The Pediatrix Clinical Data Warehouse and The 100,000 Babies Campaign—Tools for Quality Improvement in Neonatal Medicine

NICUPeri Practice

PICU

Ped Hospitalists

Ped Cardio Practice

Anesthesia Practice

Regional Office

Headquarters09.20.09

Southern CA

16 NICUs, 2 PICUs 2

OBX, 3 Hosp. Prgm.

Denver

10 NICUs, 1 OBX, 3 PICUs

1 Cardi & 2 Hosp. Prog.

South FL

7 NICUs, 2 PICUs

4 Cardi & 1 Hosp. Prog.

Puerto Rico

9 NICUs & 5 PICUs

Dallas-Ft. Worth

27 NICUs, 2 Cardi

3 OBX & 3 Hosp. Prog.Houston

11 NICUs & 1 OBX

Austin

10 NICUs, 1 Cardi

1 OBX & 2 Hosp. Prog.

San Antonio

9 NICUs, 1 OBX

& 1 Cardi

El Paso

5 NICUs

& 1 CardiPhoenix

4 NICUs, 1 Cardi

& 1 OBX

Oklahoma City

8 NICUs

Seattle/Tacoma

14 NICUs, 1 Cardi

1 PICU & 3 OBX

Chattanooga

3 NICUs

Las Vegas

6 NICUs, 2 PICUs,

& 2 Hosp. Prgm.

San Jose

3 NICUs, 1 OBX, 1 PICU

& 1 Hosp. Prog.

Tampa

6 NICUs, 1 Cardi

& 1 OBX

Kansas City

3 NICUs & 1 OBX

McAllen-Harlingen

6 NICUs

Atlanta

9 NICUs, 1 PICU

4 OBX & 1 Anesth Pr.

Charlotte

4 NICUs

Columbia

3 NICUs

Dayton

4 NICUs

Wash. DC

7 NICUs

1 Cardi &

1 Anesth Pr.

Greenville

3 NICUs

Knoxville

4 NICUs

Central FL

6 NICUs & 1 Cardi

San Francisco

4 NICUs

Akron

3 NICUs

Cleveland

3 NICUs

Nashville

9 NICUsPed ER

3

YTD 2010

> 275 Hospital NICUs

ADC 4,500-4,600

> 90,000 NICU admissions annually

Covering approximately 22% NICU patients nationally

EHR (BabySteps) present in approximately 90% of the NICUs

Active participation of NICUs in our CQI projects and outcomes metrics

4

YTD 2010

34 States – 221 core practices

137 Neonatology practices

22 MFM practices

18 Cardiology practices

16 PICU practices

10 Peds Hospitalists

7 Peds Services

5 OB Hospitalists

6 Other specialty services

CENTER FOR RESEARCH, EDUCATION, AND QUALITY (CREQ) HELPS PEDIATRIX“TAKE GREAT CARE OF THE PATIENT”

Discover Understand Teach

Empowered

providers

Educated

parentsBetter care

Implement

Better patient care You are probably not as good as you think you are

ABP Maintenance of Certification Part IV Need to demonstrate active participation in CQI every

5 years▪ Part 1 – Licensure

▪ Part 2 – Evidence of Life Long Learning

▪ Part 3 – Exam (every 10 years)

Research outcomes—new observations

Pediatrix Continuous Quality Improvement

A Model for Improving Neonatal Intensive Care

Implement

Pediatrix Continuous Quality Improvement

A Model for Improving Neonatal Intensive Care

Implement

Bedside Care BabySteps Clinical Data Warehouse

QualityStepsImplement

CQI ProjectsImproved Outcomes

Pediatrix Continuous Quality Improvement

A Model for Improving Neonatal Intensive Care

The Pediatrix model for

continuous quality

improvement starts at

the bedside

Physicians and

advanced practice

nurses provide bedside

care to thousands of

babies every day

Pediatrix Continuous Quality Improvement

A Model for Improving Neonatal Intensive Care

As daily care is provided, clinical data is entered

into the BabySteps clinical documentation

system to generate clinical notes

Key data is immediately available within the

system to guide clinical decision making:

• Growth charts, medication days, duration of

vascular catheters and endotracheal tubes, etc.

Most importantly, these multiple data points are automatically

extracted into the Clinical Data Warehouse, providing detailed

information on outcomes and key processes in that neonatal

intensive care unit

Pediatrix Continuous Quality Improvement

A Model for Improving Neonatal Intensive Care

Clinical Data Warehouse (CDW) is the largest

known database for neonatal medicine. More

than 700,000 patients and 13,000,000 patient

days currently exist in the CDW

More than 20% of the babies receiving NICU

care in the US are included in the CDW

Prior to extraction into the CDW, the clinical data undergoes an extensive

de-identification and validation process to establish compliance with

Common Rule and HIPAA regulations and ascertain data reliability

Personal identifiers are removed from the data, but the NICU location is

retained to enable each practice to view it’s own data and compare and

benchmark their results against the Pediatrix Network

Pediatrix Continuous Quality Improvement

How does data get from BabySteps to the CDW??

