1. 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

2. 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.

3. 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

4. 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

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

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

7. 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"

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

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

10. 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.

11. 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.

12. Available on our EED page at FPQC.org
EED Newsletter
To view video online:
Available on our EED page at FPQC.org

13. 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

14. 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

15. Neonatal Catheter Associated Blood Stream Infections (NCABSI)

16. 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

17. Neonatal Catheter Associated Blood Stream Infections NCABSI/FPQC—Dec
Neonatal Catheter Associated Blood Stream Infections NCABSI/FPQC—Dec 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)

18. 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 Mortality rate 12.3%, increased length of stay of 8 days and estimated average cost of $53,000 per infection.

19. Obstetric Hemorrhage Initiative (OHI)

20. 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.

21. 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

22. 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

23. OHI Kick Off
October 30, 2013

24. 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.

25. 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.

26. Golden Hour Part I: Delivery Room Management

27. 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

28. 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.

29. 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.

30. 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

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

32. Hospital Perinatal Quality Indicator Project

33. 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

34. Early Elective Deliveries Sample Hospital QI Box Plot

35. Percentage of Early Term Deliveries Hospital X, 2004-2011

36. Upcoming Projects

37. 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

38. Antenatal Steroid Use for Infants 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.

40. 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

41. 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

42. 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
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