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Perinatal Quality:Making NC the Best Place tobe Born!
SIVB II Learning Session 2October 9, 2012
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What is PQCNC?
Perinatal Quality Collaborative of North Carolina
A community of organizations,agencies and individuals
committed to making NorthCarolina the best place to be
born .
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PQCNC Mission
Promote high value perinatal careSpread best practice and reduce variationPartner with families and patientsOptimize resources
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PQCNC Table
Family MembersPerinatal providers
Doctors (OB, MFM, Neos, Peds,FP)
Nurses (Peds, NICU, & OB) Midwives
Hospital AdministratorsPayers (Medicaid, BCBSNC)State Legislators
DPHState Hospital AssociationOthers (Malpractice insurers)
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PQCNC Initiatives
39 Weeks
CABSI
Exclusive Human Milk (EHM) NICU
EHM Well Baby
Support for Intended Vaginal Birth (SIVB)
NCABSI
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39 Week Project Supporting Intended Vaginal Birth (SIVB)
Maternal Quality Initiatives
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Decrease of
43%
39 Weeks Project
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Carolinas Medical CenterPineville Presbyterian HospitalMainGaston Memorial Presbyterian HospitalMatthews
Granville Health System Forsyth Medical CenterCape Fear Valley Medical Center Mission Hospital
Carolinas Medical Center Nash General HospitalOnslow Memorial Hospital New Hanover Regional Medical CenterCarolinas Medical Center NorthEast Pitt County Memorial Hospital
Carteret General Hospital Presbyterian Hospital Huntersville
Catawba Valley Medical Center Rex HealthCentral Carolina Hospital Stanly Regional Medical CenterColumbus Regional Healthcare System University of North Carolina HospitalsFirstHealth Moore Regional Hospital Forsyth Medical Center
SIVB: Supporting Intended Vaginal Birth
Improve the rate of vaginal birth among first-time mothers PQCNC's goal was to increase the rate of vaginal birth in this
population by 25% by January 2012.
Each participating hospital set its own site-specific goal.
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SIVB in North Carolina
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Data on forty patients were collected from each hospital
Inclusion Criteria:Nulliparous
Singleton PregnancyVertex
37 weeks or more
Live fetus
Exclusion Criteria:
Placenta previaVaso previa
Previous MyomectomyCord Prolapse
Active Herpes Infection
HIV (with viral load >1000 copies)Diabetic with EFW > 4500 grams
Non-Diabetic with EFW > 5000 grams
*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries
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CESAREAN RISK FACTORS
Diabetes (any type) IUGR Maternal age greater than/equal to 35
Hypertensive disease Macrosomia (EFW greater than 4000g) Obesity
5.45%
2.52%
4.02%
11.48%
0.86%
11.33%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
Diabetes IUGR AMA HTN Macrosomia Obese
RiskFactor
Prevalence
28.8% of all patients had at least one risk factor
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25.11%23.99%24.12%23.67%
22.16%21.98%22.80%21.02%20.37%19.05%
21.26%23.54%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
OVERALL PRIMARY C/S RATE OVER TIMEALL FACILITIES
OverallC/S
GOAL=18.83%
In nine months we saw a 15% increase in the likelihood of first-timemothers delivering vaginally in 24 participating centers
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25.11%
23.99% 24.12% 23.67%22.16% 21.98%
22.80%
21.02%20.37%
19.11%
21.29%
23.95%
20.25%
18.23%19.32%
18.66% 19.06% 19.19% 18.47% 18.27%16.95% 16.59%
18.83%
20.74%
38.01%
36.34%
34.62% 34.07%
30.20% 29.74%
35.06%
28.00%
30.41%
26.42%27.62%
32.60%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
INITIATIVE-WIDE CESAREAN RATESOVERALLC/SRATE
C/SRATE-NOC/SRISKFACTORS
C/SRATE-1+C/SRISKFACTORS
Linear(OVERALLC/SRATE)
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23.9%
21.7%
18.5%
23.0%
25.4%
17.4%
26.8%
31.2%
24.9%23.5%
20.8%
24.7%
27.6%
16.9%
14.7%
23.1%23.9%
23.1%
16.5%
25.0%
21.6%
23.4%
18.8%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
110 200 210 300 320 330 350 380 390 391 392 400 420 430 490 500 510 530 540 640 650 660 680
AVERAGE C/S RATE BY FACILITY:Baseline - December
Averagefacility
c/srate
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48.77%48.57%47.77%
51.23%49.78%
50.80%52.26%51.30%
53.40%
50.00%49.88%
52.78%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
%o
fpaPents
inlabor
% OF PATIENTS IN LABOR AT ADMISSION
%ofptsin
laborat
CESAREAN RATE FOR PTSNOT IN LABOR AT
ADMISSION:31.70%
CESAREAN RATE FOR PTSIN LABOR AT ADMISSION:
14.61%
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BOTTOM LINE!
Cesarean rate for patients in labor atadmission
0-3 cm 18.38%
4+ cm 10.86%
Cesarean rate for induction patients
0-3 cm 31.34%
4+ cm 28.42%
Labor is Important
*PhaseIinvolves23hospitalsandhascollecteddataonmorethan10,000deliveries
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SIVB-2 Data
A focus on Labor!
*Phase 2 involves 31 hospitals and has collected data on more than 6,000 deliveries
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GOAL=18.83%
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15%$
33%$
24%$
0%$
5%$
10%$
15%$
20%$
25%$
30%$
35%$
In$Labor$
NOT$in$Labor$
Total$
Nulliparous*C,sec/on*Rate*,*Total*
N$=$3192$ N$=$3034$ N$=$6226$
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This is less prominent than SIVB I results
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Drilling down on the data!
Obesity
Diabetes
Hypertension
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Mothers may have more than one risk factor
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BMI
30 OR last maternal weight
200 lbs
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BMI 30 OR last maternal weight 200 lbs
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Includes gestational diabetes well orpoorly controlled; preexisting Type II or Type 1 diabetes
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Includes chronic hypertension, gestational hypertension,preeclampsia, eclampsia, HELLP syndrome
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Many mothers carry more than one risk factor
Obesity is a poor indication for induction of labor
Very conservativeestimate
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BOTTOM LINE!
Cesarean rate for patients in labor atadmission
0-3 cm 18.38%
4+ cm 10.86%
Cesarean rate for induction patients
0-3 cm 31.34%
4+ cm 28.42%
Labor is Important
*PhaseIinvolves23hospitalsandhascollecteddataonmorethan10,000deliveries
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What do we do next?
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1. Do you have a physician or team of physicianchampions?
2. Do you have adequate time, space, and/orexpertise to diagnosis labor?
3. Are your patients educated with respect to theimportance of labor?
4. Do you have multiple mechanisms to support apatients labor?5. Does your institution track vaginal delivery rate
and report it back to the providers specifically innulliparous patients?
6. Do you have an induction protocol forNulliparous patients?7. Do you Track and review elective nulliparous
inductions less than 41 wk?
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Faces of PQCNC
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Thankyou!
Quesons?
James deVente MD/PhDAssociate Professor, Dept. OB/Gyn
Medical Director of Labor and DeliveryEast Carolina University
Brody School of MedicinePager: 252-413-4153 (please page me)