Presentation on theme: "Perinatal Quality Improvement Efforts in Florida"— Presentation transcript:
1 Perinatal Quality Improvement Efforts in Florida William M. Sappenfield, MD, MPHFPQC Co-DirectorLawton and Rhea Chiles Center for Healthy Mothers and BabiesUniversity of South Florida College of Public Health
2 VisionAll of Florida’s mothers and infants will have the best health outcomes possible through receiving high quality evidence-based perinatal care.MissionAdvance perinatal health care quality and patient safety for all of Florida’s mothers and infants through the collaboration of Florida Perinatal Quality Collaborative (FPQC) stakeholders in the development of joint quality improvement initiatives, the advancement of data-driven best practices and the promotion of education and training.
3 State Perinatal Quality Collaborative Functions Promote Maternal & Infant quality improvement (QI) projectsSupport hospitals & providers develop &implement tailored guidelinesOffer QI initiative process &outcome indicatorsEducate/train providers in quality improvementProvide advice on implementing changeValues: Voluntary, Population-based, Data-driven, Evidence-based, Value-added
4 Funders/Partners Partners Florida Chapter March of DimesFlorida Department of HealthAgency for Health Care Administration/HMAFlorida Hospital AssociationFlorida BluePartnersAmerican Congress of Obstetricians and Gynecologists (ACOG) District XIIFlorida Society of Neonatologists/FL Chapter of American Academy of PediatricsFlorida Council of Nurse MidwivesFL Section Association of Women’s, Health, Obstetric, and Neonatal Nurses (AWHONN)Florida Association of Healthy Start Coalitions
5 Timeline Mar 2009 Proposed starting the FPQC Dec USF Chiles Center identified as state leadJun FPQC launched at State SummitJan st maternal initiative—Early Elective Deliveries (EED)Oct st infant initiative—Neonatal Catheter Associated Blood Stream Infections (NCABSI) Phase IJun Expanded—EED initiative: FHA HEN hospitalsAug Expanded—NCABSI Phase IIJul nd infant initiative—Golden Hour Part IAug nd maternal initiative—Obstetric Hemorrhage Initiative (OHI)
7 Florida “Big 5” Pilot Hospitals Reduction of NMI Deliveries <39 Weeks by Delivery Type 2011 Published in Obstetrics & Gynecology: "A Multistate Quality Improvement Program to Decrease Elective Deliveries Before 39 Weeks Gestation"
8 Percent of NMI Single Live Births <39 Weeks Among Term Births for Florida Hospitals by Quintile Source: FL Live Birth Certificate Data
9 Early Elective Delivery Rates (PC-01) Southeast U. S Early Elective Delivery Rates (PC-01) Southeast U.S., Jan-Sept 2013, CMS Hospital Compare
10 Early Elective Delivery Rates Percent of Florida Delivery Hospitals by Jan-Sept, 2013 Hospital EED RateSource: Centers for Medicare and Medicaid Services: Hospital Compare July 17, 2014; PC-01 Early Elective Delivery, Quarters 1-3.
11 EED Resources Educational and communications campaign Grand Rounds Hospital ConsultationsE-BulletinsProvider Education PacketsEED Focused NewsletterSpecial EED VideoConsumer campaigns through Healthy Start CoalitionsWith the success of its partnership in the March of Dimes (MOD) 2011 Big 5 Project to reduce non-medically indicated deliveries <39 weeks gestation, the FPQC has expanded this initiative to more Florida hospitals by continuing to work with the MOD and the Florida Hospital Association (FHA) through the Health Research & Educational Trust (HRET) Hospital Engagement Network (HEN). The three organizations are using the toolkit from the MOD Big 5 Project to assist participating hospitals in reducing early elective deliveries (EED). In order to sustain change in attitudes and practices of providers, payers and policymakers, this initiative also includes a three-year coordinated educational and communications campaign regarding the importance of the last weeks of pregnancy.
