Working together for healthier mothers and babies 2015 WV Hospital Guidelines and Self Assessments.

Working together for healthier mothers and babies

2015 WV Hospital Guidelines and Self Assessments


AGENDA

Finalize recommendations of standards for a multi-tiered system of maternal/neonatal levels of care including quality improvement and review measures

Develop the action plan for implementing maternal risk-appropriate care standards

West Virginia Perinatal PartnershipWorking together for

healthier mothers and babies

Differences in Levels Between 2007 2012 Perinatal Care Guideline Editions

2007 Nomenclature Old Perinatal Partnership Guidelines

2012 Nomenclature New Guidelines from ACOG AAP

Level I OBSTETRIC: Basic NBN: Level I Well Newborn Nursery

Level IIA & Level IIB OBSTETRIC: Specialty NBN: Level II Special Care Nursery

Level III *Although 2007 AAP ACOG guidelines gave three levels of Level III, the WVPP guidelines committee chose to have one level of Level III

OBSTETRIC: Subspecialty NBN: Level III Neonatal Intensive Care Unit

Level IV No Level IV in old guidelines

OBSTETRIC: Regional subspecialty perinatal health center NBN: Level IV regional neonatal intensive care unit



New Guidelines from ACOG & AAP

LEVEL I LEVEL I

OB: BASIC NBN: WELL NEWBORN NURSERY

Maternal: Surveillance and care of all patients admitted to the obstetric service, with an established triage system for identifying high risk patients who should be transferred to a facility that ‐provides specialty or subspecialty care. Proper detection and initial care of unanticipated maternal‐fetal problems that occur during labor and deliveryCapability to begin an emergency cesarean delivery within an interval based on the timing that best incorporates maternal and fetal risks and benefits Availability of appropriate anesthesia, radiology, ultrasound, laboratory, and blood bank services on a 24 hour basis ‐Care of postpartum conditions. Adequate nursery facilities and support for stabilization of small or ill neonates before transfer to a specialty or subspecialty facility Consultation and transfer arrangements Accommodations and policies that allows families, including their other children, to be together in the hospital following the birth of an infant Data collection, storage, and retrieval Quality improvement programs, including efforts to maximize patient safety

Neonatal Provide neonatal resuscitation at every delivery Evaluate and provide postnatal care to stable term newborn infants Stabilize and provide care for infants born 35–37 wk gestation who remain physiologically stable Stabilize newborn infants who are ill and those born at <35 wk gestation until transfer to a higher level of care



LEVEL IIOB: SPECIALTY NBN: SPECIAL CARE NURSERY

All Level I capabilities plus: • Provide care for infants born ≥32 wk gestation and weighing ≥1500 g

who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis Pediatric hospitalists, neonatologist, and neonatal nurse practitioners.

• Provide care for infants convalescing after intensive care • Provide mechanical ventilation for brief duration (<24 h) or

continuous positive airway pressure or both • Stabilize infants born before 32 wk gestation and weighing less than

1500 g until transfer to a neonatal intensive care facility



Level III

OB: Subspecialty NBN: Level III Neonatal Intensive Care Unit

All Level II capabilities plus: • Provide comprehensive care for infants born before 32 wks gestation

and weighing less than 1500 g and infants born at all gestational ages and birth weights with critical illness

• Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists

• Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide

• Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI and echocardiography



Level IV

OB: Regional subspecialty perinatal health center NBN: Level IV regional neonatal intensive care unit

All Level III capabilities plus: • Located within an institution with the capability to

provide surgical repair of complex congenital or acquired conditions

• Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site

• Facilitate transport and provide outreach education



Need for risk appropriate care

Hospital specific issues

»Regionalization

»Differences exist in services and level of care

»Need to focus on “quality” vs. “safety” and “best practices” vs. “regulatory” to be successful with obstetricians



Pregnancy, Labor, Delivery Care Needs

Strengthen communication and transfer agreements Utilize One Call center to identify available hospitals,

providers, and teams to facilitate the transport Address physician referral patterns Financial incentives for both transferring and accepting

physicians/hospitals Develop definitions on how to operationalize maternal

transport and maternal levels of care Quality improvement Decrease number of primary c/sections Education for mother regarding risk status Education for physicians to recognize problem Increased assessment of specific risk factors in LD that

trigger appropriate consultation and care



Barriers to care

• Geographics/politics

• Uneven level of care when policies are inconsistent in what types of patients hospitals will take

