1. Perinatal HIV Chart Review - Florida
Please include the title of your presentation, your full name and affiliations (including your role within the AETC, if applicable).
JoNell Potter, PhD
Robert Lawrence, MD
Sheryl Carney, RN

2. Background- Why Did We Do This?
Review of cases (missed opportunities) from DOH data;
Developed a chart review tool headed by Rivero & Potter;
Met with Florida Perinatal Nurse Coordinators at Annual Florida AETC meeting in October 2012 to engage & inform about the process;
January 29, 2013: Letter to RPICC Medical Directors from DOH announcing the plan for a quality review of perinatal HIV (9 Centers in Florida);
Some sites resistant - no outside reviewers, need IRB approval, no response from some, logistics complicated at some sites (multiple providers).

3. Plan: What We Did & How We Did It
Develop & Refine Perinatal Chart Review Tool
Pilot Tool in S. Florida (WPB, Broward, Miami-Dade)
Host a Statewide Summit for Key Stakeholders
DOH & AETC to Co-Host: Invite & Engage RPICC Medical Directors & Florida Perinatal Nurse Coordinators
DOH to Present Data on History of Perinatal HIV in the State and on New Perinatal HIV cases
AETC to Present Summary of Findings from South Florida Perinatal Chart Reviews
Develop a Strategic Plan for the Future

4. Regional Perinatal Intensive Care Centers (RPICC) Centers in Florida
Tampa General Hospital - Tampa, FL
Shands Teaching Hospital - Gainesville, FL
Shands -Jacksonville - Jacksonville, FL
Jackson Memorial Hospital, Jackson Health System - Miami, FL
Sacred Heart Hospital - Pensacola, FL
Winnie Palmer Hospital at Arnold Palmer Med. Center - Orlando, FL
All Children’s Hospital - St. Petersburg, FL
Bayfront Medical Center - St. Petersburg, FL
St. Mary’s Medical Center - West Palm Beach, FL
Broward General Medical Center - Ft. Lauderdale, FL
Memorial Regional Medical Center - Hollywood, FL
Lee Memorial Health System - Ft. Myers, FL

5. Significant Findings from Pilot Perinatal Record Reviews
Lack of communication and consistent documentation between HIV providers, prenatal providers, L&D providers & pediatric providers;
EMRs on different operating systems & not available to all providers across disciplines, clinics & hospitals.

6. From Our Reviews: Specific Guidelines Not Being Followed
Vaccinations in pregnancy;
Tuberculosis screening;
Hepatitis testing – A, C in particular;
Accurate history of cART use in previous pregnancies;
VL done 2-4 weeks after initiating or changing cART;
VL at weeks gestation to guide decisions for delivery mode;
Documented resistance testing – prior, current, and in patients with elevated VL despite therapy;
Accurate documentation in L&D notes of cART used during pregnancy, last dose (date & time) once admitted to L&D;
Documentation of whether the mother received a prescription or the actual medication (ZDV) for the infant before discharge.

7. Significant Findings from Pilot Perinatal Record Reviews
Little documentation of appropriate standard counseling of risks associated with cART during pregnancy, the impact of poor adherence & risk to sexual partners/neonates, pre-mastication, & follow-up care for mother & newborn.
Gaps in communication regarding pertinent data on mother (VL at/prior to delivery, no PNC, etc.) to create a strategic plan for management in L&D & an emergency consultation to pediatrics for evaluation of risk and “does this baby need more than ZDV?”

8. Problems to be Addressed with Non-Compliance with Guidelines
Problem- Inappropriate Management Issues Solution- Engage providers & offer education & training through F/C AETC;
Problem-Despite education and training, individual providers not willing to accept intervention/education and/or follow guidelines, placing women & neonates at risk;
Solution- How can this be addressed appropriately & by whom?

9. Proposed Ideas for the Future
Use of a Perinatal Chart Review Tool
- Use as a Quality Measure or use components as individual
- Performance Measures to review practice and improve performance
Tracking
- Reporting of HIV positive deliveries at time of delivery or earlier
- Reporting and Tracking of HIV exposed infants thru DOH
Data Management / Exchange / Communication
- Standard information to be reported
- Electronic record and exchange of information overseen by DOH
Local Perinatal HIV Transmission Prevention Team 
Best Practices Model
- Reproduce the model in each area around the state
- Adapt the model to specific issues in different locales

10. Perinatal Chart Review Tool
Subject #: Reviewer: Review Date:
Demographics - SECTION 1
1. Mother’s Age at 1st Visit
2. Race:
1. African American/Black
2. White
3. Asian
4. American Indian/Alaska Native
5. Native Hawaiian/ Pacific Islander
3. Hispanic, Latino, or Spanish Origin? O Yes O No
4. Primary Language:_______ Translator O Yes O No

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5. Payment Source:
1. Medicaid
2. Private Payer
3. Self Pay
4. SSI
5. Medicare
6. Other ______

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Comments:

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HIV Management in Pregnancy – SECTION 2

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Yes No N/A
Comments:

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Monitoring During Pregnancy – SECTION 3
Comments:

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Baseline Labs/Testing – SECTION 4

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Vaccines and TB Screening – SECTION 5

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Hepatitis – SECTION 6
Comments:

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CD4 – SECTION 7
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Viral Load – SECTION 8
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Resistance Testing – SECTION 9
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Opportunistic Infections – SECTION 10
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Initiation of ARV Therapy – SECTION 11

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Antepartum ARV Therapy – SECTION 12

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Labor and Delivery – SECTION 13

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Delivery Information – SECTION 14

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Testing/Care of Infant if Mother’s HIV Status is Unknown
SECTION 15

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Follow Up: Mother – SECTION 16

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Infant Antiretroviral Prophylaxis – SECTION 17

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Follow Up: Baby – SECTION 18