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Neonatal Transport Data: An Opportunity for Quality Improvement A product of: California Perinatal Transport System (CPeTS) Managed by: California Perinatal.

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Presentation on theme: "Neonatal Transport Data: An Opportunity for Quality Improvement A product of: California Perinatal Transport System (CPeTS) Managed by: California Perinatal."— Presentation transcript:

1 Neonatal Transport Data: An Opportunity for Quality Improvement A product of: California Perinatal Transport System (CPeTS) Managed by: California Perinatal Quality Care Collaborative (CPQCC)

2 Continuing Education Credit After reviewing the materials in the Neonatal Transport Data System File and viewing the presentation, go to the following link to complete the post-test and evaluation

3 Objectives Understand the new Neonatal Transport Data System; Demonstrate ability to correctly obtain and report data elements using agreed upon data definitions and procedures; Demonstrate ability to complete on-line reporting of required data elements; List 3 resources for assistance in completing data collection; and Identify available reports that can be utilized among transport partners as part of Regional Cooperation Agreements, Joint Mortality and Morbidity Conferences and to identify education, consultation and policy needs.

4 Toward Improving the Outcome of Pregnancy II System For Regionalized Perinatal Care “the development, within a geographic area, of a coordinated, cooperative system of maternal and perinatal health care in which, by mutual agreements between hospitals and physicians and based on population needs, the degree of complexity of maternal and perinatal care each hospital is capable of providing is identified so as to accomplish the following objectives: quality care to all pregnant women and newborns, maximal utilization of highly trained perinatal personnel and intensive care facilities, and assurance of reasonable cost effectiveness”. March of Dimes, Birth Defects Foundation, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, 1994.

5 California Perinatal Transport System (CPeTS) CPeTS was established by California Assembly Bill 4439, in to facilitate transports of critically ill infants and mothers with high risk conditions to Neonatal Intensive Care Units (NICUs) and Perinatal High Risk Units. to facilitate transports of critically ill infants and mothers with high risk conditions to Neonatal Intensive Care Units (NICUs) and Perinatal High Risk Units. to collect and analyze perinatal and neonatal transport data for regional planning, outreach program development, and outcome analysis. to collect and analyze perinatal and neonatal transport data for regional planning, outreach program development, and outcome analysis. CPeTS has engaged the California Quality Care Collaborative (CPQCC) to manage the data system.

6 Key Transport Issues Identified These issues included: Perceived underutilization of maternal transport; Perceived delay in decision to transport infant; Difficulty in obtaining transport placement/ acceptance; Delay in effecting transport following decision; and Consistent referring facility competency regarding infant stabilization prior to the transport team’s arrival, as well as transport team competency.

7 Title 22 - Hospital Licensing §70547 Perinatal Care Units (a4) Formal arrangements for consultation and/ or transfer of an infant to an intensive care newborn nursery, or a mother to a hospital with the necessary services for problems beyond the capability of the perinatal unit. (b) There shall be written policies and procedures developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. These policies and procedures shall reflect the standards and recommendations of the American College of Obstetricians and Gynecologists…and the American Academy of Pediatrics… (b) There shall be written policies and procedures developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. These policies and procedures shall reflect the standards and recommendations of the American College of Obstetricians and Gynecologists…and the American Academy of Pediatrics… California Code of Regulations, Title 22: Social Security, Volume 28, Revised November, Perinatal Unit General Requirements

8 AAP/ACOG Guidelines for Perinatal Care Recommends the following minimal regional evaluation of perinatal transport programs: Patient Outcome Data Unexpected neonatal morbidity (eg, hypothermia or tension pneumothorax) Unexpected neonatal morbidity (eg, hypothermia or tension pneumothorax) Mortality during transport Mortality during transport Morbidity or mortality of patients at the receiving hospital. Morbidity or mortality of patients at the receiving hospital. Logistic Information Frequency of failure to transfer patients generally considered to require tertiary care (eg, newborns born at < 32 weeks of gestation), Frequency of failure to transfer patients generally considered to require tertiary care (eg, newborns born at < 32 weeks of gestation), Availability of all the services that may be needed by the perinatal patient, Availability of all the services that may be needed by the perinatal patient, Accessibility of services, Accessibility of services, Capability to connect the patient quickly and appropriately with the services needed, and Capability to connect the patient quickly and appropriately with the services needed, and Programs to promote patient and community awareness of available and appropriate regional referral programs. Programs to promote patient and community awareness of available and appropriate regional referral programs. AAP/ACOG Guidelines for Perinatal Care, Fifth Edition, 2002

