Transcript 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
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.
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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, Evidencebased, Value-added
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Funders/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
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Timeline
Mar 2009
Dec 2009
Jun 2010
Jan 2011
Oct 2011
Jun 2012
Aug 2012
Jul 2013
Aug 2013
Proposed starting the FPQC
USF Chiles Center identified as state lead
FPQC launched at State Summit
1st maternal initiative—Early Elective
Deliveries (EED)
1st infant initiative—Neonatal Catheter
Associated Blood Stream Infections
(NCABSI) Phase I
Expanded—EED initiative: FHA HEN hospitals
Expanded—NCABSI Phase II
2nd infant initiative—Golden Hour Part I
2nd maternal initiative—Obstetric
Hemorrhage Initiative (OHI)
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Non-Medically Indicated (NMI)
Deliveries < 39 Weeks
(Early Elective Deliveries)
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Florida “Big 5” Pilot Hospitals Reduction of
NMI Deliveries <39 Weeks by Delivery Type 2011
80%
70%
Combined
Inductions
Cesareans
60%
50%
40%
30%
20%
10%
0%
Jan
Feb Mar Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Published in Obstetrics & Gynecology: "A Multistate Quality Improvement Program to
Decrease Elective Deliveries Before 39 Weeks Gestation"
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Percent of NMI Single Live Births <39 Weeks
Among Term Births for Florida Hospitals by
Quintile
30%
25%
20%
15%
10%
5%
0%
2006
2007
2008
2009
Source: FL Live Birth Certificate Data
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2010
2011
2012
2013
Early Elective Delivery Rates (PC-01)
Southeast U.S., Jan-Sept 2013, CMS Hospital Compare
MS
AL
KY
OK
GA
TX
AR
TN
FL
LA
NM
SC
NC
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14
9
8
8
7
6
6
6
5
3
3
3
0
5
10
15
PC-01 Percentage
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20
25
Early Elective Delivery Rates
Percent of Florida Delivery Hospitals by Jan-Sept, 2013
15%
33%
19%
Hospital
EED Rate
0%
1-5%
5-10%
>10%
33%
Source: Centers for Medicare and Medicaid Services: Hospital Compare July 17, 2014; PC-01 Early Elective Delivery, Quarters 1-3.
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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
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EED Newsletter
Available on our EED page at FPQC.org
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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
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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
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Neonatal Catheter Associated
Blood Stream Infections
(NCABSI)
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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
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Neonatal Catheter Associated Blood Stream Infections
NCABSI/FPQC—Dec. 2011 to Aug. 2013
Phase I
Phase II
Expanded from 9 states in Phase I to 13 states in Phase II (FL 58.8% Reduction)
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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.
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Obstetric Hemorrhage Initiative
(OHI)
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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
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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
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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
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OHI Kick Off
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Project Data: Risk Assessment
Percent of hospitals that assessed birthing women for risk of
obstetric hemorrhage upon admission
100%
90%
80%
70%
14%
15%
66%
60%
50%
40%
30%
71%
16%
20%
19%
10%
0%
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75 to 100% of
women assessed
1 to 74% of women
assessed
No women assessed
Quantification of Blood Loss
Percent of deliveries in all hospitals for which blood loss
was quantified for vaginal deliveries
35%
30%
25%
20%
15%
10%
5%
0%
Baseline
December
January
February
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March
April
May
Golden Hour Part I:
Delivery Room Management
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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
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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
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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%)
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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
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Initiative-Wide Data
Delayed Umbilical Cord Clamping
All hospitals
Original 6 hospitals
Goal
100%
90%
Percent achieved
80%
73%
70%
60%
51%
50%
42%
40%
34%
30%
20%
10%
21%
20%
27%
12%
0%
Month of Birth
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39%
66%
53%
58%
71%
54%
Hospital Perinatal
Quality Indicator Project
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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
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Early Elective Deliveries
Sample Hospital QI Box Plot
Percentage of Early Elective Deliveries
60%
50%
40%
30%
18.7%
17.8%
20%
16.6%
14.4%
13.3%
11.3%
17.6%
10%
0%
2006
2007
2008
2009
Year
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2010
2011
2012
Percentage of Early Term Deliveries
Hospital X, 2004-2011
Percentage of early-term deliveries
20%
Non-medically Indicated Early-term Delivery
Early-term Spontaneous Delivery
Early-term Medically Indicated Delivery
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
2004
2005
2006
2007
2008
Year
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2009
2010
2011
Upcoming Projects
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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
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Antenatal Steroid Use for Infants 24-33 Weeks in
19 of Florida’s Vermont Oxford Network (VON)
Hospitals, 2012
100
90
Median = 77
80
70
60
50
40
30
20
10
0
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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
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Low-Risk First-Birth (Nulliparous Term Singleton Vertex)
C-Sec
Rate
Among
116
Florida
Hospitals
80%
70%
Range: 6.6—59.5%
Median: 31.3%
Mean: 31.8%
60%
50%
40%
National Target
=23.9%
30%
20%
0%
21% of FL hospitals
meet national target
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
10%
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Source: FL Vital Records, Dec 2013
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Sign up for communications
Attend our Annual Conference in April 2015
Become a Member
Contact on our website: FPQC.org
E-mail us: [email protected]
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