patients in the pre-intervention group were initially NPO, only one high-risk patient in the post-intervention group was. Five of six patients in the post-intervention group achieved full feeding within the first 48 hours of life.
Conclusion(s): Implementation of a risk-based management protocol for prenatally suspected CoAo allowed for safer, less interventional postnatal care. Extending this protocol to the nursery may help prevent mother-baby separation by allowing patients with low suspicion of CoAo to room-in with their mothers after delivery.
Demographics of the cohort
Frequency of laboratory testing prescribed on admission
Frequency of vital signs monitoring prescribed on admission
.png)
.png)
.png)