9 California Children’s Services (CCS) § Infant morbidity and mortality data concerning birthweight, survival, transfer, incidence of certain conditions and other information as required shall be submitted to the Chief, Childrens Medical Services Branch/CCS Program annually. 4.A.(4) Maintenance of written records of each neonatal transport completed shall be available for review by CCS program staff. 4B….All guidelines and reporting requirements of the Regional Perinatal Dispatch Center shall be followed. California Children’s Services (CCS) Manual of Procedures, Chapter 3 – Provider Standards, Section 3.25 Standards for Neonatal Intensive Care Units (NICUs), State of California, Department of Health Services, California Medical Services, January 1, 1999.

10 Policy A Neonatal Transport Form must be completed for all neonates acutely transferred to or from a CCS-designated NICU, as well as all facilities participating in CPQCC. Selected data elements will be electronically reported via the CPQCC Transport Activity Report Selected data elements will be electronically reported via the CPQCC Transport Activity Report

11 Materials All California Neonatal Transport Form (ACNTF) Core CPeTS Neonatal Transport Form (CCNTF) Color-coded All California Neonatal Transport Form Policy and Procedure 2007 Data Definitions and Training Manual Sample Reports Educational Presentation Articles Transport risk index of physiologic stability (TRIPS): A practical system for assessing infant transport care by Lee, S.K., et al. (J Peds, Vol. 139, No. 2, , August, 2001) The Mortality Index for Neonatal Transportation Score: A New Mortality Prediction Model for Retrieved Neonates by Broughton, S.J. et al. (Pediatrics, Vol. 114, No. 4, , April 20, 2004)

12 Data Collection Responsibility Completing a neonatal transport record is the joint responsibility of the referring and receiving hospital. Data elements to be completed by the referring hospital are shown in 10% gray scale. Data to be completed by the transport team or receiving facility are shown in 15% gray scale on the actual form. Information collected for continuity of care should be completed by members of both the referring and receiving hospitals in order to ensure safe and effective transfer of care. Sections that pertain to quality improvement issues can be completed by staff from either facility. This page should be separated prior to placing the form into the patient record. The separated section is then handled following internal hospital policies for QI data.

13 Referring Hospital Initiate form when a neonate is identified as a potential candidate for acute transport to another facility. Information requested in the following sections should be obtained prior to calling the receiving hospital. This information is necessary in order to assess patient stability, potential complications and to co-manage care prior to transfer of care. Referral Information Patient Identification/History Infant Condition Modified TRIPS Score Provide to the receiving hospital at the time of the referring call. Completing the form prior to the call and faxing this information to the receiving facility will help to ensure safe and effective hand off of patients between providers.

14 Data Collection Patient condition should be the driving force in timing of transport initiation. Delay in referral to collect data should be avoided. If specific information is not available at the initial call it can be transmitted by telephone or fax to the transport team or receiving hospital prior to departure for the referring facility.

15 Referral: Information required at initial contact between referring and receiving center/providers to facilitate transport. T.1 Transport type  DR Attendance Requested  ASAP Neonatal  Scheduled Neonatal  Other ________________ T.2 Indication  Medical Dx/Rx Services  Growth/Discharge Planning  Surgery  Chronic Care  Insurance T.3 Date/Time(D/T) T.4 T.5 Maternal Admission to Labor & Delivery/Hospital Patient Identification/History: Information to be obtained prior to transport. Infant’s Name___________________  Singleton  Multiple __of __ T.6 Birth D/T ___________ T.7 Birth wt. __ __ __ __ gms Current wt. __ __ __ __ gms T.8 Gestational Age __ __wks__ days T.9  M  F  Unk T.10 Prenatally Diagnosed Congenital Anomalies  Y  N  Unk Describe Mother’s Name Birth Date Age __ __ yrs MedRec# T.11 G __ P  AB  L  ROM Duration __ __ hrs Fluid  Clear  Meconium Antenatal Conditions  None  Unk  Hypertension  Diabetes  Infection  Preterm Labor  Bleeding/Abrupt/Previa  Other: _____________ Significant Antepartum/Intrapartum Issues:Delivery  Spont. Vag  Op. Vag  Vacuum  Forceps  Cesarean  Primary  Repeat Apgar Scores Score N/D Unk 1 __ __   5 __ __   10__ __   15__ __   ___________ Antibiotics  Y Specify__________  N  Unk T.12 Steroids  Y  N (last T.13 Surfactant Given  Y  N  Unk  DR  NSY  NICU(first

