1. Working together for healthier mothers and babies 2015 WV Hospital Guidelines and Self Assessments

2. Working together for healthier mothers and babies AGENDA  Finalize recommendations of standards for a multi-tiered system of maternal/neonatal levels of care including quality improvement and review measures  Develop the action plan for implementing maternal risk-appropriate care standards

3. West Virginia Perinatal Partnership Working together for healthier mothers and babies Differences in Levels Between 2007 2012 Perinatal Care Guideline Editions 2007 Nomenclature Old Perinatal Partnership Guidelines 2012 Nomenclature New Guidelines from ACOG AAP Level IOBSTETRIC: Basic NBN: Level I Well Newborn Nursery Level IIA & Level IIBOBSTETRIC: Specialty NBN: Level II Special Care Nursery Level III *Although 2007 AAP ACOG guidelines gave three levels of Level III, the WVPP guidelines committee chose to have one level of Level III OBSTETRIC: Subspecialty NBN: Level III Neonatal Intensive Care Unit Level IV No Level IV in old guidelines OBSTETRIC: Regional subspecialty perinatal health center NBN: Level IV regional neonatal intensive care unit

4. West Virginia Perinatal Partnership Working together for healthier mothers and babies New Guidelines from ACOG & AAP LEVEL I OB: BASICNBN: WELL NEWBORN NURSERY Maternal: Surveillance and care of all patients admitted to the obstetric service, with an established triage system for identifying high‐risk patients who should be transferred to a facility that provides specialty or subspecialty care. Proper detection and initial care of unanticipated maternal‐fetal problems that occur during labor and delivery Capability to begin an emergency cesarean delivery within an interval based on the timing that best incorporates maternal and fetal risks and benefits Availability of appropriate anesthesia, radiology, ultrasound, laboratory, and blood bank services on a 24‐hour basis Care of postpartum conditions. Adequate nursery facilities and support for stabilization of small or ill neonates before transfer to a specialty or subspecialty facility Consultation and transfer arrangements Accommodations and policies that allows families, including their other children, to be together in the hospital following the birth of an infant Data collection, storage, and retrieval Quality improvement programs, including efforts to maximize patient safety Neonatal Provide neonatal resuscitation at every delivery Evaluate and provide postnatal care to stable term newborn infants Stabilize and provide care for infants born 35–37 wk gestation who remain physiologically stable Stabilize newborn infants who are ill and those born at <35 wk gestation until transfer to a higher level of care

5. West Virginia Perinatal Partnership Working together for healthier mothers and babies LEVEL II OB: SPECIALTY NBN: SPECIAL CARE NURSERY All Level I capabilities plus: Provide care for infants born ≥32 wk gestation and weighing ≥1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis Pediatric hospitalists, neonatologist, and neonatal nurse practitioners. Provide care for infants convalescing after intensive care Provide mechanical ventilation for brief duration (<24 h) or continuous positive airway pressure or both Stabilize infants born before 32 wk gestation and weighing less than 1500 g until transfer to a neonatal intensive care facility

6. West Virginia Perinatal Partnership Working together for healthier mothers and babies Level III OB: Subspecialty NBN: Level III Neonatal Intensive Care Unit All Level II capabilities plus: Provide comprehensive care for infants born before 32 wks gestation and weighing less than 1500 g and infants born at all gestational ages and birth weights with critical illness Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI and echocardiography

7. West Virginia Perinatal Partnership Working together for healthier mothers and babies Level IV OB: Regional subspecialty perinatal health center NBN: Level IV regional neonatal intensive care unit All Level III capabilities plus: Located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site Facilitate transport and provide outreach education

8. West Virginia Perinatal Partnership Working together for healthier mothers and babies Need for risk appropriate care Hospital specific issues »Regionalization »Differences exist in services and level of care »Need to focus on “quality” vs. “safety” and “best practices” vs. “regulatory” to be successful with obstetricians

9. West Virginia Perinatal Partnership Working together for healthier mothers and babies Pregnancy, Labor, Delivery Care Needs Strengthen communication and transfer agreements Utilize One Call center to identify available hospitals, providers, and teams to facilitate the transport Address physician referral patterns Financial incentives for both transferring and accepting physicians/hospitals Develop definitions on how to operationalize maternal transport and maternal levels of care Quality improvement Decrease number of primary c/sections Education for mother regarding risk status Education for physicians to recognize problem Increased assessment of specific risk factors in LD that trigger appropriate consultation and care

10. West Virginia Perinatal Partnership Working together for healthier mothers and babies Barriers to care Geographics/politics Uneven level of care when policies are inconsistent in what types of patients hospitals will take Lack of nursing personnel to cover the care of patients who are left on the unit when one of their own needs to go on the transport Conflicts in plan of care b/t intensivist and obstetrician Low-volume hospital lack expertise in dealing with complications

