Perinatal Quality Improvement Efforts in Florida William M. Sappenfield, MD, MPH FPQC Co-Director Lawton and Rhea Chiles Center for Healthy Mothers and Babies University of South Florida College of Public Health

Vision All of Florida’s mothers and infants will have the best health outcomes possible through receiving high quality evidence-based perinatal care. Mission Advance 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.

State Perinatal Quality Collaborative Functions Promote Maternal & Infant quality improvement (QI) projects Support hospitals & providers develop & implement tailored guidelines Offer QI initiative process & outcome indicators Educate/train providers in quality improvement Provide advice on implementing change Values: Voluntary, Population-based, Data-driven, Evidence-based, Value-added

Funders/Partners Partners Florida Chapter March of Dimes Florida Department of Health Agency for Health Care Administration/HMA Florida Hospital Association Florida Blue Partners American Congress of Obstetricians and Gynecologists (ACOG) District XII Florida Society of Neonatologists/FL Chapter of American Academy of Pediatrics Florida Council of Nurse Midwives FL Section Association of Women’s, Health, Obstetric, and Neonatal Nurses (AWHONN) Florida Association of Healthy Start Coalitions

Timeline Mar 2009 Proposed starting the FPQC Dec 2009 USF Chiles Center identified as state lead Jun 2010 FPQC launched at State Summit Jan 2011 1st maternal initiative—Early Elective Deliveries (EED) Oct 2011 1st infant initiative—Neonatal Catheter Associated Blood Stream Infections (NCABSI) Phase I Jun 2012 Expanded—EED initiative: FHA HEN hospitals Aug 2012 Expanded—NCABSI Phase II Jul 2013 2nd infant initiative—Golden Hour Part I Aug 2013 2nd maternal initiative—Obstetric Hemorrhage Initiative (OHI)

Non-Medically Indicated (NMI) Deliveries < 39 Weeks (Early Elective Deliveries)

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"

Percent of NMI Single Live Births <39 Weeks Among Term Births for Florida Hospitals by Quintile Source: FL Live Birth Certificate Data

Early Elective Delivery Rates (PC-01) Southeast U. S Early Elective Delivery Rates (PC-01) Southeast U.S., Jan-Sept 2013, CMS Hospital Compare

Early Elective Delivery Rates Percent of Florida Delivery Hospitals by Jan-Sept, 2013 Hospital EED Rate Source: Centers for Medicare and Medicaid Services: Hospital Compare July 17, 2014; PC-01 Early Elective Delivery, Quarters 1-3.

EED Resources Educational and communications campaign Grand Rounds Hospital Consultations E-Bulletins Provider Education Packets EED Focused Newsletter Special EED Video Consumer campaigns through Healthy Start Coalitions With 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.

Available on our EED page at FPQC.org EED Newsletter To view video online: http://health.usf.edu/publichealth/chiles/fpqc/eed Available on our EED page at FPQC.org

EED Video: “We Just Haven’t Gone Far Enough” view it online at the EED page via FPQC.org Robert W. Yelverton, MD Chair, District XII ACOG Karen E. Harris, MD, MPH Vice-Chair, District XII ACOG Available on our EED page at FPQC.org

49 Florida hospitals have qualified for a banner Banner Opportunity Many 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

Neonatal Catheter Associated Blood Stream Infections (NCABSI)

Where We Started Individual 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 reduction National collaboratives combined had a baseline of 2.51 infections per 1000 line days Baseline rate in Florida from NHSN data was 2.96 infections per 1000 line days

Neonatal Catheter Associated Blood Stream Infections NCABSI/FPQC—Dec Neonatal Catheter Associated Blood Stream Infections NCABSI/FPQC—Dec. 2011 to Aug. 2013 Phase I Phase II Florida 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)

Where We’ve Come Detailed 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 2013. Mortality rate 12.3%, increased length of stay of 8 days and estimated average cost of $53,000 per infection.

Obstetric Hemorrhage Initiative (OHI)

Obstetric Hemorrhage Initiative Obstetric hemorrhage is a leading cause of maternal mortality in Florida Objective: Improved outcomes in morbidity and mortality related to obstetric hemorrhage, including hysterectomies and massive transfusions Meets new national guidelines for OB patient safety Partnering 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.

