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Philadelphia OB Project Improving Patient Safety, the Quality of Care and Reducing Liability in a Metropolitan Obstetrical Population through Inter-Institutional.

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Presentation on theme: "Philadelphia OB Project Improving Patient Safety, the Quality of Care and Reducing Liability in a Metropolitan Obstetrical Population through Inter-Institutional."— Presentation transcript:

1 Philadelphia OB Project Improving Patient Safety, the Quality of Care and Reducing Liability in a Metropolitan Obstetrical Population through Inter-Institutional Collaboration Guiding Principles and Checklists for 6 University Obstetrical Practices Owen Montgomery M.D. FACOG Chairman Department of Obstetrics and Gynecology Drexel University College of Medicine

2 Philadelphia OB Project US News and World Report 6 Top Ranked Hospitals in Philadelphia ranked amongst the best in US/ region #1 Hospital of the University of Pennsylvania #2 Thomas Jefferson University Hospital #3 Temple University Hospital #4 Hahnemann University Hospital #4 Pennsylvania Hospital #8 Einstein Medical Center All 6 have Obstetrical Residency Programs

3 Philadelphia OB Project The University of Pennsylvania is the oldest and one of the finest medical schools in the United States. Founded in 1765 Penn prides itself on educating the leaders of tomorrow in patient care, biomedical research, and medical education. among the top five in US research-oriented medical schools. 4500 deliveries 26.2% C/S rate

4 Philadelphia OB Project Founded in 1824, Jefferson Medical College has awarded more than 27,000 medical degrees and has more living graduates than any other medical school in the nation. Jefferson Medical College is recognized for its balanced approach to medical education, and approximately one out of four to one out of five applicants throughout the U.S. apply to Jefferson. 2500 deliveries 32.3% C/S rate

5 Philadelphia OB Project Temple University School of Medicine is recognized as an institution that offers an exceptional clinical education to a diverse and socially-conscious student body. 10,000 living medical graduates are practicing in the fifty states and other parts of the world. Temple University School of Medicine ranks fifth in the nation in African American medical school graduates 4000 deliveries 32.2% C/S rate

6 Philadelphia OB Project Drexel University College of Medicine is merger of two of the earliest medical colleges in the United States Medical schools Hahnemann Medical College 1848 Woman’s Medical College of Pennsylvania 1850 Woman’s was the very first medical school for women in the world. DUCOM has the largest medical student enrollment of any private medical school in the nation. National Center of Excellence in Women’s Health 2500 deliveries 24.3% C/S rate

7 Philadelphia OB Project Pennsylvania Hospital, “the nation’s first hospital”, is a 515- bed acute care facility that provides a full range of diagnostic and therapeutic medical services and functions as a major teaching and clinical research institution. The hospital was founded in 1751 by Benjamin Franklin and Dr. Thomas Bond to care for the “sick-poor and insane of Philadelphia.” 5000 deliveries 35.3% C/S rate

8 Philadelphia OB Project Einstein Medical Center’s is rooted in healing, caring and learning. Philadelphia's largest independent Academic Medical Center with 7 (8) hospitals a distinguished history extending back to 1866 Started a gynecological clinic in 1896 Albert Einstein gave permission to use his name for the new medical center 1951 Einstein hospital has provided care for the disadvantaged of north-east Philadelphia for over one-hundred years 4000 deliveries (not including new Montgomery site) 31.9% C/S rate

9 Philadelphia OB Project SUMMARY: Hospital OB units in Pennsylvania Statewide, 1997 = 147 Statewide, 2009 = 103 Number of Closures = 44 Number of Openings = 3 Net Loss Statewide = 41 % change = 29.9% SUMMARY: Hospital OB units Southeast PA SEPA, 1997 = 41 SEPA, 2009 = 23 Number of Closures = 19 Number of Openings = 2 Net Loss = 17 % change = 43.9%

10 Philadelphia OB Project MATERNITY UNITS CLOSED (Southeastern PA) Bucks Warminster (2000) Chester Brandywine Hospital (2008) Delaware Mercy Fitzgerald Maternity Unit (2003) Montgomery Elkins Park (2001) Central Montgomery Medical Center (2009) Philadelphia Temple East-Northeastern Hospital (2009) Chestnut Hill Hospital Maternity Unit (2008) Jeanes Hospital (2007) Frankford Hospital (2006) Parkview (2003) Methodist (2002) Mercy Philadelphia Hospital (2002) Episcopal (2001) Roxborough Memorial Hospital (1999) City Avenue (1999) Germantown (1998) Nazareth Hospital (1998) Medical College of Pennsylvania (1997)

11 Philadelphia OB Project MATERNITY UNITS AND HOSPITALS STILL OPEN (Southeastern PA) Bucks Doylestown Hospital Grand View Hospital Lower Bucks Hospital St. Mary Medical Center Chester Chester County Hospital Jennersville Regional Hospital Paoli Hospital Phoenixville Hospital Delaware Crozer-Chester Medical Center Delaware County Memorial Hospital Riddle Memorial Hospital Montgomery Abington Memorial Hospital Bryn Mawr Hospital Einstein Montgomery (open 10/2012) Holy Redeemer Health System Lankenau Hospital Mercy Suburban Hospital (just closed late 2009 ) Montgomery Hospital Medical Center (closed 10/2012) Pottstown Memorial Medical Center

12 Obstetric Care Availability Consequence of Liability  20 Obstetric Units have closed in Southeastern Pennsylvania since 1997.  The largest decrease is in Philadelphia with 13 closures leaving only 6 hospitals in the city with Obstetrical Units  Number of births in the city not changed 1996-23,706 births 2010- 23,508 births.  Of the 23,000 deliveries 99% are performed by physicians or midwives employed by hospitals.  The “practice” of Obstetrics and Gynecology by self employed physicians in Philadelphia is extinct.

