Iowa’s Top Ten List

1. Iowa’s Top Ten List Stephen K. Hunter, MD., PhD Professor Director: Division of Maternal-Fetal-Medicine University of Iowa Hospitals and Clinics Associate Director: Iowa Statewide Perinatal Care Program Iowa State Department of Public Health

2. Iowa Statewide Perinatal Care Program History Formed in 1973 Team Initially consisted of an OB nurse, Neonatal nurse & a pediatrician/neonatologist. OB consultant and perinatal nutritionist added later Hospital Visits In 1973 – 141 hospitals providing OB care 2010 – approximately 80 Iowa Regionalized System of Perinatal care Established in large and medium sized communities Receive best care close to home Perinatal mortality rates among best in nation

3. Iowa Statewide Perinatal Care Program Hospital visitations Mainstay of the program Face-to face education of physicians and nurses providing obstetrical and newborn care In past year direct educational contact with 337 physicians and 272 nurses Since the Perinatal Team travels the entire state its members have a unique perspective on the care of mothers and babies in Iowa.

4. Iowa Statewide Perinatal Care Program Level 1 Level II Level IIR Level III

5. No. of Hospitals in Iowa by Level of Care Level of Care Level I Level II Level IIR Level III # of Hospitals 60 12 6 3

6. #10: Smoking in Pregnancy

7. #10: Smoking in Pregnancy • Women who smoke during pregnancy are more likely to have: • An ectopic pregnancy • Vaginal bleeding • Placental abruption • Placenta previa (a low-lying placenta that covers part or all of the opening of the uterus) • A stillbirth

8. #10: Smoking in Pregnancy • Babies born to women who smoke during pregnancy are more likely to be born: • With birth defects such as cleft lip or palate • Prematurely • At low birthweight • Underweight for the number of weeks of pregnancy • Babies born prematurely and at low birthweight are at risk of other serious health problems, including lifelong disabilities (such as cerebral palsy, mental retardation and learning problems), and in some cases, death. 

9. #10: Smoking in Pregnancy

10. #10: Smoking in Pregnancy • Compared with women who smoked through-out pregnancy, first-trimester quitters reduced their odds of delivering a preterm non-SGA newborn by 31%, a term SGA newborn by 55% and a preterm SGA newborn by 53%. • Second-trimester quitters reduced their odds of delivering preterm non-SGA and term SGA newborns but to a lesser magnitude. • Polakowski et al., Obstet & Gynecol. 114(2):318, 2009

11. #9: Stillbirth Work-Up

12. #9: Stillbirth Work-Up • Two questions our patients will always ask; • Why did it happen?, and • Will it happen again? • “If ye seek, ye shall find.” • May not always be true in the area of stillbirth, but I can promise that if you DON’T seek, you will NOT find.

13. #9: Stillbirth Work-Up Number 102, March 2009 (Replaces Committee Opinion Number 383, October 2007) Management of Stillbirth The most important tests in the evaluation of a stillbirth are fetal autopsy; examination of the placenta, cord, and membranes; and karyotype evaluation.

14. #8: Pitocin

15. #8: Pitocin

16. #8: Pitocin • Areas of Concern • Lack of standardization of Pitocin protocols

18. #8: Pitocin • Areas of Concern • Lack of standardization of Pitocin protocols • Not recognizing or treating hyperstimulation • Physicians ordering increases when not in-house or have not personally looked at FHR and Toco strips (Cowboy mentality) • Simultaneous use of Pitocin and maternal oxygen

19. There may be many appropriate ways to treat a conditionWhen using a team approach (with changing teams) – let’s pick one and get real good at it

20. Beware of the Cowboy Mentality

21. #7: Access to Care

22. Iowa Statewide Perinatal Care Program History Hospital Visits In 1973 – 141 hospitals providing OB care 2010 – approximately 80