Key OHI QI Elements Readiness Develop an Obstetric Hemorrhage Protocol Develop a Massive Transfusion Protocol Construct an OB Hemorrhage Cart Ensure Availability of Medications and Equipment Recognition Antepartum Risk Assessment Quantification of Blood Loss Active Management of the Third Stage of Labor Response Perform Interdisciplinary Hemorrhage Drills Debrief after OB Hemorrhage Events

OHI 31 Florida hospitals and 4 North Carolina hospitals 18-24 month initiative Hospital applicant data indicated improvement needed Assessment of risk for OB hemorrhage upon hospital admission Quantification of blood loss

OHI Kick Off October 30, 2013

Project Data: Risk Assessment Percent of hospitals that assessed birthing women for risk of obstetric hemorrhage upon admission Comparison 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.

Quantification of Blood Loss Percent of deliveries in all hospitals for which blood loss was quantified for vaginal deliveries Percent of charts that indicated blood loss was quantified for vaginal deliveries using at least 1 of the approved quantification methods.

Golden Hour Part I: Delivery Room Management

While there is no direct causation, studies show a strong association The Golden Hour Transition from fetal  neonatal life Many complex physiologic changes Interventions 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) Mortality While there is no direct causation, studies show a strong association

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 weight Interventions 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.

Delivery Room Management Goal is to enhance teamwork and implement evidence-based practices on: Teamwork Thermoregulation Oxygen administration Delayed cord clamping Hospital baseline data indicated major need in the areas of: Assignment of delivery room team member roles Delayed 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.

Golden Hour Pilot Hospitals ACADEMIC TGH/USF ACH/Johns Hopkins NON-ACADEMIC St. Joseph’s Hospital Baptist Hospital Miami Florida Hospital Tampa South Miami Hospital Sarasota Memorial Hospital Broward Health Medical Center Plantation General Hospital

Delayed Umbilical Cord Clamping Initiative-Wide Data Delayed Umbilical Cord Clamping

Hospital Perinatal Quality Indicator Project

Indicator Project Partnered with DOH and AHCA to access existing linked birth certificates and hospital discharge data Recruited 7 hospital teams and 8 state organizations to consult on Florida’s pilot indicators and reports Develop both health care and data quality reports Consult national experts Test the use of pilot reports in pilot hospitals Use pilot efforts and plans to promote Florida development

Early Elective Deliveries Sample Hospital QI Box Plot

Percentage of Early Term Deliveries Hospital X, 2004-2011

Upcoming Projects

Antenatal Corticosteroid Treatment (ACT) Includes FL, CA, IL, NY & TX Focus on ACOG & Joint Commission measure (PC-03) Also focus on the “sweet spot” Launch in Fall 2015 Develop initiative with 2015 start Workgroup Training tools Site recruitment plan Anticipate further MOD grant support

Antenatal Steroid Use for Infants 24-33 Weeks in 19 of Florida’s Vermont Oxford Network (VON) Hospitals, 2012 Median = 77 When 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.

Primary Cesarean Sections Higher risk of morbidity for mothers and neonates Higher risk of health care cost Florida had the 4th highest overall Cesarean section rate among U.S. states. 38.1% of births in 2012, increasing since 1996 Primary cesareans drive the increasing rate Virtually all subsequent births will be by cesareans

21% of FL hospitals meet national target Low-Risk First-Birth (Nulliparous Term Singleton Vertex) C-Sec Rate Among 116 Florida Hospitals 41 Range: 6.6—59.5% Median: 31.3% Mean: 31.8% National Target =23.9% 21% of FL hospitals meet national target A 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: Induction Medical conditions Race/Ethnicity—Cuban, Haitian, Non-Mexican Hispanics, Black Maternal age—more than 30 years Private or Medicaid insurance The only significant hospital risk factor is location; South Florida has the highest rate. Source: FL Vital Records, Dec 2013

Get involved with the FPQC Sign up for communications Attend our Annual Conference in April 2015 Become a Member Contact on our website: FPQC.org E-mail us: fpqc@health.usf.edu Get connected on Facebook: www.facebook.com/FPQCatUSF