Good practices in collecting umbilical cord and placental blood 1

Abstract Objective: to identify the factors related to the quality of umbilical cord and placental blood specimens, and define best practices for their collection in a government bank of umbilical cord and placental blood. Method: this was a descriptive study, quantitative approach, performed at a government umbilical cord and placental blood bank, in two steps: 1) verification of the obstetric, neonatal and operational factors, using a specific tool for gathering data as non-participant observers; 2) definition of best practices by grouping non-conformities observed before, during and after blood collection. The data was analyzed using descriptive statistics and the following statistical software: Statistica(r) and R(r). Results: while there was a correlation with obstetrical and neonatal factors, there was a larger correlation with operational factors, resulting in the need to adjust the professional practices of the nursing staff and obstetrical team involved in collecting this type of blood. Based on these non-conformities we defined best practices for nurses before, during and after blood collection. Conclusion: the best practices defined in this study are an important management tool for the work of nurses in obtaining blood specimens of high cell quality.


Introduction
According to ANVISA (Brazil's National Health Surveillance Agency), umbilical cord and placental blood (UCPB) may be collected by a nurse or other duly qualified university-level technician during the third stage of a normal or Cesarean delivery (1) . The goal of the procedure is to collect hepatopoietic stem cells (HSCs) for government umbilical cord and placental blood banks (UCPBBs), for subsequent used for transplantation and for the treatment of a number of malignant and nonmalignant diseases (2) .
Quality assurance of the HSCs collected depends directly on the performance of the obstetrical team professionals. For this reason, cellularity has been the focus of attention of the nursing staff, because of the need to collect a suitable volume of HSCs to supply the UCPBBs.
Thus, awareness of the obstetric, neonatal and operational factors that can influence the volume and cellularity of the UCPB specimens must be included among the numerous competences of nurses working in the UCPBBs. Knowing what these factors are, enables defining best practices for collecting a suitable volume of UCPB specimens with adequate cellularity, contributing to satisfactory outcomes in a number of different situations and contexts (5) . The term "best practices" has been widely used in healthcare since 1990, starting with a discussion on tools to manage quality in healthcare institutions, sponsored by the Pan-American Health Organization (6) .
This study attempts to identify factors related to the quality of UCPB specimens, and to define best practices for their collection within a UCPBB.

Method
A descriptive survey using a quantitative approach, conducted at an off-site HSC collection center of the UCPBB of a university hospital located in the south of the country. A nurse is responsible for managing the service at the study location, for selecting and attracting women to donate UCPB specimens, for harvesting the stem cells, entering the data into the national umbilical cord stem-cell registry (Renacord), shipping the specimens, for populating production and quality indicators, and for follow-up visits. We reiterate that in this service all UCPB specimens are collected by nurses.
This study was conducted in two steps: 1a) Verification of the obstetric, neonatal and operational factors, using a specific data collection tool and observing as a non-participants; 2a) definition of best practices by grouping non-conformities observed before, during and after UCPB collection.  We used a semi-structured data collection tool designed based on the historical data on the output of the study location, identifying the causes and interferences in the disposal of UCPB specimens at that service, as well as a review of the current literature on the factors that influence volume and cellularity.

Content validation was obtained from nurses and experts working in other UCPBBs of the Brasil Cord
Network, using the Delphi Technique. The criteria for selecting these experts included nurse qualification and experience (7) , and the history of UCPBB production. We selected four nurses, but only three fulfilled the inclusion criteria. We conducted three rounds, with "agree" and "disagree" options for each item of the questionnaire, and the option "considerations" for other contributions Lopes LA, Bernardino E, Crozeta K, Guimarães PRB.
provided by the nurses. Following the third round and after reaching a consensus, we decided we had the final data collection questionnaire for the first step of the study.
For quality of specimens we defined a minimum cellularity of 7x10 8 of total nucleated cells for UCPB collection, considering the value used by the UCPBB in question.
The data collected during this step was tabulated and systematized using an Excel spreadsheet, and submitted to descriptive quantitative statistical analyses, and to content analyses by approximation before being processed using R ® and Statistica ® software.
Initially, the data was summarized by calculating descriptive measures, means, minimums, maximums and standard deviations for continuous variables, and frequency tables for the categorical variables. To identify the reasons that UCPB specimens had been discarded, we applied non-parametric association statistical techniques, based on the assumption that data normality had not been achieved, using Lilliefors's adherence test.
To check the association between continuous variables we used Spearman's coefficient, with 5% as the significance level (p<0.05). For the categorical variables (comparison of two independent samples, we used Mann-Whitney or Kruskal-Wallis (comparison between more than two independent samples). We adjusted the multiple regression models for the variables "cellularity" and "volume" using a Stepwise procedure.
Based on the data collected in the first step, we prepared a list of best practices for this UCPBB, considering the results of the obstetrical, neonatal and operational factors we analyzed. This list was grouped by the researchers into three categories: before, during and after UPCB collection, and then submitted for analysis and consensus at expert meetings. Fourteen obstetrics professionals participated in these meetings (obstetricians, residents in obstetrics, professors of obstetrics and nurses). This group met for a total of 19 hours and 20 minutes of one-on-one discussions. Content validation by the experts included the assessment of the overall list of good practices and individual actions (clarity and relevance) (7) . There was no disagreement with any of the items submitted, thus the list of good practices for UCPB collection at this UCPBB was validated.

