Iowa’s Top Ten List

Iowa’s Top Ten ListIowa’s Top Ten List

Stephen K. Hunter, MD., PhDStephen K. Hunter, MD., PhDProfessorProfessor

Director: Division of Maternal-Fetal-MedicineDirector: Division of Maternal-Fetal-MedicineUniversity of Iowa Hospitals and ClinicsUniversity of Iowa Hospitals and Clinics

Associate Director: Iowa Statewide Perinatal Associate Director: Iowa Statewide Perinatal Care ProgramCare Program

Iowa State Department of Public HealthIowa State Department of Public Health

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

Iowa Statewide Perinatal Care Iowa Statewide Perinatal Care ProgramProgram

Hospital visitationsHospital visitations Mainstay of the programMainstay of the program Face-to face education of physicians and nurses Face-to face education of physicians and nurses

providing obstetrical and newborn careproviding obstetrical and newborn care In past year direct educational contact with 337 In past year direct educational contact with 337

physicians and 272 nursesphysicians and 272 nurses

Since the Perinatal Team travels the entire state Since the Perinatal Team travels the entire state its members have a unique perspective on the its members have a unique perspective on the care of mothers and babies in Iowa.care of mothers and babies in Iowa.

Iowa Statewide Perinatal Care Iowa Statewide Perinatal Care ProgramProgram

Level 1 Level 1 Level II Level II Level IIR Level IIR Level III Level III

No. of Hospitals in Iowa by No. of Hospitals in Iowa by Level of CareLevel of Care

Level of CareLevel of Care Level ILevel I Level IILevel II Level IIRLevel IIR Level IIILevel III

# of Hospitals# of Hospitals 6060 1212 66 33

#10: Smoking in Pregnancy

Women who smoke during pregnancy are Women who smoke during pregnancy are more likely to have:more likely to have:An ectopic pregnancy An ectopic pregnancy Vaginal bleeding Vaginal bleeding Placental abruption Placental abruption Placenta previa (a low-lying placenta that Placenta previa (a low-lying placenta that

covers part or all of the opening of the uterus) covers part or all of the opening of the uterus) A stillbirth A stillbirth

Babies born to women who smoke during Babies born to women who smoke during pregnancy are more likely to be born:pregnancy are more likely to be born: With birth defects such as cleft lip or palate With birth defects such as cleft lip or palate Prematurely Prematurely At low birthweight At low birthweight Underweight for the number of weeks of pregnancy Underweight for the number of weeks of pregnancy

Babies born prematurely and at low birthweight Babies born prematurely and at low birthweight are at risk of other serious health problems, are at risk of other serious health problems, including lifelong disabilities (such as cerebral including lifelong disabilities (such as cerebral palsy, mental retardation and learning palsy, mental retardation and learning problems), and in some cases, death. problems), and in some cases, death.

Maternal Smoking

Medicaid

Non-Medicaid

All mothers

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

#9: Stillbirth Work-Up

Two questions our patients will always ask;Why did it happen?, andWill 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.

#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.

#8: Pitocin

Areas of ConcernLack of standardization of Pitocin protocols

#8: Pitocin

Areas of ConcernLack of standardization of Pitocin protocolsNot recognizing or treating hyperstimulationPhysicians 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

There may be many appropriate ways to treat a condition

When using a team approach (with changing teams) – let’s pick one and

get real good at it

Beware of the Cowboy Mentality

#7: Access to Care

Iowa Statewide Perinatal Care Program

HistoryHospital Visits

In 1973 – 141 hospitals providing OB care2010 – approximately 80

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 DirectorPenny Smith, RNC, Neonatal Nurse ConsultantAmy Sanborn, RNC, Obstetric Nurse Consultant

Iowa Level I Hospital Survey

Survey Questions1. 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?

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?

