Perinatal Quality Improvement Efforts in Florida
William M. Sappenfield, MD, MPHFPQC Co-Director
Lawton and Rhea Chiles Center for Healthy Mothers and BabiesUniversity of South Florida College of Public Health
2
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.
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 improvementProvide advice on implementing change
Values: Voluntary, Population-based, Data-driven, Evidence-based, Value-added
4
Funders/PartnersFlorida Chapter March of Dimes Florida Department of Health Agency for Health Care Administration/HMA Florida Hospital Association Florida Blue
American Congress of Obstetricians and Gynecologists (ACOG) District XIIFlorida Society of Neonatologists/FL Chapter of American Academy of PediatricsFlorida Council of Nurse MidwivesFL Section Association of Women’s, Health, Obstetric, and Neonatal Nurses (AWHONN)Florida Association of Healthy Start Coalitions
Partners
5
TimelineMar 2009 Proposed starting the FPQCDec 2009 USF Chiles Center identified as state leadJun 2010 FPQC launched at State SummitJan 2011 1st maternal initiative—Early Elective Deliveries (EED)Oct 2011 1st infant initiative—Neonatal Catheter Associated Blood Stream Infections (NCABSI) Phase IJun 2012 Expanded—EED initiative: FHA HEN hospitalsAug 2012 Expanded—NCABSI Phase II Jul 2013 2nd infant initiative—Golden Hour Part IAug 2013 2nd maternal initiative—Obstetric Hemorrhage Initiative (OHI)
7
Florida “Big 5” Pilot Hospitals Reduction of NMI Deliveries <39
Weeks by Delivery Type 2011
0%
10%
20%
30%
40%
50%
60%
70%
80%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
CombinedInductionsCesareans
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
2006 2007 2008 2009 2010 2011 2012 20130%
5%
10%
15%
20%
25%
30%
9
Early Elective Delivery Rates (PC-01)Southeast U.S., Jan-Sept 2013, CMS Hospital Compare
NCSCNMLAFLTNARTXGAOKKYAL
MS
0 5 10 15 20 25333
5666
788
914
22
PC-01 Percentage
10
Early Elective Delivery RatesPercent of Florida Delivery Hospitals by Jan-Sept, 2013
33%
33%
19%
15%
0%1-5%5-10%>10%
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 ConsultationsE-BulletinsProvider Education PacketsEED Focused NewsletterSpecial EED VideoConsumer campaigns through Healthy Start Coalitions
13
EED Video:“We Just Haven’t Gone Far
Enough”
Robert W. Yelverton, MDChair, District XII ACOG
Karen E. Harris, MD, MPHVice-Chair, District XII ACOG
Available on our EED page at FPQC.org
Banner OpportunityMany 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
14
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 reductionNational collaboratives combined had a baseline of 2.51 infections per 1000 line daysBaseline rate in Florida from NHSN data was 2.96 infections per 1000 line days
16
Neonatal Catheter Associated Blood Stream Infections
NCABSI/FPQC—Dec. 2011 to Aug. 2013
Expanded from 9 states in Phase I to 13 states in Phase II (FL 58.8% Reduction)
17
Phase I Phase II
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.
18
Obstetric Hemorrhage Initiative
Objective: Improved outcomes in morbidity and mortality related to obstetric hemorrhage, including hysterectomies and massive transfusions
Meets new national guidelines for OB patient safety
20
Obstetric hemorrhage is a leading cause of maternal mortality in Florida
Key OHI QI ElementsReadiness• Develop an Obstetric Hemorrhage Protocol• Develop a Massive Transfusion Protocol • Construct an OB Hemorrhage Cart• Ensure Availability of Medications and EquipmentRecognition• Antepartum Risk Assessment• Quantification of Blood Loss• Active Management of the Third Stage of LaborResponse• Perform Interdisciplinary Hemorrhage Drills• Debrief after OB Hemorrhage Events
21
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 loss22
Project Data: Risk Assessment
24
Percent of hospitals that assessed birthing women for risk of obstetric hemorrhage upon
admission
Baselin
e
Dece...
Janu
ary
Febr..
.
Mar
chApr
ilM
ay0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
71%
19%
15%
16%
14%
66% 75 to 100% of women assessed1 to 74% of women assessedNo women assessed
Quantification of Blood Loss
25
Percent of deliveries in all hospitals for which blood loss
was quantified for vaginal deliveries
Baseline December January February March April May0%
5%
10%
15%
20%
25%
30%
35%
The Golden Hour
Transition from fetal neonatal lifeMany 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
27
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
28
Delivery Room Management
Goal is to enhance teamwork and implement evidence-based practices on:
Teamwork ThermoregulationOxygen administration Delayed cord clamping
Hospital baseline data indicated major need in the areas of:
Assignment of delivery room team member rolesDelayed cord clamping (near 0%)
29
Golden Hour Pilot Hospitals
ACADEMICTGH/USF
ACH/Johns Hopkins
30
NON-ACADEMICSt. Joseph’s Hospital
Baptist Hospital MiamiFlorida Hospital TampaSouth Miami HospitalSarasota Memorial
HospitalBroward Health Medical
CenterPlantation General
Hospital
Initiative-Wide Data
31
Delayed Umbilical Cord Clamping
July
Augus
t
Sept
embe
r
Octob
er
Nov
embe
r
Decem
ber
Janu
ary
Febru
ary
Mar
chApr
ilM
ay0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20%12%
21%27%
34%
42% 39%
73%
53%58%
54%51%
66%71%
All hospitals Original 6 hospitals Goal
Month of Birth
Perc
en
t ach
ieve
d
Indicator Project
Partnered with DOH and AHCA to access existing linked birth certificates and hospital discharge dataRecruited 7 hospital teams and 8 state organizations to consult on Florida’s pilot indicators and reportsDevelop both health care and data quality reports Consult national expertsTest the use of pilot reports in pilot hospitalsUse pilot efforts and plans to promote Florida development
33
Early Elective DeliveriesSample Hospital QI Box Plot
34
2006 2007 2008 2009 2010 2011 20120%
5%
10%
15%
20%
25%
18.7%17.8%
14.4%16.6%
13.3% 11.3%
17.6%
Year
Perc
enta
ge o
f Ear
ly E
lecti
ve D
eliv
erie
s
Percentage of Early Term Deliveries
Hospital X, 2004-2011
35
2004 2005 2006 2007 2008 2009 2010 20110%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%Non-medically Indicated Early-term DeliveryEarly-term Spontaneous DeliveryEarly-term Medically Indicated Delivery
Year
Perc
enta
ge o
f ear
ly-te
rm d
eliv
erie
s
Antenatal Corticosteroid Treatment (ACT)
Includes FL, CA, IL, NY & TXFocus on ACOG & Joint Commission measure (PC-03)Also focus on the “sweet spot”Launch in Fall 2015
37
Antenatal Steroid Use for Infants 24-33 Weeks in
19 of Florida’s Vermont Oxford Network (VON) Hospitals, 2012
Se-ries1
0
10
20
30
40
50
60
70
80
90
100
Median = 77
38
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
41Source: FL Vital Records, Dec 2013
1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109 1130%
10%
20%
30%
40%
50%
60%
70%
80%
41
Range: 6.6—59.5%Median: 31.3%Mean: 31.8%
National Target =23.9%
21% of FL hospitals meet national target
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: [email protected]
Get connected on Facebook: www.facebook.com/FPQCatUSF
42
Top Related