12 Available on our EED page at FPQC.org EED NewsletterTo view video online:Available on our EED page at FPQC.org
13 EED Video: “We Just Haven’t Gone Far Enough” view it online at the EED page via FPQC.orgRobert W. Yelverton, MDChair, District XII ACOGKaren E. Harris, MD, MPHVice-Chair, District XII ACOGAvailable on our EED page at FPQC.org
14 49 Florida hospitals have qualified for a banner Banner OpportunityMany hospitals have implemented hard stops for Early Elective Delivery – for those who have successfully reduced their rate below 5%, the March of Dimes and ACOG District XII offer recognition through their Banner program.49 Florida hospitals have qualified for a banner
16 Where We StartedIndividual hospitals tracked their own data and reported through CDC’s National Healthcare Safety Network (NHSN)Rates NOT reported through Vermont Oxford Network (VON)No comprehensive statewide plans for infection reductionNational collaboratives combined had a baseline of 2.51 infections per 1000 line daysBaseline rate in Florida from NHSN data was 2.96 infections per 1000 line days
17 Neonatal Catheter Associated Blood Stream Infections NCABSI/FPQC—Dec Neonatal Catheter Associated Blood Stream Infections NCABSI/FPQC—Dec to Aug. 2013Phase IPhase IIFlorida has reduced central line infections by over 58.8% by August 2013.Expanded from 9 states in Phase I to 13 states in Phase II (FL 58.8% Reduction)
18 Where We’ve ComeDetailed results between December 2011 and August 2013 indicated that 150 infections were avoided in Florida - saving 18 lives, reducing length of stay by more than 1,199 days and saving over $7.9 million.Based on current central line-associated bloodstream infection (CLABSI) rates as of August Mortality rate 12.3%, increased length of stay of 8 days and estimated average cost of $53,000 per infection.
20 Obstetric Hemorrhage Initiative Obstetric hemorrhage is a leading cause of maternal mortality in FloridaObjective: Improved outcomes in morbidity and mortality related to obstetric hemorrhage, including hysterectomies and massive transfusionsMeets new national guidelines forOB patient safetyPartnering with the Perinatal Quality Collaborative of North Carolina in the recruitment of hospitals, the FPQC will provide 35 hospitals in both states with technical assistance from an advisory team, team training and an implementation toolkit.
21 Key OHI QI Elements Readiness Develop an Obstetric Hemorrhage Protocol Develop a Massive Transfusion ProtocolConstruct an OB Hemorrhage CartEnsure Availability of Medications and EquipmentRecognitionAntepartum Risk AssessmentQuantification of Blood LossActive Management of the Third Stage of LaborResponsePerform Interdisciplinary Hemorrhage DrillsDebrief after OB Hemorrhage Events
22 OHI31 Florida hospitals and 4 North Carolina hospitals18-24 month initiativeHospital applicant data indicated improvement neededAssessment of risk for OB hemorrhage upon hospital admissionQuantification of blood loss
24 Project Data: Risk Assessment Percent of hospitals that assessed birthing women for risk of obstetric hemorrhage upon admissionComparison of baseline and monthly reported data are beginning to show changes in practice and policies.the percent of all reporting hospitals that assessed birthing women for risk of OH upon admission and documented the OH risk score in clinical record.The goal is that utilizing an evidence-based scoring tool all women admitted for birth will be assessed for risk of OH upon admission and the score documented in clinical record so that risk is considered in the patient care plan for labor and delivery.
25 Quantification of Blood Loss Percent of deliveries in all hospitals for which blood losswas quantified for vaginal deliveriesPercent of charts that indicated blood loss was quantified for vaginal deliveries using at least 1 of the approved quantification methods.
27 While there is no direct causation, studies show a strong association The Golden HourTransition from fetal neonatal lifeMany complex physiologic changesInterventions in this time period may affect:Short term morbidities (e.g. thermoregulation, hypoglycemia)Long term morbidities (e.g. chronic lung disease, retinopathy of prematurity, intraventricular hemorrhage)MortalityWhile there is no direct causation, studies show a strong association
28 Golden Hour Part I: Delivery Room Management Objective: Improved outcomes in very low birth weight babies ≤30 6/7 weeks gestational age or ≤1500g birth weightInterventions during the time period between fetal and neonatal life have been shown to have a great influence on a baby’s future morbidities. Because optimizing delivery room management of newborns provides many opportunities to impact outcomes positively with a lower occurrence of preventable illnesses, the FPQC has chosen to support a “Golden Hour Part I: Delivery Room Management” quality improvement initiative for infants with a gestational age ≤30 6/7 wks OR birth weight ≤1500 g.