23. Iowa Level I Hospital Survey Dear Hospital CEO, The Iowa Statewide Perinatal Care Program is trying to obtain data from all hospitals in Iowa regarding labor & delivery services. We are engaging in this study due to concerns we have over discontinuation of obstetric services by many hospitals in the state in recent years. When the Perinatal Program began over 35 years ago, there were approximately 140 hospitals in the state providing obstetric services. We are currently down to approximately 80, with many discontinuing this service in the last 10-15 years. To try and discern the reasons for this we are asking you to fill out a short survey provided with this letter and return to our office in the stamped envelope provided. It should only take 2-3 minutes of your time to complete. We are hoping for a high percentage of surveys returned. The information obtained will be very helpful to us as we try to keep convenient, high-quality obstetric services available to the women of Iowa. Sincerely, The Iowa Statewide Perinatal Care Program: Michael Acarregui, MD, Director Stephen Hunter, MD, PhD, Associate Director Penny Smith, RNC, Neonatal Nurse Consultant Amy Sanborn, RNC, Obstetric Nurse Consultant

24. Survey Questions 1. Does your hospital currently provide prenatal and labor & delivery services? ____ Yes ____ No 2. If no, has your hospital ever provided prenatal and labor & delivery services? ____ Yes ____ No 3. If your hospital previously provided prenatal and labor & delivery services but no longer does, what year were these services discontinued?

25. 4. If your hospital previously provided prenatal and labor & delivery services but no longer does, what was/were the reason(s) for discontinuing these services? (Check all that apply) ____ Inability to recruit physicians willing or capable of providing OB care ____ Inability to retain physicians willing or capable of providing OB care ____ Inability to recruit physicians willing or capable of performing cesarean sections ____ Inability to retain physicians willing or capable of performing cesarean sections ____ Inability to recruit physicians willing or capable of providing OB anesthesia ____ Inability to retain physicians willing or capable of providing OB anesthesia ____ Inability to recruit nurses trained in providing OB care ____ Inability to retain nurses trained in providing OB care ____ Concerns regarding quality of OB care and services provided ____ Medical-legal liability concerns ____ Financially non profitable to the hospital ____ Close proximity to a competing hospital (duplicative services for a geographical area) ____ Other (please explain) 5. If your hospital currently provides labor & delivery services has your hospital ever considered discontinuing this service?

26. Iowa Level I Hospital Survey-Results No. of Level I hospitals currently providing OB care & not considering closing 40 No. of Level I hospitals currently providing OB care but have considered closing 13 No. of Level I hospitals that previously provided care but currently do not 29 (15 in the last 12 years)

27. Iowa Level I Hospital Survey-Results Most common Reasons Cited for Closure of OB services; Inability to recruit or retain physicians (OB providers, surgeons, anesthesia) and nurses capable or willing to provide OB care Concerns regarding quality of OB care and services provided Medical-legal liability concerns

28. Challenges faced in rural Iowa Access to Care Inability to recruit or retain physicians (OB providers, surgeons, anesthesia) and nurses capable or willing to provide OB care

29. Access to Care Study Highlights Grim Realities of Rural Obstetric Access, Lynda Waddington. Jun 9 2009 (http://www.rhrealitycheck.org) “According to figures assembled from national databases, the number of hospitals that provided obstetric services dropped by 23 percent from 1985-2000.” “The most frequently cited reasons for closing obstetric units were low volumes of deliveries in rural communities, financial vulnerabilities due to high proportion of patients on Medicaid, and difficulties in staffing obstetric units. Reasons for difficulties in staffing obstetric units include malpractice burdens for physicians, changes in physicians’ attitudes towards work and quality of life, and the cost involved in recruiting supporting specialists such as anesthesiologists and surgeons.” The Status and Future of Small Maternity Services in Iowa. Herman A. Hein. JAMA 255: 1899-1903, 1986. “The Iowa Hospital Association anticipates that numerous small hospitals will be forced to close within the next several years.”

30. #6: Progesterone for H/O PTD/Short Cx

31. #6: Progesterone for H/O PTD/Short Cx • Preterm Birth • 12.9 million births worldwide (9.6%) • United States 12.8% in 2006 • Iowa 11.5% in 2008 • The leading cause of perinatal morbidity and mortality. • Contributes to 70% of neonatal mortality and ~ half of long-term neurodevelopmental disabilities.

