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Trifecta for Change: Enhancing Antenatal Care in Ontario

Trifecta for Change: Enhancing Antenatal Care in Ontario. TEC Talk May 27 th , 2013 Mari Teitelbaum Michael Pluscauskas, Sandra Dunn, Tracy Carr, Brenda Bonner, Douglas Cochen. BORN Ontario. The best possible beginnings for lifelong health. Facilitation of Care: Access to Information.

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Trifecta for Change: Enhancing Antenatal Care in Ontario

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  1. Trifecta for Change: Enhancing Antenatal Care in Ontario TEC Talk May 27th, 2013 Mari Teitelbaum Michael Pluscauskas, Sandra Dunn, Tracy Carr, Brenda Bonner, Douglas Cochen

  2. BORN Ontario The best possible beginnings for lifelong health

  3. Facilitation of Care: Access to Information • Sarah, from Toronto, is having a weekend away with friends, she is 34 weeks pregnant • Delivers unexpectedly at the London Health Sciences Centre • How will the delivering obstetrician access her pregnancy health records?

  4. Pregnancy in Ontario 140k women Cared for by: Delivering: • Midwife • Family doctor • Community obstetrician • High risk obstetrician • Nurse practitioner Birth Centre Pregnancy Care Reminders Ultrasound LMP Newborn Screening within 48 hrs of birth Plan labour & birth GBS Screening Prenatal Education Prenatal Screening Transmit Forms to Hospital Diabetes Screening

  5. Antenatal Forms • Consistent care • Facilitates communication • Gold standard • Up to 10% of the time the forms are missing – early delivery, unexpected location or lost • Practices associated with the pathway change regularly

  6. First Visit(s): Early Prenatal Care If 1st visit 14-20+6wks Soft Markers for Aneuploidy: establish risk + counsel Single umbilical artery Thickened nuchal fold Fetal anatomy review Choroid plexus cysts EICF Grade 2, 3 echogenic bowel Expert review 35+ or MSS +ve or other soft markers Mild ventriculomegaly Other Enlarged cysterna magna Isolated + risk > 1/600 Previous C-Section: Consider VBAC vs. Repeat C-Section Expert review + further evaluation pyelectasis Fetal karyotyping pelvis >10mm 3rd trimester scan pelvis ≥ 5mm Neonatal u/s First Visit (s): Identify Risk Factors and Management Plan Subsequent Visits: Ongoing Prenatal Care (see next page) WEEK 0- 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 hr GCT Ultrasound Finalize EDB Laboratory Investigations MSS High risk Fetal anatomy / morphology 18-20 wks > 10 days discrepancy with LMP date Adjust EDB 2nd Test: Hb, ABO/Rh, Repeat ABS Dating scan 11-14 wks (early if larger than dates) If 2 U/S, use 1st for EDB Administer Rh-IG Hb Antibody Screen Last Pap Consult with specialist and genetic counselor 10-13+6 wks Fetal Structural Anomaly MCV Rubella Immune GC/Chlamydia > 5 days discrepancy with LMP estimate Refer to tertiary ultrasound unit Abnormal Cervical Length Change ABO HBsAg HIV Urine C&S 1 hr GCT Repeat 1hr GCT in high risk -ve Rh Sickle Cell VDRL Adjust EDB Establish Risk + Counsel Placental Edge Overlap Repeat U/S, consider further imaging SOGC guidelines for screening options Value 7.8-10.3 If father known, consider Rh test Rh -ve 1 AbN test Glucose intolerance 3rd Trimester exam and follow-up re: need for C-Section 2 hr GCT Second trimester screening (Quad) declined or twins Give Rh-IG (28wks) Father +ve Glucose Level AbN Assess preterm birth risk MSAFP IPS FTS NT Value >10.3 SOGC Guidelines Consult OB to establish fetal surveillance plan AbN level maternal serum marker Soft Markers for Aneuploidy (see box above) Diagnostic and Screening Tests Diagnose Gestational Diabetes Follow Canadian Diabetes Association Guidelines 2nd trimester screen for open neural tube defects Prenatal Genetic Investigations CVS / amnio

  7. A1A2 Pilot Project • Launched in 2011, partnership between E-Health Ontario and BORN, the project had 3 Goals • Improve practitioner use of high quality clinical practice guidelines (CPGs) and pathways for antenatal care. (partnership of BORN and Centre for Effective Practice) • Automate the flow of data collected on A1/A2 to facilitate care to women who may arrive at an Ontario birthing hospital without an antenatal record • Enhance the quality of data available to support QI, system planning and surveillance of pregnancy and birth • Participants • 1 EMR Vendor (OSCAR) • 4 family health teams • 3 hospitals

  8. Clinical Input

  9. EMR Enhancements ✓ Providers

  10. ✓ Patients ✓ Providers System Enhancements BORN Registry

  11. ✓ Patients ✓ Providers ✓ System System Impact BORN Registry

  12. Trifecta: Pregnancy Pathway Clinical pathway embedded in primary care practice Value to the provider beyond what is in their chart Created by clinicians and subject matter experts using OMA standard forms Patient information available when and where it is needed Connection to the individual patient – clinical impact and outcomes Trusted & Authoritative

  13. Pilot Learning • 573 records in the BORN Information System • Preliminary evaluation findings: ‘Good’* • Integration & Coordination of Care • Evidence-based Care & Patient Safety • Workflow Efficiency • Critical Success Factors • Well defined scope • Governance • The Trifecta • Many new opportunities!

  14. So many to Thank • eHealth Ontario • Participating family health teams • OSCAR • Perinatal Services BC • Centre for Effective Practice

  15. Questions

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