16 Modified TRIPS Scores The modified Transport Risk Index of Physiologic Stability (TRIPS) Score contained in the Infant Condition Section will provide uniform assess of patient status and stability Obtained three times: Within 15 minutes of the time of referral by referring hospital staff Within 15 minutes of the time of referral by referring hospital staff Within 15 minutes of transport team arrival at referring facility by transport team Within 15 minutes of transport team arrival at referring facility by transport team Within 15 minutes of team return to receiving NICU by receiving hospital staff Within 15 minutes of team return to receiving NICU by receiving hospital staff

17 Critical Components of the Modified TRIPS Score Responsiveness Respiratory Status Oxygen Index completed if patient is on mechanical ventilation only Oxygen Index completed if patient is on mechanical ventilation only Vital Signs Blood Glucose Blood Gases (if obtained) and type of respiratory support provided

18 Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU. Referral a Initial TT Eval b NICU Admit c T.14 Time (24 hour) T.15 Responsiveness  RespiratoryT.16 Rate T.17 O 2 Saturation T.18 Status  Oxygen Index* T.19 MAP FiO 2 PAO 2 Vital SignsT.20 HR T.21 BP Sys/ Dia, Mean T.22 Pressors  Y  N YNYN Y NY N T.23 Temp. C° T.24 Blood Glucose Bld. Gas T.25 Resp. Support  pH PCO 2 BE  Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cry.  Resp Support: None, Hood/NC. NCPAP, ETT  Respiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated but not on respirator) 3=Other * Oxygen Index completed if pt. is on vent.

19 Referring Hospital The following sections should be completed prior to transport with the most current data available. Clinical Information Other Significant Issues Referral Process Information / Materials Sent with Transport Team and Care Providers. Additional comments, documentation of procedures, patient response to procedures and other significant information can be recorded in the Comments section at any point in the transport process.

20 Clinical Information Date Time Results Bld. Screening: Hearing  Y  N  Unk Metabolic  Y  N  Unk Subs Exp  Y  N  Ukn Imaging: Other (specify) IV Access/Fluids (type, rate, site) Bld. (type,vol) Last Feeding (type/rt/vol) First Last Meds given within last 24°  Eye care  Vit. K Date/Time Med Dose Rt. Allergies  Y type  N  Unk Surgery  Y  N Indication  NEC  CHD  Other Death  No   Prior to team arrival  Prior to departure  Prior to arrival at NICU**

21 Transport Team/Receiving Hospital Transport team/Receiving hospital staff should review all information in the following sections. Referral Information Patient Identification/History Infant Condition Modified TRIPS Score (referral) sections. Upon return to receiving NICU (within 15 minutes of arrival) the third and final (NICU admit) Infant Condition Modified TRIPS Score section should be completed. Infant Condition Modified TRIPS Score (referral) sections. On arrival at the referring hospital, the transport team members are responsible for assigning the second Infant Condition Modified TRIPS Score section within 15 minutes of arrival (Initial Transport Team).

22 Modified TRIPS Score: to be recorded on referral, within 15 minutes of arrival at referring hospital and admit to NICU. Referral a Initial TT Eval b NICU Admit c T.14 Time (24 hour) T.15 Responsiveness  RespiratoryT.16 Rate T.17 O 2 Saturation T.18 Status  Oxygen Index* T.19 MAP FiO 2 PAO 2 Vital SignsT.20 HR T.21 BP Sys/ Dia, Mean T.22 Pressors  Y  N YNYN Y NY N T.23 Temp. C° T.24 Blood Glucose Bld. Gas T.25 Resp. Support  pH PCO 2 BE  Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant 2=Lethargic, no cry 3=Vigorously withdraws, cry.  Resp Support: None, Hood/NC. NCPAP, ETT  Respiratory Status: 1=Respirator 2= Severe (apnea, gasping, intubated but not on respirator) 3=Other * Oxygen Index completed if pt. is on vent.