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)

Iowa Level I Hospital Survey-ResultsMost 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

Challenges faced in rural IowaAccess to Care

Inability to recruit or retain physicians (OB providers, surgeons, anesthesia) and nurses capable or willing to provide OB care

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.”

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

Preterm Birth 12.9 million births worldwide (9.6%)United States 12.8% in 2006Iowa 11.5% in 2008The leading cause of perinatal morbidity and

mortality.Contributes to 70% of neonatal mortality and

~ half of long-term neurodevelopmental disabilities.

Meis et al. 2003 NEJMMeis et al. 2003 NEJMWeekly injections of 17P starting at 16-20 wks Weekly injections of 17P starting at 16-20 wks

in women with H/O PTD.in women with H/O PTD.Reduced incidence of PTD in 17P group vs Reduced incidence of PTD in 17P group vs

Placebo.Placebo.<37 wks 36.3 % vs 54.9%<37 wks 36.3 % vs 54.9%< 35 wks 20.6% vs 30.7%< 35 wks 20.6% vs 30.7%<32 wks 11.4% vs 19.6%<32 wks 11.4% vs 19.6%

Daily vaginal progesterone has been shown to be as effective as IM 17P

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%

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.

Where are the problems?Not treating appropriate women.

H/O PTDMid-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.

Average cost for 1 day in the NICU: $4,000-$5,000

#5: Documentation

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)

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.

Top 2 Sources of Hospital Liability Exposure

1. Failure to appropriately document.2. Failure to appropriately assess and

intervene.

“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”

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

#5: Documentation

Areas of concernShoulder DystociaOperative Vaginal Deliveries

DocumentationDocumentation

Strongly RecommendStrongly RecommendWritten or (better) dictated pre-op noteWritten or (better) dictated pre-op noteWritten or (better) dictated post-op noteWritten or (better) dictated post-op noteDetails of discussion with patientDetails of discussion with patientDetails of procedure with times, number of Details of procedure with times, number of

pulls, pop-offs, VE suction, fetal descentpulls, pop-offs, VE suction, fetal descentDetails of maternal/neonatal traumaDetails of maternal/neonatal traumaRationale for decisions at the time (indication)Rationale for decisions at the time (indication)

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.

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.

#5: Documentation

How do we improve?The use of Standardized documents and

checklists

And Finally…Beware the EMRUsually designed for ease of data input

and capture of chargesOften “narrative” unfriendly. Therefore

very difficult to tell a story.Output is often very disorganized. Again,

making it very difficult to figure out the story.

#4: Communication#4: Communication

“There are some patients we cannot help; there are none we cannot harm.”

Arthur Bloomfield, MD

“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.”

Cyril Chantler, MD, Lancet, 2001

“…modern health care is the mostcomplex activity ever undertaken by

human beings.” Ken Kizer

Highly complicated technologies Panoply of powerful drugs Widely differing professional backgrounds Unclear lines of authority Highly variable physical settings Unique combinations of diverse patients Communication barriers Care processes widely vary Time pressured environment

Institute of Medicine Report-1999

44,000-98,000 people die each year in the United States due to preventable medical

errors

Thoughtful Communication

Communication breakdowns are at the root of 85% of all adverse events reported in obstetric units.

Communication Be able to provide accurate information

Communication

Be sure everyone understands what you are saying

Communication

Make sure everyone understands what you are doing.

#4 Communications

Areas where we can improveFetal Heart Rate Terminology (NICHD)

EFM & OB LiabilityEFM & OB Liability

““No tool is more universally used to No tool is more universally used to demonstrate alleged negligence in demonstrate alleged negligence in obstetrical claims than the electronic fetal obstetrical claims than the electronic fetal monitor”monitor”

L. Greenwald, Pro Mutual Risk Management Services, 1998L. Greenwald, Pro Mutual Risk Management Services, 1998

Intrapartum FHR monitoring is a Intrapartum FHR monitoring is a ubiquitous procedure that impacts the lives ubiquitous procedure that impacts the lives of more than 7 million mothers and babies of more than 7 million mothers and babies every year in the United States aloneevery year in the United States alone

