PERINATAL QUALITY IMPROVEMENT EFFORTS

IN FLORIDAEQRO Meeting

November 17, 2015

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VisionAll of Florida’s mothers and infants will have

the best health outcomes possible through receiving high quality evidence-based perinatal care. Missio

nAdvance perinatal health care quality and patient safety for all of Florida’s mothers and infants through the collaboration of FPQC stakeholders in the development of joint quality improvement initiatives, the advancement of data-driven best practices and the promotion of education and training.

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Funders/PartnersFlorida Chapter March of Dimes Florida Department of Health Agency for Health Care Administration/HMA Florida Hospital Association Florida Blue

ACOG District XII--ObstetriciansFlorida Society of Neonatologists/FCAAPFlorida Council of Nurse MidwivesAWHONN--NursesFlorida Association of Healthy Start Coalitions

Partners

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FPQC Initiatives to Date

2011 2012 2013 2014 2015Early Elective DeliveryNeonatal Catheter InfectionsObstetric HemorrhageGolden HourAntenatal SteriodsHypertension in PregnancyBreast Milk in the NICUHospital Perinatal QI Indicators

EARLY ELECTIVE DELIVERIES (EED)

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Non-Medically Indicated (NMI) Deliveries Less than 39 Weeks

Gestation

Delivery prior to 39 weeks without medical indication is linked to neonatal morbidities and mortalities with no benefit to mother or infant

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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"

FPQC EffortsBig 5 Project: 6 Florida hospitals, year-long pilotGrand Rounds Literature summaries of EED research (e-bulletins)Individual hospital consultationsProvider education packets and materials for hospitalsRegular data analysis of state EED ratesResource Newsletter and Video with ACOG ChairsLetters to CEOs of high rate hospitalsMarch of Dimes and ACOG District XII Hospital Recognition BannersPromotion of initiative at conferences and QI symposia

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Early Elective Delivery Rates (PC-01)Southeast U.S., October 2013 – September 2014

CMS Hospital Compare

NCSCGATNNMFLTXLAAROKALKYMS

0 2 4 6 8 10 12PC-01 Percentage

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Early Elective Delivery RatesPercent of Florida Delivery Hospitals for October 2013 – September

2014 (n=103)

32%

44%

15%

10%

0%1-5%6-10%>10%

Hospital EED Rate

Source: Centers for Medicare and Medicaid Services: Hospital Compare July 28, 2015; PC-01 Early Elective Delivery

65 Florida hospitals have qualified for a banner and are listed on FPQC website

• Adequate Hard Stop policy• Rate <5% for at least 6 months

Banner Hospitals

80 total applicants

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Neonatal Catheter Associated Blood Stream Infections(NCABSI)

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Where We’ve Come

Based on current 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.

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Golden Hour:Delivery Room Management

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Golden Hour:Delivery Room Management

Objective: Improved outcomes in very low birth weight babies ≤30 6/7 weeks gestational age OR ≤1500g birth weightInterventions in the first hour may affect:

Short term morbidities (e.g. thermoregulation, hypoglycemia)Long term morbidities (e.g. CLD, ROP, IVH)Mortality 15

Golden Hour Pilot Hospitals

ACADEMICTGH/USF

ACH/Johns Hopkins

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NON-ACADEMICSt. Joseph’s Hospital

Baptist Hospital MiamiFlorida Hospital TampaSouth Miami HospitalSarasota Memorial

HospitalBroward Health Medical

CenterPlantation General

Hospital

Initiative-Wide Data

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Delayed Umbilical Cord Clamping

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

57%48%

22%

11%

23%29%

34%44%

52%

73%

56%

70%74%

68%

58%63%66%

76%86%

58%

All hospitals Original 6 hospitals Goal

Month of Birth

Perc

en

t ach

ieve

d

Obstetric Hemorrhage Initiative

(OHI)

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OHI31 Florida hospitals and 4 North Carolina hospitals

Objective: Decrease short and long-term morbidity and mortality related to maternal hemorrhage.

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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

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Florida OHI Initiative HospitalsRisk Assessment on Admission

Percent of Hospitals Assessing for Risk of Obstetric Hemorrhage at Birth Admission and documenting score in clinical records

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Baselin

e

Decem

ber

Janu

ary ...

Febru

ary

Mar

chApr

ilM

ayJu

ne July

Augus

t

Septe

mbe

r

Octob

er

Nov

embe

r

Decem

ber

Janu

ary ...