11. West Virginia Perinatal Partnership Working together for healthier mothers and babies Barriers Obstetricians resistant to obtaining assistance and others are resistant to reach out Reimbursement to hospital and physicians Shortage of perinatologists, specialists in general Uncertainty regarding health care reform Obstetricians don’t feel transport is necessary Hospitals want to keep mom for reimbursement purposes, feel they have other resources if necessary including internist and surgeon

12. West Virginia Perinatal Partnership Working together for healthier mothers and babies Neonatal Care Risk-appropriate neonatal care –Infants born outside a level III hospital have a significantly increased likelihood of neonatal death and chronic lung disease (Chung et al., 2009; Laswell et al., 2010) –Maternal sociodemographic and medical conditions increase the risk of poor neonatal outcome including age, race, acculturation level, gravida, psychiatric disorders, and hypertension (DeLange et al., 2008; Jones & Bond, 1999; Shapiro-Mendoza et al., 2008)

13. West Virginia Perinatal Partnership Working together for healthier mothers and babies Neonatal Care Adequacy of prenatal care and distance from a regional center increased the risk for outborn deliveries (Attar et al., 2006) Mortality decreases with improved access to neonatal resources. (Merlo et al., 2005) Odds of mortality were highest in lower-level, lower-volume units (Chung et al., 2010; Phibbs et al., 2007)

14. West Virginia Perinatal Partnership Working together for healthier mothers and babies Neonatal Levels of Care Definitions and criteria for neonatal levels of care and mechanisms for measuring and improving neonatal risk-appropriate care vary widely across the states –33/50 states used some sort of designation to describe the levels of neonatal services available (Blackmon, Barfield, & Stark, 2009) –7 states have mechanisms of measurement for risk-appropriate care, but vary in level definition, clinical capacity, and population served (Nowakowski et al., 2010)

15. West Virginia Perinatal Partnership Working together for healthier mothers and babies Maternal Care Evidence to support maternal levels of care to improve outcomes are few – Maternal mortality in women who experience a peripartum hysterectomy at high-volume hospitals was 71% lower compared with low-volume hospitals (Wright et al., 2010) – Availability of obstetric interventions, reduced transport time, and reduced financial barriers decreased overall maternal mortality rates (Fournier et al., 2009)

16. West Virginia Perinatal Partnership Working together for healthier mothers and babies Perinatal Care WV Wide variability in –Policies –Training/education –Consultation –Joint review of outcome data

17. West Virginia Perinatal Partnership Working together for healthier mothers and babies Perinatal Care Collaboratives Websites of all 50 states and DC reviewed –17 states – no information found –12 states – efforts noted, nothing concrete –14 states – basic information –7 states – more developed guidelines

18. West Virginia Perinatal Partnership Working together for healthier mothers and babies Perinatal Care Collaboratives Patient oriented criteria and materials – Brochure for patients regarding risk appropriate facility and provider recommendations (Arkansas) Provider oriented criteria and materials – Medical criteria for consultation described (IN, TN) – Transport/consultation requirements (MD, TN, AZ, AK) – Tiered system with financial incentives for rural providers to partner with MFM (Oklahoma)

19. West Virginia Perinatal Partnership Working together for healthier mothers and babies Perinatal Care Collaboratives Facility orientated criteria and materials –Reported levels of maternal care (IN, TN) –Levels of care segmented into 3-6 groupings based on regionalization, services, patients, provider info and volume (AZ, IN, MD, MN, NY, TN) –Regional Cooperation Agreements required (AZ, NY) –Air and ground transport recommendations spelled out (AZ, MD) –QI efforts mandated (FL, IL, NJ) –Certificate of Need used (MS)

20. West Virginia Perinatal Partnership Working together for healthier mothers and babies Perinatal Care Collaboratives Funding Issues –Regionalization funded by birth certificate tax (AZ) –Regionalization funded by calculations of number of facilities and responsibilities (MI)

21. West Virginia Perinatal Partnership Working together for healthier mothers and babies Perinatal Issues Statewide History of perinatal regionalization described (MN) Seven states with comprehensive information that might be helpful (AZ, AK, CA, GA, IN, NY, TN)

22. Working together for healthier mothers and babies Molly Scarborough McMillion RN, BSN, IBCLC, CCE, CPST Special Projects Consultant WV Perinatal Partnership Office 304.793.6584Cell 304.667.4362 mmcmillion@osteo.wv.edu www.wvperinatal.org Coordinated by the West Virginia Higher Education Policy Commission, Division of Health Sciences