On Accreditation of Healthcare OrganizationsOn Accreditation of Healthcare Organizations

Sentinel EventSentinel Event Issue 30-July 21, 2004Issue 30-July 21, 2004

AlertAlert

Preventing infant death and injury during deliveryPreventing infant death and injury during delivery

Reviewed 47 cases of perinatal death or major permanent injury Reviewed 47 cases of perinatal death or major permanent injury

in non-anomalous newborns weight > 2,500 gramsin non-anomalous newborns weight > 2,500 grams

Leading risk factor: Poor communication of abnormal Leading risk factor: Poor communication of abnormal

FHR patternsFHR patterns

On Accreditation of Healthcare OrganizationsOn Accreditation of Healthcare Organizations

Sentinel EventSentinel Event Issue 30-July 21, 2004Issue 30-July 21, 2004

AlertAlert

RecommendationsRecommendationsEducate nurses, residents, nurse midwives, and Educate nurses, residents, nurse midwives, and

physicians to use physicians to use standardized terminologystandardized terminology

to communicate abnormal fetal heart rate tracingsto communicate abnormal fetal heart rate tracings

NICHD FHR TerminologyNICHD FHR Terminology

The five basic components of a FHR tracing are:The five basic components of a FHR tracing are: Baseline rateBaseline rate Baseline variabilityBaseline variability AccelerationsAccelerations DecelerationsDecelerations Changes or trends over timeChanges or trends over time

Basic Issues: Basic Definitions

Know what you are talking about, or look like a fool.

None of us is as smart as all of us. ~ Ken Blanchard

#3: Preeclampsia

Pre-eclampsia/Eclampsia in the state of Pre-eclampsia/Eclampsia in the state of Iowa-What do we know and where are the Iowa-What do we know and where are the problemsproblems

Maternal deaths Maternal deaths Pre-eclampsia related practice problems Pre-eclampsia related practice problems

encountered during hospital visit reviewsencountered during hospital visit reviewsEclampsiaEclampsia

Iowa Maternal Deaths 1987-2010 Iowa Maternal Deaths 1987-2010 (Total/PET)(Total/PET)

0123456789

1987 1991 1995 1999 2003 2007

TotalPreeclampsia

Maternal MortalityMaternal Mortality

Iowa Maternal Deaths 1987-2010 Iowa Maternal Deaths 1987-2010 (Total/PET)(Total/PET)

Why the increased frequency since 2005?Why the increased frequency since 2005?? Increased incidence? Increased incidence

Increased obesity rates in IowaIncreased obesity rates in Iowa Co-morbiditiesCo-morbidities

? Increased severity? Increased severity? The normalization of deviance? The normalization of deviance

Medical Errors Related to Medical Errors Related to Preeclampsia ObservedPreeclampsia Observed

Did not consider diagnosisDid not consider diagnosis MisdiagnosedMisdiagnosed Maternal transfers to ER or neurology without Maternal transfers to ER or neurology without

OB notification or consultOB notification or consult No hourly I/O’sNo hourly I/O’s General diet on MgSO4General diet on MgSO4 Ambulating on MgSO4Ambulating on MgSO4 No MgSO4 administeredNo MgSO4 administered Lack of appreciation for the diseaseLack of appreciation for the disease

EclampsiaEclampsia

Dr. Zlatnik Perinatal Letter Vol. XXVI, no. 4Dr. Zlatnik Perinatal Letter Vol. XXVI, no. 4 22 cases reviewed22 cases reviewed

Potentially preventable in 10 casesPotentially preventable in 10 cases 3 patient errors (No prenatal care 2, left hospital AMA 1)3 patient errors (No prenatal care 2, left hospital AMA 1) 7 MD or RN errors7 MD or RN errors