Febru

ary

Mar

chApr

il0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

70%

46%40%

26%20%

26%18%20%15%15%10%12%9% 9%10%10%10% 8%

18%

20%29%

31%31%20%

18%14%21%12%

13%18%19%

13%19%14%17%

17%

11%

34%31%43%

49%54%

65%66%64%74%77%

70%72%78%

71%76%72% 75%

Assessment for Risk of Obstetric Hemorrhage

75 to 100% of women assessed

1 to 74% of women assessed

No women assessed

Florida OHI Initiative HospitalsQuantification of Blood Loss

Percent of Vaginal Deliveries where blood loss was quantified (chart audit)

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Basel

ine

Decem

ber

Jan-

14

Febru

ary

Mar

chApr

ilM

ayJu

ne July

Augus

t

Septe

mbe

r

Oct

ober

Nov

embe

r

Decem

ber

Jan-

15

Febru

ary

Mar

chApr

il0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

4%8% 9%

14%21%22%

32%32%38%

44%49%47%45%46%

52%55%61%62%

Month

Perc

en

t ach

ieved

PROPOSED PROJECT: PRIMARY CESAREAN SECTION REDUCTION

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Low-Risk First-Birth (Nulliparous Term

Singleton Vertex) Primary Cesarean Rate, 116 FL

Hospitals

24Source: FL Vital Records, Dec 2013

1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 111 1160%

10%

20%

30%

40%

50%

60%

70%

80%

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Range: 6.6—59.5%Median: 31.3%Mean: 31.8%

National Target =23.9%

21% of FL hospitals meet national target

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FPQC Initiatives to Date

2011 2012 2013 2014 2015Early Elective DeliveryNeonatal Catheter InfectionsObstetric HemorrhageGolden HourAntenatal SteriodsHypertension in PregnancyBreast Milk in the NICUHospital Perinatal QI Indicators

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OHI Round 2

Obstetric Hemorrhage is still an issue in Florida (16% of all pregnancy-related deaths)

Round 2 will be a hospital-led version of our Round 1 initiative

Recruitment: November 2015

Antenatal Corticosteroid Treatment

(ACT)

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Antenatal Corticosteroids Treatment (ACT)

Why ACT?Proven reduction in neonatal morbidity and mortalityGoal of 100% administration to at-risk mothers 24-34 weeks gestational age not being metOptimal timing of ACT 24 hours – 7 days prior to preterm delivery often not achievedLack of understanding & standardized ACT protocols leads to inconsistent medical practicePoor documentation of ACT

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Florida ACT Project

Pilot Hospitals

Central FloridaFlorida Hospital AltamonteFlorida Hospital OrlandoFlorida Hospital Celebration HealthTampa General HospitalBayfront Health Baby PlaceIndian River Medical Center

South FloridaHoly Cross HospitalBroward Health Medical CenterMemorial Regional HospitalJackson Memorial HospitalSouth Miami HospitalBaptist Hospital of Miami

North FloridaSacred Heart Hospital PensacolaTallahassee Memorial HospitalUF Health Jacksonville

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Human Milk in the NICU

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Mothers Own Milk (MOM)

Global Aim:Within 2 years of project start, greater than 50% of very low birth weight infants admitted to the NICU will receive greater than or equal to 50% of mothers own milk (MOM) at discharge

Primary Drivers:Intent to provide breast milk, establishing supply, maintaining supply, and transitioning to breast

FPQC Perinatal QI Indicators

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Initial Proposed QI Indicators

Perinatal QI IndicatorsNon-medically indicated deliveries—PC-01Nulliparous, term, single, vertex cesareans—PC-02Antenatal corticosteroid use—PC-03 Failed inductions of laborSevere Maternal Morbidity—CDC Unexpected Newborn Complications—CMQCC

Data Quality Score Card

Perinatal Quality Indicator Project

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Hypertension in Pregnancy (HIP) Initiative

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Why do we need a quality improvement initiative?

National and State data on maternal mortality give us incentive.