Factors influencing volume and cellularity of umbilical cord and placental blood specimens
The following obstetrical factors influence volume

Non-conformities in collecting umbilical cord and placental blood
Based on our analysis of the results of the first step of the study, we found the obstetrical team often

Discussion
Obstetric and neonatal factors, "placental weight" and "newborn weight" were also found in other studies to influence SCUP volume and cellularity (5,(8)(9) . However, there is no indication of minimum or maximum placental weight for harvesting UCPB specimens. No studies were found on the obstetrical factor "characteristics of the umbilical cord segment" (diameter and blood flow).
On the influence of operational factors related to handling the placenta on UCPB volume and cellularity, there is evidence that incorrect sectioning of the umbilical cord (less than five centimeters from the abdomen) (2) results in smaller volumes and cellularity (8)(9)(10) . For this reason, they were considered when defining best practices for UCPB collection.
The time between collecting the SCUP, transporting and processing the unit was considered here to be an operational factor, and depends largely on the professional performance of the nurse. The nurse is responsible for the logistics of adequately transporting units for early processing. It is known that delaying the processing of blood specimens results in a gradual decrease in the number of nucleated, viable and CD34+ cells, thus time between collection and processing should be minimized (11) .
Given the results presented herein, we defined a list of best practices to collect SCUP, given that there is not much scientific evidence for collecting SCUP.
An evidence-based practice could be a great ally to the UCPBB nurse, helping promote service excellence.
Regarding the object of this study, we found that the nurse is responsible for selecting and attracting UCPB donors, for collecting specimens, donor serology, nursing management and donor follow-up. Therefore, the nurse must be vigilant regarding the different factors that can interfere in the operation of UCPB harvesting and storage in order to comply with all recommendations and apply the best practices available to get suitable SCUP cellularity and volume.
In addition to being aware of the factors that influence SCUP volume and cellularity, the technical competence of the nurse, his or her interaction with the obstetrical team and the collaboration between them are essential for a successful harvest. It is considered good practice for the nurse to keep a training program for the obstetrical team to optimize donor selection (12) and ensure proper placental handling.
Among the best practices tools available to the nurse, we highlight communication and planning.
Communication, as an articulator, is essential for nursing management and to enable the work (13) of all of the professionals directly or indirectly involved in UCPB specimen collection. Planning activities is essential for the proper harvesting of UCPB (14) , ensuring the process is efficient, practical and safe.
Thus, adopting good practices in UCPB assumes a change in attitude and actions on the individual, www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2016;24:e2770 collective and organizational level, implying in potential benefits for the care provided (6) .

Conclusion
This study identified factors related to the quality of UCPB specimens, and defined best practices for their collection within an UCPBB.
Considering that at the study location specimen collection is done exclusively by nurses, finding factors that have a positive influence on volume and cellularity is essential for defining professional practices for obtaining high quality blood specimens.
This study shows the need to develop and improve the technical skills of the obstetrical team when handling the placenta in the third stage of delivery to harvest SCUP. In this process, the role of the nurse in operations and service management is strategic for the UCPBB healthcare team.
The study conducted at a single UCPBB, and the possibility of validating good practices by the service team could be considered limitations for this study.
However, given the shortage of studies in this area, and the wealth of information, the data obtained can foster new studies or contribute to defining good practices to be adopted by other UCPBB. In the same way, the good practices listed could serve as a guide to be used by obstetrical professionals, especially those who are starting as resident physicians or nurses, as the results of this study were obtained at a teaching hospital.