Dr Hunter 2005-2010Dr Hunter 2005-2010 28 cases reviewed28 cases reviewed

Potentially preventable in 8 cases Potentially preventable in 8 cases (all MD/RN error)(all MD/RN error) Of 28 cases, 13 were postpartum (0 days to 14 days)Of 28 cases, 13 were postpartum (0 days to 14 days)

Educate physicians and other clinicians Educate physicians and other clinicians who care for women with underlying who care for women with underlying medical conditions about the additional medical conditions about the additional risks that could be imposed if pregnancy risks that could be imposed if pregnancy were added…were added…

Educate emergency room personnel about the possibility Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths or after she delivers and is discharged. These deaths may occur in another hospital, away from the women’s may occur in another hospital, away from the women’s usual prenatal or obstetric care givers. Knowledge of usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate pregnancy may affect the diagnosis or appropriate treatment.treatment. Example: Patient arrived at ER after seizures while pregnant. Example: Patient arrived at ER after seizures while pregnant.

No OB consult for 3 hoursNo OB consult for 3 hours

ConclusionsConclusions

Morbidity and Mortality due to Morbidity and Mortality due to pre-eclampsia/eclampsia/HELLP continues to be pre-eclampsia/eclampsia/HELLP continues to be a problem in Iowaa problem in Iowa

Access to care may become more of an issue if Access to care may become more of an issue if the rate of rural obstetrical unit closures continuethe rate of rural obstetrical unit closures continue

Standardization of protocols and simulation drills Standardization of protocols and simulation drills need to be incorporated into both the training need to be incorporated into both the training and competency maintenance of all personnel and competency maintenance of all personnel who provide OB care.who provide OB care.

#2: Elective Inductions

Induction

> 2 fold ↑ in rate since 1990:1990 9.5%2005 22.3%

Induction of labor (medical or elective) ↑ risk for Cesarean in nulliparous women

Luthy et al. 2004; Main et al. 2006 NCHS

Elective induction of Labor In Nulliparous Women

Almost doubles risk of Cesarean birth

Individual physician effect

Luthy et al. 2004

Cesarean Delivery for “Failed Induction”

Influenced by multiple factorsNot all factors are clinical

PIL “Physician Intolerance to Labor”Convenience?

CPD “Cesarean Prior to Dinner”

#1: Cesarean Sections for Stillbirths

First, Do No Harm

Total and primary cesarean rate an vaginal birth after previous cesarean (VBAC): United States, 1989-2004 Centers for Disease Control

Risks to the Mother

•Cesarean 1st birth is associated with a higher risk in subsequent pregnancies of:

•Placenta previa•Placental abruption•Uterine scar dehiscence•Uterine rupture in the 2nd pregnancy

Getahun et al. 2006, Gillian 2006, Lydon-Rochelle 2001

•There is a dose-response pattern in the risk of placenta previa, with increasing numbers of previous Cesareans increasing the risk•Getahun et al. 2006

In Women with Placenta Previa↑ Risk of Placenta Accreta

• With 1 prior Cesarean 10-25%• With ≥ 2 prior Cesareans >50%

Creasy & Resnik 2004; Silver, Landon, Rouse et al. 2006

•Prospective observational cohort•30,132 women who had CD without labor•19 academic centers over 4 years (1999-2002)

Obstet Gynecol June 2006;107:1226-32

Maternal MorbidityAssociated with Multiple Repeat Cesareans

•Placenta previa/accreta•Hysterectomy•Blood transfusion ≥4 units RBCs•Cystotomy•Bowel or ureteral injury•Ileus•Post-op ventilation (maternal)•Longer operative time•Increased days of hospitalization

Placenta Previa and Accretaby Number of Cesareans

In the 723 women with placenta previa…

Cesarean Risk for Accreta 1st 3% 2nd 11%

3rd 40% 4th 61% ≥5th 67%

Maternal mortalityVBAC 1.6/100,000Elective RCS, 5.6/100,000

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