13 Obstetric Care Availability Consequence of Liability Philadelphia Health Commissioner Task Force Sharing “quality outcome data” and “Quality Initiatives” between institutions impossible Absence of peer review protection by the Health Commissioner. Each of the 6 remaining institutions use different Electronic Health Records or no EHR for Obstetrics This makes sharing of data impractical and/or prohibited by institutional legal counsel.

14 Obstetric Care Availability Consequence of Liability  Deputy Mayor/Health Commissioner  Chairs of all 6 University OB/GYN Programs  Hospital Association of Pennsylvania all working together but NO significant improvement in the reimbursement and medical liability situation. To assure quality care and patient safety with increasing volume of patients: It is necessary for all remaining Obstetrical Units to work together to find new ways to insure quality care while reducing liability.

15 Philadelphia OB Project MATERNITY UNITS REMAINING OPEN Philadelphia County Albert Einstein Medical Center Hahnemann University Hospital (Drexel University College of Medicine) Hospital of the University of Pennsylvania Pennsylvania Hospital Temple University Hospital Thomas Jefferson University Hospital

16 Philadelphia OB Project The Philadelphia OB Chairs are concerned about their continued ability to provide quality, safe obstetrical care. Group formed in 2008 to meet with the City Health Commissioner:  low reimbursement  high medical liability costs  closure of 14 obstetrical units in the last 10 years  5 units in the past 5 years.  increased and unplanned volume in the remaining 6 units  major unpredicted fluctuations in volume from day to day  regular safe staffing by nurses, physicians very difficult.

17 Philadelphia OB Project The Philadelphia OB Chairs agree to work with the Health Commissioner to develop a city wide RHIO for all Obstetrical patients in Philadelphia.  Improve care for patients who come to an Obstetrical Unit without access to their OB record (10- 15% throughout city, 33% at TEMPLE)  Improve efficiency in obtaining diagnoses and previous laboratory data  Improve outcomes while reducing costs  Develop a central de-identified city data base for: continuous quality improvement and  outcomes data research.

18 Philadelphia OB Project

19 Philadelphia OB Chairs Response The Philadelphia OB Chairs have agreed to the following initiatives to maintain the highest level of quality care and patient safety:  Continue to provide the highest level of obstetrical care to all women in the City of Philadelphia  Provide 24/7 coverage of the remaining Obstetrical Units with a Board Certified or eligible OB/GYN Physician  The OB Physician will work for a maximum of 24 hours  The OB Physician will have No other patient duties during the 24 hours  The OB Physician will have No patient duties after the 24 hours of OB unit coverage  The OB Physician will supervise the care of all patients without regard to insurance coverage or site of Prenatal care

20 Philadelphia OB Project Number 526 May 2012 Standardization of Practice to Improve Outcomes Protocols and checklists have been shown to improve patient safety through standardization and communication. Standardization of practice to improve quality outcomes is an important tool in achieving the shared vision of patients and their health care providers

21 Philadelphia OB Project Guidelines for Single (national) standard for induction of labor and timing of Cesarean Sections. ACOG and March of Dimes Campaign: NO Elective Deliveries before 39 completed weeks Hard Stop for Inductions and Scheduled Cesarean Sections Leepfrog Quality Indicator

22 Philadelphia OB Project Guidelines for Standardization of Interpretation and Management of Fetal Heart Rate recordings Agree to a single standardized ACOG national nomenclature for interpretation of fetal heart rate tracings Decrease variability in care from provider to provider and institution to institution. Mandate for all Obstetrical Providers: Attendings, Midwives, Resident Physicians and Obstetrical Nurses 12 hour on line advanced course in Fetal Heart Rate Interpretation APS or GE are ACOG approved as on line courses

23 Philadelphia OB Project Guidelines for Standardization of Education and Management of Shoulder Dystocia Mandatory Formal Educational Program for all Obstetrical Providers: Attendings, Midwives, Residents, Labor Nurses Regular Team Training and Drills for Shoulder Dystocia Simulation training ACOG Standard Forms for recording maneuvers and timing Documentation and Certification Staff privilege requirement

24 Philadelphia OB Project Guidelines for Standardization of Post Partum Discharge Requirements Instructions for Follow up Screening for Post Partum Depression and Intimate Partner Violence Smoking Cessation, Immunization, Contraception, Breast Feeding Post partum visits and testing for HTN, GDM Instructions for specific concerns: chest pain, headache bleeding, fever Self care and Neonate care

25

26 Maternal Mortality in New Jersey

27 Safe Motherhood in Massachusetts Pregnancy-associated injury deaths: Violence, substance abuse, and motor vehicle collisions, 1990-1999 Massachusetts Department of Public Health Public Health Council Meeting May 28, 2002

28 Distribution of injury and medical causes of pregnancy-associated death 1990-1999 n=80n=152 n=80 n=152 There were 232 pregnancy- associated deaths. Over one-third were injury-related.

