title: Steps for implementing delayed cord clamping in a hospital setting.
abstract: BACKGROUND
  Delayed umbilical cord clamping (DCC) permits placental-to-newborn transfusion and results in an increased neonatal blood volume at birth. Despite endorsement by numerous medical governing bodies, DCC in preterm newborns has been slow to be adopted into practice. The purpose of this article is to provide a framework to guide medical providers interested in implementing DCC in a hospital setting. A descriptive implementation guideline is presented based on the author's personal experiences and the steps taken at the University of Washington (UW) to implement DCC in premature newborns <37 weeks' gestational age. Quality improvement data was obtained to assess compliance with DCC performance over the initial six months following initiation of the treatment protocol in July 2014. An anonymous electronic survey was administered to obstetrical providers in January 2015 to assess DCC policy awareness and adherence.
  
  
  RESULTS
  Important steps to consider regarding implementation of DCC in a hospital settings include applying a multidisciplinary educational approach aimed at motivating potential stakeholders potentially impacted by DCC, addressing safety concerns regarding DCC, and developing a standardized DCC treatment protocol. In the first month following DCC protocol implementation at UW, 79.2% (19/24) of premature newborns admitted to the neonatal intensive care unit received DCC, but compliance decreased over time, with DCC documented in only 40.1% (61/150) of newborns during the 6-month period following implementation. The majority of obstetrician survey respondents (90.9%, 20/22) were aware of the UW DCC policy for preterm deliveries, had performed DCC in the past 6 months (95.5%, 21/22), felt that they had sufficient understanding of the risks and benefits of DCC (90.9%, 20/22) and cited concerns for maternal hemorrhage and the need to resuscitate the baby as the main reasons to perform immediate cord clamping instead of DCC.
  
  
  CONCLUSIONS
  Healthcare providers interested in implementing DCC may benefit from a procedural practice plan that includes an assessment of organizational readiness to adopt a DCC protocol, methods to measure and encourage staff compliance, and ways to track outcome data of infants who underwent DCC. Strategies to improve protocol awareness after DCC has been implemented are recommended since compliance may decrease over time.
authors.affiliation: Department of Pediatrics, Division of Neonatology, University of Washington, Box 356320, Seattle, WA 98195-6320 USA.
authors.forename: Ryan M
authors.initials: RM
authors.lastname: McAdams
authors.affiliation: Department of Pediatrics and Department of Obstetrics and Gynecology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH USA.
authors.forename: Carl H
authors.initials: CH
authors.lastname: Backes
authors.affiliation: Department of Obstetrics and Gynecology, Darlington Memorial Hospital, Darlington, UK.
authors.forename: David J R
authors.initials: DJ
authors.lastname: Hutchon
keywords: Anemia; Birth; Newborn; Placental transfusion; Preterm