29 Delivery Room Management Goal is to enhance teamwork and implement evidence-based practices on:TeamworkThermoregulationOxygen administrationDelayed cord clampingHospital baseline data indicated major need in the areas of:Assignment of delivery room team member rolesDelayed cord clamping (near 0%)Each hospital has identified a “core team” with a Physician lead, Nurse lead, Data management lead and Administrator lead to organize and direct their hospital’s multi-disciplinary team as they develop individualized guidelines, collect data and share best practices.The FPQC plans to follow up this initiative with Golden Hour Part II which will address immediate post-delivery management.
30 Golden Hour Pilot Hospitals ACADEMICTGH/USFACH/Johns HopkinsNON-ACADEMICSt. Joseph’s HospitalBaptist Hospital MiamiFlorida Hospital TampaSouth Miami HospitalSarasota Memorial HospitalBroward Health Medical CenterPlantation General Hospital
33 Indicator ProjectPartnered with DOH and AHCA to access existing linked birth certificates and hospital discharge dataRecruited 7 hospital teams and 8 state organizations to consult on Florida’s pilot indicators and reportsDevelop both health care and data quality reportsConsult national expertsTest the use of pilot reports in pilot hospitalsUse pilot efforts and plans to promote Florida development
34 Early Elective Deliveries Sample Hospital QI Box Plot
35 Percentage of Early Term Deliveries Hospital X, 2004-2011
37 Antenatal Corticosteroid Treatment (ACT) Includes FL, CA, IL, NY & TXFocus on ACOG & Joint Commission measure (PC-03)Also focus on the “sweet spot”Launch in Fall 2015Develop initiative with 2015 startWorkgroupTraining toolsSite recruitment planAnticipate further MOD grant support
38 Antenatal Steroid Use for Infants Weeks in 19 of Florida’s Vermont Oxford Network (VON) Hospitals, 2012Median = 77When women were asked when they believed was the earliest point in the pregnancy (GA in weeks) that it is safe for a baby to be born, the data are still more positive than the previous study (Figure 6). However, these differences were smaller with nearly half of all respondents indicating delivery before 37 weeks was safe to deliver. This is important because if women do not perceive a risk to delivering early, they may be more likely to elect to deliver early as the due date approaches.
40 Primary Cesarean Sections Higher risk of morbidity for mothers and neonatesHigher risk of health care costFlorida had the 4th highest overall Cesarean section rate among U.S. states.38.1% of births in 2012, increasing since 1996Primary cesareans drive the increasing rateVirtually all subsequent births will be by cesareans
41 21% of FL hospitals meet national target Low-Risk First-Birth (Nulliparous Term Singleton Vertex) C-Sec Rate Among 116 Florida Hospitals41Range: 6.6—59.5%Median: 31.3%Mean: 31.8%National Target =23.9%21% of FL hospitals meet national targetA recent analysis of Florida birth certificates showed that across the 116 delivery hospitals in the state, the primary cesarean rate among low-risk first-birth deliveries ranged from 6.6% to 59.5%; roughly one-fifth of the hospitals (21%) meet the Healthy People 2020 national goal for such deliveries of 23.9% or less.This wide variations in hospital cesarean rates in Florida suggests clinical practice patterns may contribute and provides an opportunity for improvement.The leading maternal and infant risk factors in Florida associated with primary cesarean among low risk women include:InductionMedical conditionsRace/Ethnicity—Cuban, Haitian, Non-Mexican Hispanics, BlackMaternal age—more than 30 yearsPrivate or Medicaid insuranceThe only significant hospital risk factor is location; South Florida has the highest rate.Source: FL Vital Records, Dec 2013
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