Clinical data

(medications, procedures,

diagnoses, cultures, lab

results, etc) is entered

into BabySteps

Key fields (563 data

points) are extracted and

imported into the CDW

database to generate

specific clinical reports

Pediatrix Continuous Quality Improvement

How does the CDW work?Multiple clinical

reports are available,

including mortality and

many morbidities.

Numerous reports are

available on nutrition,

medication use,

ventilator days, central

catheter use and

much more

Clinical reports can be filtered in various ways,

such as by birth weight, gestational age,

inborn/outborn status, region, and NICU volume

Clinical Data Warehouse evolution Most detailed database for neonatal medicine More than 700,000 pts. and 13,000,000 pt. days Forms the basis for many CQI projects at both corporate

and local levels Queried for information by NIH, FDA, NICHD Neonatal

Network Recognized by AAP and ABP for its scope

▪ Pediatrix selected as charter member of AAP/ABP Quality Improvement Committee

▪ CDW and QualitySteps will serve as basis for Board Maintenance of Certification Part IV for Pediatrix MDs (“Portfolio Sponsor”) of ABP – first (and only) group to date granted this privilege

Pediatrix Continuous Quality Improvement

CDW Report Example: Breast Milk in the First Week

Breast Milk in the First Week

Gestation: All; Birth Weight: 501 - 1500g

Admit Group: Inborn; Network: High Volume PDX Sites

Report Name:

Filters:

Pediatrix Network

33rd-66th Percentile

(blue area)

Specific NICU’s

Breast Milk Rate

(green line)

Pediatrix Continuous Quality Improvement

QualitySteps: CQI Project Documentation Tool

Data from the CDW is

used to determine what

areas are in need of

improvement

QualitySteps provides

resources and guidance

for the development and

implementation of CQI

projects

QualitySteps serves as a CQI project management tool. Project goals, teams,

progress notes, additional data, and more are collected and stored on the

system, enabling multidisciplinary teams to collaborate efficiently on projects

The Run Chart will have all the data points you documented along with annotations.

By programming an appropriate series of questions, QualityStepshas the flexibility to be used in any specialty of medicine

Currently developing anesthesiology module as seen here

Pediatrix Continuous Quality Improvement

Implementing CQI Projects

During project

implementation, data from

BabySteps continuously

feeds into the CDW, with a

one week time lag

This provides the essential

data feedback needed for

ongoing improvement

Implement

Pediatrix Continuous Quality Improvement

Improved Outcomes

The information that begins

at the bedside is

transformed into in

improvements that come

back to the bedside

The end result: improved

patient outcomes

Activity Reports: Types of discharges (home, transfer, in-hospital, etc.); Admissions by GA; Admissions by BW; Length of stay; Average daily census; Type of delivery

Morbidity and Mortality Reports: Mortality; Survival, BPD at 28 days of life, BPD at 36 weeks’ gestational age, IVH, Late-onset sepsis, NEC, PDA, PVL, RDS and surfactant use, ROP, Severe IVH, Severe ROP, Pneumothorax; Catheter-related blood stream infection (rate/1000d)

Management Reports: Maximal ventilator support, Median ventilator Days, Temperature from DR to NICU, Types of lines inserted and duration of use, Median daily weight gain during the first 28 days; Hepatitis B immunization rates; Infants breast feeding during hospitalization; Per cent of infants breast feeding at discharge; Breast milk in the first week of life; TPN Use Day 1; DR surfactant use; Bilirubin reports; Discharge Needs (oxygen, monitoring, NG feeding)

Infection reports: Percent of NICU admissions treated with antibiotics; Median days of antibiotic therapy with negative cultures; Use of cefotaxime; Percent of patients treated without cultures; Nosocomial/ line sepsis—infections/ 1000 catheter days

Medication reports: All common medications in the NICU, frequency of use Summary Dashboard Report and Network Trends Reports Practice Trend Report

o Dashboard report for assessing the outcomes of any NICU during a defined period of time.

o Performance Compared to 33-66% for PDX Medical Group (blue bar)

Pediatrix Continuous Quality Improvement

Examples of Improved Outcomes: Sample Pediatrix

Network Trends

0.0

5.0

10.0

15.0

2004 2005 2006 2007 20082009 2010

33

50

66 0.0%5.0%

10.0%15.0%20.0%25.0%

33

50

66

35.50

36.00

36.50

37.00

33

50

66

0.0%20.0%40.0%60.0%80.0%

33

50

66

Catheter Associated Infections Chronic Lung Disease

Admission Temperatures Breast Milk Use

Data show for babies 501-1500 gms, “33, 50, 66” represent the Pediatrix Network percentiles

Report still in

validation stage,

hospital names

covered until

data can be

verified

Lowest 10 performers

Copyright , MEDNAX PSO 2010

Top 10 performers

Denial: These data can’t be right!

Anger: Why are they picking on me? Don’t I have enough

to do already?

Bargaining: My patients must be sicker than everyone

else’s, my NICU is different, I don’t agree with those data

definitions, etc.

Depression: I can’t do anything about it anyway….

Acceptance: OK…what can I do to improve the outcomes

in my NICU?