29 Leading causes of pregnancy- associated death 1990-1999  Homicide leading cause overall (n=30) 2 out of 3 were cases of domestic violence  Other leading causes of injury deaths: Motor vehicle collisions (n=21) Drug overdose (n=16) Suicide (n=7)  Leading causes of medical deaths: Cancer (n=28) Acute and chronic respiratory conditions (n=23) Cardiovascular disease and conditions (n=11 ) Peripartum and postpartum cardiomyopathy (n=8)

30 Number of injury deaths by cause and period of risk, 1990-1999

31 Opportunities - Number of provider visits by period of risk, 1990-1999

32 Affects approximately 1.5 million women each year Affects as many as 324,000 pregnant women each year May be more common than conditions for which pregnant women are routinely screened Possibly associated with unintended pregnancy, delayed prenatal care, smoking, alcohol and drug abuse Facts About Intimate Partner Violence (IPV)

33 Routinely Screen Every Patient At first prenatal visit At least once per trimester At postpartum checkup At routine ob-gyn visits and preconception visits

34 Philadelphia OB Project Guidelines for Standardization of Post Partum Discharge Instruction in Philadelphia Purpose : to assist the medical providers and staff of the Philadelphia Obstetrical Units to cooperatively establish the components of standard postpartum instructions, to maximize the ability of the new mother to care for herself and her neonate and to identify potential problems related to her maternal and general health.

35 Philadelphia OB Project Principles: 1)all new mothers should receive prior to discharge instruction and educational materials about the following areas of care: Self-care and care of the neonate Appropriate Rest Early Ambulation Health and Regular Diet:

36 Philadelphia OB Project National recommendations: 1800 kcal per day or 550 kcal/day additional Vitamins, especially Calcium, Vitamin D, Iron as needed Perineal Hygiene Routine Care of the Breast, Bladder and Vulva

37 Philadelphia OB Project 2) All new mothers should receive the appropriate recommended Immunizations prior to discharge including: Anti D, Tdap, Rubella 3) All new mothers should receive education and support in the Promotion of Breast feeding 4) All new mothers should receive education about, access to, and discussion of : Contraception /Family Planning with or without breast feeding

38 Philadelphia OB Project 5) All new mothers should receive support for their psychosocial health and prior to discharge specifically receive “Screening for Post Partum Depression” using the Edinburgh Depression Screening or equivalent with appropriate follow-up (appendix supplied). “Intimate partner violence” screening with community resources

39 Philadelphia OB Project Additionally, new mothers should be instructed on when and how to contact their provider if: their depression symptoms last longer than 2 weeks or gets worse, they are unable to perform daily activities, they have no interest in the baby, or they feel they may harm themselves or the baby.

40 Philadelphia OB Project 6) All new mothers should receive educational information and instruction in : Smoking Cessation (as appropriate) Dangers of Alcohol and Drug

41 Philadelphia OB Project 7) All new mothers should be instructed what signs and symptoms to look for after discharge and when and how to contact their providers. These conditions include but are not limited to: Observation of chills or fever of 100.4 or greater or aches and chills Excessive bleeding (more than 4 soaked pads within an hour for 2 hours) Severe chest or abdominal pain that does not go away or any other severe pain

42 Philadelphia OB Project  Inability to urinating or pain with urination  Persistent headache or blurred vision  Tenderness, redness, hard areas and pain in their breast  Inability to have a bowel movement or diarrhea for more than 3 days  Swelling, redness, or tenderness in their legs  Redness or foul smelling discharge around stitches or surgical wound

43 Philadelphia OB Project 8) All new mothers should receive appropriate Post-Partum Follow-Up Visits: Usually this is in 7-14 days for surgical follow-up and high risk conditions: PIH, Preeclampsia or medical, obstetrics or inter-current complications. Routine Post Partum visits are usually in 4-6 weeks

44 Philadelphia OB Project 9) All new mothers should receive appropriate Home Visits as dictated by : their medical condition and allowed by state guidelines and insurance coverage

45 Philadelphia OB Project References: Guidelines for Perinatal Care. American Academy of Pediatrics (and) the American College of Obstetricians and Gynecologists, 6 th Edition. Copyright© October 2007, by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. J.L. Cox, JM. Holden, F T Sagovsky (1987), Post Partum Depression Screen. British Journal of Psychiatry, June, Vol. 150. You and Your Baby: Prenatal Care, Labor and Deliver, and Postpartum Care. Patient Education Booklet. Copyright© September, 2011 by the American College of Obstetricians and Gynecologists.


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