32. #6: Progesterone for H/O PTD/Short Cx • Meis et al. 2003 NEJM • Weekly injections of 17P starting at 16-20 wks in women with H/O PTD. • Reduced incidence of PTD in 17P group vs Placebo. • <37 wks 36.3 % vs 54.9% • < 35 wks 20.6% vs 30.7% • <32 wks 11.4% vs 19.6% • Daily vaginal progesterone has been shown to be as effective as IM 17P

33. #6: Progesterone for H/O PTD/Short Cx • Vaginal progesterone has now been shown to reduce the rate of preterm birth and neonatal morbidity in asymptomatic, low-risk women with a sonographic short cervix (10-20mm) in the midtrimester. • Hassan et al. 2011 • <35 wks, 14.5% vs 23.3% • <33 wks, 8.9% vs 16.1% • <28 wks, 5.1% vs 10.3% • Romero et al. 2012 • <33 wks, 12.4% vs 22.0% • <35 wks, 20.4% vs 30.5%

34. #6: Progesterone for H/O PTD/Short Cx • Number 522, April 2012 Incidentally Detected Short Cervical Length The American College of Obstetricians and Gynecologists and the American Institute of Ultrasound in Medicine recommend that a cervical length measurement be performed at the time the ultrasound examination is undertaken for fetal anatomic survey at around 18–22 weeks of gestation.

35. #6: Progesterone for H/O PTD/Short Cx • Where are the problems? • Not treating appropriate women. • H/O PTD • Mid-trimester short cervix (10-20mm) • Difficulty in getting insurance coverage, especially Medicaid for Progesterone. • Logistics of getting a mid-trimester transvaginal cervical length measurement on all pregnant patients.

36. #6: Progesterone for H/O PTD/Short Cx Average cost for 1 day in the NICU: $4,000-$5,000

37. #5: Documentation

38. Fact: Medical Malpractice claims are an inescapable reality Statistics: 2 of every 3 physicians have been sued 1 of every 3 physicians have been sued > 3x Virtually every hospital has been sued multiple times. When hospitals are sued, nurses are named individually. 50% of all cases filed are dismissed or dropped w/o payment. 35% of all cases are settled out of court. < 15% of all cases are resolved at trial. 40% of tried cases result in Plaintiffs verdict (6% of all cases)

39. Fact: 6 of the top 10 largest Med-Mal verdicts in 2005 involved perinatal care. Statistically: Nurses practicing in perinatal care settings are the most likely to be involved in med-mal litigation.

40. Top 2 Sources of Hospital Liability Exposure 1. Failure to appropriately document. 2. Failure to appropriately assess and intervene.

41. Fact: “The finest care rendered under the best circumstances may be difficult if not impossible to defend if the care is not documented.” – Charles Ward, M.D., “Critical Care of the Neonate”

42. Fact: Not only are healthcare providers required to take appropriate action, they are required to accurately document their findings, interventions, and patient response to intervention.

43. #5: Documentation • Areas of concern • Shoulder Dystocia • Operative Vaginal Deliveries

44. Documentation • Strongly Recommend • Written or (better) dictated pre-op note • Written or (better) dictated post-op note • Details of discussion with patient • Details of procedure with times, number of pulls, pop-offs, VE suction, fetal descent • Details of maternal/neonatal trauma • Rationale for decisions at the time (indication)

45. Strategies to Decrease Liability Related to Documentation. Provide an accurate account of all events related to care of the patient. A healthcare professional may not be asked to testify in a malpractice case until several years after the event occurred. If the healthcare provider/staff has documented all aspects of care, remembering the event will be much easier. Document assessment, planning, intervention and evaluation. Careful documentation will serve as evidence that the current standard of care was followed. Document data collected at each assessment and any special circumstances of problems noted. Document factually, without placing blame.

46. Strategies to Decrease Liability Related to Documentation. (contd) Document completely to avoid gaps in the record. Gaps may suggest that the patient may have been neglected. Document follow-through on nursing plan and physician’s orders for treatment. Any omissions in carrying out the physician’s order should be documented. Document response to medications and treatment.

47. #5: Documentation • How do we improve? • The use of Standardized documents and checklists

50. And Finally…Beware the EMR Usually designed for ease of data input and capture of charges Often “narrative” unfriendly. Therefore very difficult to tell a story. Output is often very disorganized. Again, making it very difficult to figure out the story.