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

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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.

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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

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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

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

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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)

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Non-Medically Indicated (NMI) Deliveries < 39 Weeks

(Early Elective Deliveries)

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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"

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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%

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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

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PC-01 Percentage

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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.

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EED Resources

Educational and communications campaign

Grand Rounds Hospital ConsultationsE-BulletinsProvider Education PacketsEED Focused NewsletterSpecial EED VideoConsumer campaigns through Healthy Start Coalitions

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EED Newsletter

Available on our EED page at FPQC.org

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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

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Neonatal Catheter Associated Blood Stream Infections(NCABSI)

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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

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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)

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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.

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Obstetric Hemorrhage Initiative

(OHI)

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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

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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

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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

OHI Kick Off

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Project Data: Risk Assessment

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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

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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%

Golden Hour Part I:Delivery Room Management

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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

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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

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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%)

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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

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

Hospital Perinatal Quality Indicator Project

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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

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Early Elective DeliveriesSample Hospital QI Box Plot

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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

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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

Upcoming Projects

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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

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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

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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

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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%

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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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Contact on our website: FPQC.org

E-mail us: fpqc@health.usf.edu

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