UnknownOther

AnesthesiaCerebrovascular accidentAmmiotic fluid embolism

CardiovascularThrombotic embolism

CardiomyopathyInfection

Hypertensive disorderHemorrhage

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

3.7%12.0%

1.5%2.9%

6.2%8.5%

9.8%10.2%

13.2%15.9%16.1%

Caus

e of

Dea

th

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Pregnancy-Related Mortality by Cause, Florida, 1999-2013

Percent of Pregnancy Related Deaths

The Issue

Hypertensive disorders occur in 5-10% of pregnancies in the U.S.From 1999-2013, hypertensive disorders accounted for 15.9% of pregnancy-related deaths in FloridaMaternal mortality review reports from Florida, North Carolina and California found that maternal deaths due to hypertensive disorders had significant opportunities for intervention

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Pregnancy-Associated Mortality Review Results

Women at increased risk of death due to hypertension were: Obese (BMI 30 or +) (Reference: Normal weight BMI 20-24.9) 35-years or older (Reference: Age 24 or less) Non-Hispanic Black (Reference: Non-Hispanic White) Late or no prenatal care (Reference: Prenatal care first trimester)

Hypertensive women were at higher risk of having: Preterm (28 or < weeks) (Reference: 37 or +) Had cesarean delivery (Reference: Vaginal delivery

Preterm (28 or < weeks)

Obese (BMI 30 or +)

Age 35 or older

Has cesarean Non-Hispanic Black

Late or no prenatal care

0.0

2.0

4.0

6.0

8.0

10.0

12.0

PRM

RH p

er 1

00,0

00 Li

ve B

irths

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Pregnancy-Related Deaths (PRD)Due to Hypertensive

Disorders1999-2012 (FL Dept. of Health

PAMR Report)Preeclampsia

Affects up to 10% of all pregnancies in the United StatesMajor cause of poor outcomes and mothers’s deaths 

70% PRDs classified as preeclampsia or eclampsia  Hemorrhagic stroke (43.7%), encephalopathy (23%), and HELLP syndrome (17.2%) accounted for 83.9% of all deaths due to hypertensive disorders.

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Causes Preeclampsia Eclampsia

NOS Hypertension in

PregnancyTotal Deaths Number (%)

Embolic stroke 1 0 1 2 (2.3%)Hemorrhagic stroke

13 14 11 38 (43.7%)DIC-Disseminated Intravascular Coagulation 1 1 0 2 (2.3%)HELLP syndrome 12 3 0 15 (17.2%)Other (includes encephalopathy) 7 4 9 20 (23.0%)Unknown/NOS 1 4 5 10 (11.5%)Total Deaths Due to Hypertension 35 26 26 87

Pregnancy-Related Deaths Due to Hypertension by Causes, Florida

1999-2012 (n=87)

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ATTENTION:

• 60% of preeclampsia deaths are preventable

Main et al. Obstet Gynecol. 2015 Apr;125(4):938-47

• In over 40% of pregnancy-related deaths in Florida, there is at least one major health care or system quality improvement (QI) opportunity, mainly through improved medical care.

Hernandez et al. Pregnancy-Related Deaths, Florida, 1999-2010: Opportunities to Improve Maternal Outcomes

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Recommendations from Florida PAMR

Clinical FactorsClinicians should:

Screen all women for previous history of preeclampsia, pre-existing diabetes, high blood pressure, advanced maternal age, and obesity to recognize a patient at risk for hypertensive disordersMaintain vigilance and monitoring for pulmonary edema all patients with preeclampsia and treat these patients aggressivelyEnsure that patients placed on antihypertensive medication(s) during a hospitalization demonstrate a stable blood pressure prior to discharge and have access to those medications if needed after discharge

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Recommendations from Florida PAMR

System FactorsHealth care practitioners and birthing facilities should ensure policies, procedures, and standards of care are met in the care and treatment of a woman at a risk of or with an existing hypertensive disorder

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Recommendations from Florida PAMR

Individual and Community FactorsAll medical practitioners should review medical conditions that may impact on a pregnancy with all women of childbearing ageHealth care practitioners should increase patient awareness about the significance of shortness of breath by including this as a warning sign in postpartum discharge instructions

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Executive Summary: Hypertension in Pregnancy

(HIP)

American College of Obstetricians and

Gynecologists

Obstet Gynecol 2013;122:1122-31

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ACOG Executive Summary on Hypertension In Pregnancy,

Nov 2013 1. The term “mild” preeclampsia is discouraged for clinical classification. The recommended terminology is:

a. “preeclampsia without severe features” (mild)b. “preeclampsia with severe features” (severe)

2. Proteinuria is not a requirement to diagnose preeclampsia with new onset hypertension

3. The total amount of proteinuria > 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia.

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ACOG Executive Summary on Hypertension In Pregnancy, Nov 2013

cont.

4. Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic

5. Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild)

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ACOG Executive Summary on Hypertension In Pregnancy, Nov 2013

cont.

6. Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications.

7. Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension

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ACOG Executive Summary on Hypertension In Pregnancy, Nov 2013

cont.

