QI Collaboration in Colorado Colorado Perinatal Care Council Initiatives Alfonso Pantoja, MD Chair

Colorado Perinatal Care Council (CPCC) Mission: It is a volunteer, non-profit, advisory group whose members represent a variety of professions, hospitals and organizations with an expertise or interest in perinatal care. Its major focus is the coordination and improvement of perinatal care services in Colorado CPCC has been operational since April 1976 (35 years!)

2010 Colorado Perinatal Quality Collaborative Aim: To reduce prematurity-related perinatal morbidity and mortality by applying potential better practices (PBPs) to prenatal, intrapartum and neonatal care Outcomes to be tracked by CDH Perinatal Statistics and Colorado VON report

PERINATAL CARE CORE MEASURE SET SELECTION FORM Data MUST be collected on EACH MEASURE and submitted to The Joint Commission. ✓ Elective Delivery Cesarean Section ✓ Antenatal Steroids ✓ Health Care-Associated Bloodstream Infections in Newborns ✓ Exclusive Breast Milk Feeding

Colorado VON Group Report Denver Health Medical Center Exempla Good Samaritan Medical Center Exempla Saint Joseph Hospital Poudre Valley Health System St. Mary’s Hospital & Medical Center The Children’s Hospital in Aurora UCHSC Presbyterian-St. Luke’s Medical Center Swedish Medical Center Rose Medical Center

6

8

PBPs to Decrease Elective Deliveries Before 39 Weeks of Gestation ✦ Provider Education: Series of presentations at local OB/GYN Department meetings with extensive education of both medical and nursing staff on adverse neonatal outcomes ✦ “Physician champion” delivers the message with consistent messaging and support from leadership ✦ A patient education sheet explains neonatal outcome risks and the policy  Practitioners are either required to obtain permission from their individual hospital OB/GYN Department Chair or attending perinatologist to schedule an elective delivery < 39 weeks  Performance for each practitioner is monitored and reported to staff and individual practitioners with ongoing feedback from the Peer Review Committee

Reduction in elective birth <39 weeks: 3 approaches to change Clark SL, Frye DR, Meyers JA et al Am J Obstet Gynecol 2010 HARD STOP SOFT STOP EDUCATION ONLY

6500 late pre-terms born in CO every year

Source: Health Statistics Section, Colorado Department of Public Health andEnvironment data are provisional. (Left/primary axis) (Right/secondary axis)

Source: Health Statistics Section, Colorado Department of Public Health andEnvironment data are provisional.

Cesarean Section Deliveries by Maternal County of Residency. Colorado Residents

CLABSIs in Colorado

Antenatal Corticosteroids The benefits of antenatal administration of corticosteroids (ACS) to fetuses [ weeks] at risk of preterm delivery vastly outweigh the potential risks. These benefits include: A reduction in the risk of RDS A substantial reduction in mortality and IVH

PBPs Antenatal Corticosteroids 1. Timing: Because treatment with corticosteroids for less than 24 hours can be associated with significant reductions in neonatal mortality, RDS and IVH, antenatal corticosteroids should be given unless immediate delivery is anticipated 2. Fetuses exposed to ACS prior to 24 weeks gestation had decreased mortality and higher Apgar scores compared to those infants not exposed 3. Antenatal steroids are equally effective in the setting of preterm rupture of membranes 4. A single “rescue” course of AC in patients who have been previously treated but who again threaten to deliver before 34 weeks: There is benefit in composite morbidity and a decrease in the presence and severity of RDS.

Colorado is now one of the ten states that have met all of the Healthy People 2010 Breastfeeding Goals! Increase Exclusive Breast Milk Feedings

Target Goal U.S. Rate (CO) Based on 2005 NIS Prelim. Data U.S. Rate (CO) Based on 2006 NIS Prelim. Data Ever Breastfed 75% 74.1% (85.9%) 73.9% (82.5%) At 6 months 50% 42.9% (40.0%) 43.4% (59.5%) At 12 months 25% 21.5% (23.6%) 22.7% (30.5%) Exclusively thru 3 mos. 40% 32.1% (43.9%) 33.1% (49.2%) Exclusively thru 6 mos. 17% 12.3% (14.8%) 13.6% (22.6%) Healthy People 2010 Breastfeeding Goals for the Nation

Can do 5 PRAMS* data from Colorado found that 5 of the BFHI practices significantly extended breast-feeding duration in all socioeconomic groups. Baby stayed in mother’s room Given telephone number to call for help Baby breastfed in first hour Baby fed only breast milk No pacifier use in hospital *Pregnancy Risk Assessment Monitoring System

CPCC QI Initiatives ↑Antenatal steroids↓Late Preterm Births↑Breast Milk↓CLABSI Champions develop PBPs ☑ Create a VON State Report ☑ Collaborate with MOD, CDH, CMS, CHA ☑ Align hospitals with PBPs ☑ Create a culture of transparency ❐

Gracias