23 Transport Team/ Receiving Hospital The following sections should be completed prior to transport with the most current data available in consultation with staff from the referring facility. Clinical Information Other Significant Issues Referral Process Timeline Information / Materials Sent with Transport Team and Care Providers Additional comments, documentation of procedures, patient response to procedures and other significant information can be recorded in the Comments section at any point in the transport process.

24 Clinical Information Date Time Results Bld. Screening: Hearing  Y  N  Unk Metabolic  Y  N  Unk Subs Exp  Y  N  Ukn Imaging: Other (specify) IV Access/Fluids (type, rate, site) Bld. (type,vol) Last Feeding (type/rt/vol) First Last Meds given within last 24°  Eye care  Vit. K Date/Time Med Dose Rt. Allergies  Y type  N  Unk Surgery  Y  N Indication  NEC  CHD  Other Death  No   Prior to team arrival  Prior to departure  Prior to arrival at NICU**

25 Referral Process T.26 Referring Hospital Name Code Telephone Number Referring OB Referring Peds Informant T.27 Previously Transported?  Y  N From: Hospital Name Code T.28 Birth Hospital (if not listed above) Hospital Name Code Receiving Hospital Accepting Physician T.29 Trans. Team On-Site Leader  Sub-specialist MD  Peds  Other MD/Resident  NNP  Transport Spec.  Nurse Present prior to transport team arrival  Y  T.30 Team From  Receiving Hospital  Contract Service (CPQCC TT ID )  Referring Hosp. T.31 Mode  Ground  Helicopter  Fixed Wing Indication Transport Carrier

26 Timeline Date Time Comments T.32 Transport Team Departure for Referring T.33 Transport Team Arrival at Referring Transport Team Departure from Referring Transport Team Arrival at Receiving Information/Materials To Be Sent With Transport Team (check all provided) Chart (pt. record)  Maternal  Neonatal Blood Specimen  Maternal  Neonatal  Placenta  Imagining copies  Other, specify Care Providers name /title signature D/T of arrival

27 Confidential Neonatal Transport Improvement Potential Information gathered at any point during the resuscitation, stabilization, referral, and transport process regarding quality improvement issues, may be recorded in the Confidential Neonatal Transport Issues with Improvement Potential Form. Information gathered at any point during the resuscitation, stabilization, referral, and transport process regarding quality improvement issues, may be recorded in the Confidential Neonatal Transport Issues with Improvement Potential Form. Form should be separated from the first two pages of the form prior to placing the form into the patient record. The separated section is then handled following internal hospital policies for QI data. Form should be separated from the first two pages of the form prior to placing the form into the patient record. The separated section is then handled following internal hospital policies for QI data. Issues identified should reviewed jointly by referring and receiving hospitals staff at Mortality and Morbidity Reviews, annual review of Regional Cooperation Agreement or other appropriate QI venue. Issues identified should reviewed jointly by referring and receiving hospitals staff at Mortality and Morbidity Reviews, annual review of Regional Cooperation Agreement or other appropriate QI venue. These issues may also be used to identify joint policy and procedure requirements, educational opportunities and or gaps in services that should be referred to team responsible for annual review and negotiation of the Memorandum of Understanding (MOU). These issues may also be used to identify joint policy and procedure requirements, educational opportunities and or gaps in services that should be referred to team responsible for annual review and negotiation of the Memorandum of Understanding (MOU).

28 Transport Issues with Improvement Potential (Quality Improvement Data)  Delay in transport, describe: ______________________________________________ Related to  Amb./vehicle issues  Traffic  Missed opportunity for maternal transport  Delay in transferring infant  Transport Team Difficulties, describe: _______________________________________  Required elements of elements form incomplete, describe: _____________  Equipment Difficulties, describe: __________________________________________  Unplanned Intervention During Transport, describe: ____________________________ Related to  Airway  Vascular Access  Return to Referring Hospital  Other _______________________________  CPR during transport  Death prior to admission to receiving NICU**  None  Other, describe

29 Comments Referred for Joint Mortality/Morbidity Review  Y  N  Unk Date of Review Outcome of Review:  Policy/Procedure Change  Joint QI Project  Education Offering  Consultation  Other: describe Follow up:

30 On-line Reporting of Data Selected data elements (found in Red highlighted, BOLD on the sample and NTR forms) will be electronically reported via the CPQCC Transport Activity Report. Selected data elements (found in Red highlighted, BOLD on the sample and NTR forms) will be electronically reported via the CPQCC Transport Activity Report. This reporting should take place following the transport but prior to submitting routine Admission/Discharge Data to the CPQCC. All transported patients are eligible for inclusion in the CPQCC dataset. This reporting should take place following the transport but prior to submitting routine Admission/Discharge Data to the CPQCC. All transported patients are eligible for inclusion in the CPQCC dataset.

31 Data Definitions Data definitions and directions for completing each item on the NTR can be found in the attached 2007 Manual of Definitions – Neonatal Transport Data Collection Tools. Data definitions and directions for completing each item on the NTR can be found in the attached 2007 Manual of Definitions – Neonatal Transport Data Collection Tools.

32 RECEIVING HOSPITAL REPORT Acute Transport Activity Infants 1,500 grams or less born between 01/01/2006 and 12/31/2006 CenterSame CCS Level within CPQCC Center-Network Comparison (N=141)(N Centers=94 ) N%Last Year's% Median % Lower Quartile % Upper Quartile Acute Transport Type Dr Attendance Requested ASAP Neonatal Scheduled Neonatal Other Birth Weight For a finer birth weight breakdown, click here. 750 grams or less ,000 grams ,001-1,500 grams Gestational Age For a finer gestational age breakdown, click here. under 25 weeks to 27 weeks to 30 weeks to 33 weeks to 37 weeks to 41 weeks

33 Thank You!

34 Neonatal Transport Data Work Group Allen Fischer, MD Philippe S. Friedlich, MD Balaji Govindaswami, MD, MPH Andrew Hopper, MD Robert Kahle, MD Frank L. Mannino, M.D. Gil Martin, MD Rod Phibbs, MD Francis Poulain, MD Bob Roth, MD Terri Slagle, MD Leslie Williams Data Collection Advisory Committee Jeanetter Asselin Grace Villarin Duenas Co-Chairs Jeffrey Gould, MD, MPH Al Hackel, MD Staff D. Lisa Bollman, RNC, MSN Barbara Murphy, RN, MSN Grace Villarin Duenas Dani Kerns Katherine Cross Beate Danielsen Pemita Pa’aga Fulani Irving

35 Key Informants &Focus Group Participants Northern California Jackie Bagatta Laura Berrito Alice Black Michelle Cordova Robin Courtney Jo Danner Louise Fry Al Hackel Allan Fischer Allan Fishman Mary Lynch Barbara Mochizuki Barbara Murphy Lois Owen Rod Phibbs Richard Powers Gloria Santos Pamela Stanley Wendi Stover Jill Thornton Christa Thomas Lori Saunders Christine Williams Leslie Williams Barbara Werner Southern California D. Lisa Bollman Uday Devaskar Vijay Dhar Ralph E. Franceschini Phillippe S. Friedlich Mary Goldberg Balaji Govindaswami Jeff Gould Al Hackel Sudeep Kukreja Frank Mannino Sally McGann Andy Mossa Barbara Murphy Mark Speziale Arthur Strauss Sophia Tse Cherry Uy Ulrika Walfridsson-Schultz David Wirtschafter

36 Beta Test Facilities California Medical Center Children’s Hospital of Central California Children’s Hospital & Research Center at Oakland Lucille Packard Children Hospital at Stanford Presbyterian Intercommunity Medical Center Santa Clara Valley Medical Center St. Francis Medical Center St. Mary Medical Center Sutter Memorial Hospital, Sacramento University of California, Davis Medical Center University of California, San Francisco

37 Special thanks to the following groups for their input review and advice: CPQCC Executive Committee Perinatal Quality Improvement Committee Data Collection Advisory Group Data Center Staff CPeTS: Executive Committee Northern California Perinatal Quality Improvement Committee Southern California Perinatal Quality Improvement Committee Regional Perinatal Programs of California California Department of Health Services, Maternal, Child and Adolescent Health Branch/Office of Family Planning and Childrens Medical Services (CMS); California Childrens Services (CCS)


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