8. The postpartum period is potentially dangerous. Patient education for early detection during and after pregnancy is important

9. Long-term health effects should be discussed

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A Deadly Combination Severe Preeclampsia -

HELLP Syndrome - Eclampsia Associated with an increased risk of adverse

outcomes such as:Placental Abruption

Renal Failure

Subcapsular Hepatic Hematoma

Preterm Delivery

Fetal or Maternal Death

Recurrent Preeclampsia

ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514, 2012; Tuffnell D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880.

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We need to remember…

Forty percent of patients with New-onset hypertension or New-onset proteinuria will develop classic preeclampsia.

In patients with severe preterm preeclampsia, the disease can rapidly progress to significant maternal morbidity and/or mortality

Barton JR, Sibai BM. Prediction and prevention of recurrent preeclampsia. Obstet Gynecol. 2008;112(2 PART 1): 359-372

Hypertension Safety Patient Bundle

ReadinessEvery unit

Recognition / PreventionEvery patient

ResponseEvery case of severe hypertension/preeclampsia

Reporting / Systems LearningEvery unit

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Early RecognitionPatients presenting with vague symptoms of:

headache abdominal pain shortness of breath generalized swelling complaints of “I just don’t feel right”

should be evaluated for atypical presentations of preeclampsia or “severe features”

Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol. May 2009;200(5):481 e481-487.

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Early Response

Optimal interventionControlling blood pressure Prevent deaths due to stroke in women with preeclampsia

Over the last decade, the UK has focused QI efforts on aggressive treatment of both systolic and diastolic blood pressure and has demonstrated a reduction in deaths

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Management of Suspected Severe Preeclampsia < 34 Weeks Gestation

Proceed to delivery for:• Recurrent severe hypertension despite therapy• Other contraindications to expectant management

Initial 24-48 hours observation• Initiate antenatal corticosteroids if not previously administered• Initiate 24 hour urine monitoring as appropriate• Ongoing assessment of maternal symptoms, BP, urine output• Daily lab evaluation (minimum) for HELLP and renal function• May observe on an antepartum ward after initial evaluation

Antenatal corticosteroid treatment completed:• Expectant management not contraindicated• Consider ongoing in-patient expectant management

Adapted from Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks’ gestation. American Journal of Obstetrics & Gynecology, September 2011, pg. 191-198. CMQCC Preeclampsia Toolkit 2013

No contraindications to expectant management – Short Term

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Readiness

Being ready to provide the early recognition and response requires a coordinated effort

Locally developed policies and protocols based on evidence of effectiveness are key to readiness and response

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Readiness and Recognition

All patients with severe preeclampsia, irrespective of gestational age, should have an evaluation by an obstetrician as soon possibleAn organized tool to identify “clinical signs,” of high concern or triggers can aid clinicians to recognize and respond in a more timely manner to avoid delays in diagnosis and treatment

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Readiness and Recognition Tools

Algorithms for acute treatment of severe hypertension and eclampsia should be readily available or preferably posted in all clinical areas that may encounter pregnant women –HIP will provide tools that may be adapted locally for use.

(CMQCC Preeclampsia Toolkit)

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Late Postpartum Eclampsia

>48 hours following delivery, up to 4 weeks PPApproximately 15% of cases of eclampsia63% no antepartum hypertensive diagnosisThe magnitude of blood pressure elevation does not appear to be predictive of eclampsiaThe most common presenting symptom was headache, which occurred in about 70% of patients; other prodromal symptoms included shortness of breath, blurry vision, nausea or vomiting, edema, neurological deficit, and epigastric pain

Al-Safi Z, Imudia A, Filetti L, et al. Delayed Postpartum Preeclampsia and Eclampsia. Obstet Gynecol. 2011;118(5):1102-1107.

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Care Continues Post-Discharge from Hospital

Early post-discharge follow-up recommended for all patients diagnosed with preeclampsia/eclampsiaPreeclampsia Toolkit recommends post-discharge follow-up:

Within 3-7 days if medication was used during labor and delivery OR postpartumWithin 7-14 days if no medication was used

Postpartum patients presenting to the ED with hypertension, preeclampsia or eclampsia should either be assessed by or admitted to an obstetrical service

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Education is a part of Readiness and Recognition

Staff will require trainingNew procedures, protocols, policyHuddles and DebriefsSimulation

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Education cont.