Courtesy of Dan Ellsbury, MD, Pediatrix Medical Group

CQI Quality Summits (3x annually) Three day CQI experience

▪ Led by Dan Ellsbury, MD, and Robert Ursprung, MD▪ One session held in conjunction with NEO Conference

(Feb.)▪ Upcoming Meeting in Dallas (Nov.)

PDX physicians expected to attend one session every two years

CQI efforts underway in MFM, Pediatric Cardiology, Anesthesiology▪ Anesthesiology practices to partner in this process

using QualitySteps program

No other group has more than 4 approved projects on ABP web site

Comprehensive Oxygen Management for the Prevention of ROP

Evidence-Based Principles of ROP Toolkit:

•Avoid hyperoxia

•Avoid large oxygen saturation fluctuations

•Educate all NICU staff and parents about ROP

•Provide mechanisms to assess actual implementation

“COMP-ROP”

27.5%

19%

18%

9%

12 g/ day

15.5 g/day

5.8%

6.4%

3.5%

Toolkit introduced

Common use of antibiotics:Infant with suspected sepsis(Most common NICU admission)

Hypothesis:Ampicillin-Gentamicin andAmpicillin-Cefotaxime areequivalent approaches…or are they?Evaluated > 128,000 infants

Clark et al., Pediatrics 2006; 117:67

23 to 26 27 to 30 31 to 34 35 to 38 39 to 42

Adjusted Odds Ratio 1.14554672 1.61184607 1.78188665 1.87900805 1.43224032

0

0.5

1

1.5

2

2.5

Adjusted Odds Ratio

Clark et al., Pediatrics 2006; 117:67

Wks. gestation

N > 128,000

Odds

Ratio

Example: Cefotaxime UseAfter dissemination of data showing fungal infection and increased mortality with

cefotaxime use, network use of cefotaxime dropped markedly

Fungal infection

and cefotaxime

Increased mortality

Medication Use, Pediatrix NetworkInfants <1000 grams

0

5

10

15

20

25

30

35

40

2003 2004 2005 2006 2007 2008

Cefotaxime

H2-blockers

Metoclopramide

Epo

Spironolactone

Percent of babies receiving the med

Singh BS, Clark RH,

Powers RJ, and Spitzer AR.

J. Perinatol. 2009; 29:497

Ibuprofen-Indomethacin Comparison Inhaled Nitric Oxide in Premies Neonatal Renal Insufficiency

March 2010 Clinics in Perinatology on CQI, edited by Ellsbury and Spitzer

Sankar M et al., submitted

Clark RH, et al. J. Perinatol., 2010; 30: 800-804

Significant numbers of premature infants have renal problems in the neonatal period

Categorization of these issues is variable from NICU to NICU, yet it is very important to establish clear criteria for renal failure

Mean LOS decrease of ~2 days

16 d

14 d

Olsen et al., Pediatrics 2010;125:e214–e224

Significant Differences from Lubchenko growth charts, done in Denver more than 40 years ago Problems: few survivors

<30 weeks gestation, altitude at Denver

To be distributed nationally by Abbott Nutrition

Pediatrics 2010;125:e214–e224

Dan Ellsbury MDDirector, Continuous Quality ImprovementCenter for Research and EducationPediatrix Medical Group

Perform an innovative, comprehensive system redesign of critical practices and procedures in neonatal intensive care

Over a two year period, redesign the system of care provided to 100,000 NICU babies within Pediatrix Medical Group

Build a reusable national infrastructure for continuous quality improvement in neonatal intensive care

Extend campaign to include academic centers

The problem is not the clinician, it is the complex system in which the clinician practices (Institute of Medicine)

The most efficient and productive way to improve outcomes is by re-engineering care to produce optimal outcomes Imploring clinicians to “try harder” is not productive: we must fix the system,

not fight the system

Re-engineering requires accurate, detailed data BabySteps Data Warehouse and QualitySteps for data

collection

Enhance Nutrition: Maximize breast milk use, use a standardized feeding protocol, and provide

early protein

Improve Medication Use: Optimize use of antenatal steroids, caffeine, and surfactant. Optimize

antibiotic choice and exposure, decrease cephalosporin use, H-2 blocker use, and postnatal steroid use, standardize oxygen management

Minimize Mechanical Ventilation: Minimize ventilator duration, Optimize nasal CPAP technique

Optimize Central Line Use: Standardized central line insertion process, standardized central line

maintenance process, and minimize central line duration

Reduce Suboptimal Admission Temperatures: Standardize initial thermal management

Catheter Associated Bloodstream Infection (CABSI) 501-1500 gm, all PDX sites.

2010 is a partial year

CABSI Toolkit

100000 Babies

Breast Milk in the First Week501-1500 gm, all PDX sites.

2010 is a partial year

Admit Temperature (Inborns)501-1500 gm, all PDX sites.

2010 is a partial year

CLD at 28 Days501-1500 gm, all PDX sites.

2010 is a partial year

0

5

10

15

20

25

2004 2005 2006 2007 2008 2009 2010

Cefotaxime

Metoclopramide

H2 Blockers

Postnatal Steroids