• Lack of nursing personnel to cover the care of patients who are left on the unit when one of their own needs to go on the transport

• Conflicts in plan of care b/t intensivist and obstetrician

• Low-volume hospital lack expertise in dealing with complications



Barriers• Obstetricians resistant to obtaining assistance and

others are resistant to reach out

• Reimbursement to hospital and physicians

• Shortage of perinatologists, specialists in general

• Uncertainty regarding health care reform

• Obstetricians don’t feel transport is necessary

• Hospitals want to keep mom for reimbursement purposes, feel they have other resources if necessary including internist and surgeon



Neonatal Care

Risk-appropriate neonatal care

– Infants born outside a level III hospital have a significantly increased likelihood of neonatal death and chronic lung disease (Chung et al., 2009; Laswell et al., 2010)

– Maternal sociodemographic and medical conditions increase the risk of poor neonatal outcome including age, race, acculturation level, gravida, psychiatric disorders, and hypertension

(DeLange et al., 2008; Jones & Bond, 1999; Shapiro-Mendoza et al., 2008)



Neonatal Care

Adequacy of prenatal care and distance from a regional center increased the risk for outborn deliveries (Attar et al., 2006)

Mortality decreases with improved access to neonatal resources. (Merlo et al., 2005)

Odds of mortality were highest in lower-level, lower-volume units (Chung et al., 2010; Phibbs et al., 2007)



Neonatal Levels of CareDefinitions and criteria for neonatal levels of care and mechanisms for measuring and improving neonatal risk-appropriate care vary widely across the states

– 33/50 states used some sort of designation to describe the levels of neonatal services available

(Blackmon, Barfield, & Stark, 2009)

– 7 states have mechanisms of measurement for risk-appropriate care, but vary in level definition, clinical capacity, and population served

(Nowakowski et al., 2010)



Maternal CareEvidence to support maternal levels of care to improve outcomes are few

– Maternal mortality in women who experience a peripartum hysterectomy at high-volume hospitals was 71% lower compared with low-volume hospitals

(Wright et al., 2010)

– Availability of obstetric interventions, reduced transport time, and reduced financial barriers decreased overall maternal mortality rates (Fournier et al., 2009)



Perinatal Care WV

Wide variability in

– Policies

– Training/education

– Consultation

– Joint review of outcome data



Perinatal Care Collaboratives

Websites of all 50 states and DC reviewed

– 17 states – no information found

– 12 states – efforts noted, nothing concrete

– 14 states – basic information

– 7 states – more developed guidelines




Patient oriented criteria and materials

– Brochure for patients regarding risk appropriate facility and provider recommendations (Arkansas)

Provider oriented criteria and materials

– Medical criteria for consultation described (IN, TN)

– Transport/consultation requirements (MD, TN, AZ, AK)

– Tiered system with financial incentives for rural providers to partner with MFM (Oklahoma)




Facility orientated criteria and materials

– Reported levels of maternal care (IN, TN)

– Levels of care segmented into 3-6 groupings based on regionalization, services, patients, provider info and volume (AZ, IN, MD, MN, NY, TN)

– Regional Cooperation Agreements required (AZ, NY)

– Air and ground transport recommendations spelled out (AZ, MD)

– QI efforts mandated (FL, IL, NJ)

– Certificate of Need used (MS)




Funding Issues

– Regionalization funded by birth certificate tax (AZ)

– Regionalization funded by calculations of number of facilities and responsibilities (MI)



Perinatal Issues Statewide

History of perinatal regionalization described (MN)

Seven states with comprehensive information that might be helpful (AZ, AK, CA, GA, IN, NY, TN)


Molly Scarborough McMillion RN, BSN, IBCLC, CCE, CPSTSpecial Projects ConsultantWV Perinatal Partnership

Office 304.793.6584 Cell [email protected]

www.wvperinatal.org Coordinated by the West Virginia Higher

Education Policy Commission, Division of Health Sciences

http://www.wvperinatal.org/

Working together for healthier mothers and babies 2015 WV Hospital Guidelines and Self Assessments.

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