Use of preeclampsia-specific checklists, team training and communication strategies, and continuous process improvement strategies will likely reduce hypertensive related morbidity

Use of patient education strategies, targeted to the educational level of the patients, is essential for increasing patient awareness of signs and symptoms of preeclampsia

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A Mother’s Perspective:

“As a first time expectant mother, I didn't know preeclampsia existed. My providers never shared with me the signs and symptoms. I didn't want to be one of "those" patients who ran to their doctor over every little thing. My providers at that time also had inadequate knowledge on the hypertensive disorders of pregnancy. This is a common and deadly combination.” J.K., first time mom

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Survivor shares her story:

“It was during my third high risk pregnancy that I found the Preeclampsia Foundation and their wealth of information. During this time I also transferred my care to another hospital that had specialists better equipped to handle preeclampsia.”- B.B- four time survivor of preeclampsia

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Patient Education Materials

This and many other patient education materials can be ordered from www.preeclampsia.org/market-place

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Request from a Mom:

“Considering that preeclampsia is a brutal disease- you can die and your baby can die- It is nothing to mess with. We need a special protocol in place to help manage it.”

- K.D. preeclampsia survivor

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Reporting

Quality Improvement entails tracking progress from baseline throughout the improvement periodFPQC will provide an online tool to track progress on specified measuresReports back to projects will be available

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The Power of a Collaborative

Represents a “community of change” Shares benchmark performance and approaches to overcoming obstacles Individual hospitals positively influence outcomes for participating institutionsDevelops a high quality, reliable database Disseminates risk-adjusted, confidential reports Supports the comparison of performance between hospitals Supports perinatal providers Sustainable, long-term improvement

Gould, JB. The role of regional collaboratives: the California Perinatal Quality Care Collaborative model.Clin Perinatol. 2010 Mar;37(1):71-86.

Lee HC, et al. Antenatal steroid administration for premature neonates in California. Obstet Gynecol. 2011 Mar;117(3):603-9Cite new article from CPQCC

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A note about chronic hypertension

Complicates up to 8% of pregnanciesEight fold increased risk for preeclampsia,Maternal risk CVA and MIIncreased preterm birth

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Pregnancy Related Mortality 1987-2010

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Adverse Pregnancy OutcomesCondition Recurrence Risk

Preterm birth 2- to 3-fold increasePeriviable birth (20-26 weeks) 6.9% (35.6% PTB)

Preeclampsia 5.9%HELLP Syndrome 19 - 27%2nd trimester Severe Preeclampsia 21% (65% preeclampsia)

Gestational diabetes 30 - 84%

Abruptio placentae 4.4%

Stillbirth 2.5%

Cesarean Delivery 50% (recurrent cause)

Neural tube defects 2.3% (3-7%)

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Utilization of Primary Care after Medically Complicated Pregnancy (Medicaid)

0

10

20

30

40

50

60

70

80

90

100

GDM DM Hypertension Control

(%)

Bennett-WL et al. J Gen Int Med 2013;29:630-45

N=37,751 Maryland Deliveries, 2003-2009

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Utilization of Primary Care after Medically Complicated Pregnancy (Commercial)

0

10

20

30

40

50

60

70

80

90

100

GDM DM Hypertension Control

(%)

Bennett-WL et al. J Gen Int Med 2013;29:630-45

N=37,751 Maryland Deliveries, 2003-2009

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Pregnancy offers an exceptional opportunity to determine who is at risk for future adverse pregnancy outcomes

In 1st world countries, most women receive prenatal care, most births occur in hospitalmost new mothers seek newborn caremany new mothers seek family planning services

Postpartum visit Gateway to interpregnancy care

Risk assessmentCare plan developmentMedical / Non-medical InterventionsReferrals

Many have been unable or do not take advantage of the opportunity, and providers are not focused on interpregnancy care as part of well-woman care

Johnson K, et al. CDC/ATSDR Select Panel on Preconception Care. MMWR Recomm Rep. 2006Johnson K, Gee R Sem. Perinatol 2015;39:315-15

Interpregnancy Care: The Paradigm

HIP Hospital Map

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33 Florida hospitals1 Colombia

hospital

HIP Initiative Timeline

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HIP Resources

FPQC.org Current Project: Hypertension in Pregnancy

CMQCC.org Resources and Toolkits: Preeclampsia Toolkit

Council on Patient Safety in Women’s Health Care

Severe Hypertension in Pregnancy Patient Safety Bundle

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Maternal and Neonatal HealthcareQuality Improvement

National and Local Speakers

QUESTIONS

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www.fpqc.org

fpqc@health.usf.edu