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Perinatal Quality Improvement Efforts in Florida

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. Mission.

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Perinatal Quality Improvement Efforts in Florida

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

  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 • 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 Florida Chapter March of Dimes Florida Department of Health Agency for Health Care Administration/HMA Florida Hospital Association Florida Blue

  5. Timeline Mar 2009Proposed starting the FPQC Dec 2009USF Chiles Center identified as state lead Jun 2010FPQC launched at State Summit Jan 20111stmaternal initiative—Early Elective Deliveries (EED) Oct 20111st infant initiative—Neonatal Catheter Associated Blood Stream Infections (NCABSI) Phase I Jun 2012Expanded—EED initiative: FHA HEN hospitals Aug 2012 Expanded—NCABSI Phase II Jul 20132nd infant initiative—Golden Hour Part I Aug 20132ndmaternal 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., Jan-Sept 2013, CMS Hospital Compare

  10. Early Elective Delivery RatesPercent 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

  12. EED Newsletter Available on our EED page at FPQC.org

  13. EED Video:“We Just Haven’t Gone Far Enough” 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. 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. 2011 to Aug. 2013 Phase II Phase I Expanded from 9 states in Phase I to 13 states in Phase II (FL 58.8% Reduction)

  18. Where We’ve Come 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.

  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

  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

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

  25. Quantification of Blood Loss Percent of deliveries in all hospitals for which blood loss was quantified for vaginal deliveries

  26. Golden Hour Part I:Delivery Room Management

  27. 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

  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%)

  30. Golden Hour Pilot Hospitals 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 ACADEMIC TGH/USF ACH/Johns Hopkins

  31. 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 DeliveriesSample Hospital QI Box Plot

  35. Percentage of Early Term DeliveriesHospital 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

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

  39. 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

  40. Low-Risk First-Birth (Nulliparous Term Singleton Vertex)C-Sec Rate Among 116 Florida Hospitals Range: 6.6—59.5% Median: 31.3% Mean: 31.8% National Target =23.9% 21% of FL hospitals meet national target 41 Source: FL Vital Records, Dec 2013

  41. 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

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