philadelphia ob project improving patient safety, the quality of care and reducing liability in a...

Philadelphia OB Project

Improving Patient Safety, the Quality of Care and Reducing Liability

in a Metropolitan Obstetrical Population through Inter-Institutional CollaborationGuiding Principles and Checklists for

6 University Obstetrical Practices

Owen Montgomery M.D. FACOG

Chairman Department of Obstetrics and Gynecology

Drexel University College of Medicine


US News and World Report 6 Top Ranked Hospitals in Philadelphia

ranked amongst the best in US/ region

#1 Hospital of the University of Pennsylvania

#2 Thomas Jefferson University Hospital

#3 Temple University Hospital

#4 Hahnemann University Hospital

#4 Pennsylvania Hospital

#8 Einstein Medical Center

All 6 have Obstetrical Residency Programs

Philadelphia OB Project• The University of Pennsylvania is

the oldest and one of the finest medical schools in the United States.

• Founded in 1765 Penn prides itself on educating the leaders of tomorrow in patient care, biomedical research, and medical education.

• among the top five in US research-oriented medical schools.

• 4500 deliveries • 26.2% C/S rate

Philadelphia OB Project• Founded in 1824, Jefferson

Medical College has awarded more than 27,000 medical degrees and has more living graduates than any other medical school in the nation.

• Jefferson Medical College is recognized for its balanced approach to medical education, and approximately one out of four to one out of five applicants throughout the U.S. apply to Jefferson.

• 2500 deliveries• 32.3% C/S rate


Temple University School of Medicine is recognized as an institution that offers an exceptional clinical education to a diverse and socially-conscious student body.

10,000 living medical graduates are practicing in the fifty states and other parts of the world.

Temple University School of Medicine ranks fifth in the nation in African American medical school graduates

4000 deliveries

32.2% C/S rate


Drexel University College of Medicine is merger of two of the earliest medical colleges in the United States Medical schools

Hahnemann Medical College 1848

Woman’s Medical College of Pennsylvania 1850

Woman’s was the very first medical school for women in the world.

DUCOM has the largest medical student enrollment of any private medical school in the nation.

National Center of Excellence in Women’s Health

2500 deliveries

24.3% C/S rate

Philadelphia OB Project• Pennsylvania Hospital, “the

nation’s first hospital”, is a 515-bed acute care facility that provides a full range of diagnostic and therapeutic medical services and functions as a major teaching and clinical research institution.

• The hospital was founded in 1751 by Benjamin Franklin and Dr. Thomas Bond to care for the “sick-poor and insane of Philadelphia.”

• 5000 deliveries• 35.3% C/S rate

Philadelphia OB Project• Einstein Medical Center’s is rooted in

healing, caring and learning.

• Philadelphia's largest independent Academic Medical Center with 7 (8) hospitals a distinguished history extending back to 1866

• Started a gynecological clinic in 1896

• Albert Einstein gave permission to use his name for the new medical center 1951

• Einstein hospital has provided care for the disadvantaged of north-east Philadelphia for over one-hundred years

• 4000 deliveries (not including new Montgomery site)

• 31.9% C/S rate


• SUMMARY: Hospital OB units in Pennsylvania

• Statewide, 1997 = 147• Statewide, 2009 = 103

• Number of Closures = 44• Number of Openings = 3• Net Loss Statewide = 41

• % change = 29.9%

• SUMMARY: Hospital OB units Southeast PA

• SEPA, 1997 = 41• SEPA, 2009 = 23

• Number of Closures = 19• Number of Openings = 2

• Net Loss = 17• % change = 43.9%


MATERNITY UNITS CLOSED (Southeastern PA)

BucksWarminster (2000)

ChesterBrandywine Hospital (2008)

DelawareMercy Fitzgerald Maternity Unit (2003)

MontgomeryElkins Park (2001) Central Montgomery Medical Center (2009)

PhiladelphiaTemple East-Northeastern Hospital (2009) Chestnut Hill Hospital Maternity Unit (2008) Jeanes Hospital (2007) Frankford Hospital (2006)Parkview (2003)Methodist (2002)Mercy Philadelphia Hospital (2002)Episcopal (2001) Roxborough Memorial Hospital (1999) City Avenue (1999) Germantown (1998)Nazareth Hospital (1998) Medical College of Pennsylvania (1997)


MATERNITY UNITS AND HOSPITALS STILL OPEN (Southeastern PA)BucksDoylestown HospitalGrand View HospitalLower Bucks HospitalSt. Mary Medical Center

ChesterChester County HospitalJennersville Regional HospitalPaoli Hospital Phoenixville Hospital

DelawareCrozer-Chester Medical CenterDelaware County Memorial HospitalRiddle Memorial Hospital

MontgomeryAbington Memorial Hospital

Bryn Mawr Hospital

Einstein Montgomery (open 10/2012)

Holy Redeemer Health System

Lankenau Hospital

Mercy Suburban Hospital (just closed late 2009 )

Montgomery Hospital Medical Center (closed 10/2012)

Pottstown Memorial Medical Center

Obstetric Care AvailabilityConsequence of Liability

20 Obstetric Units have closed in Southeastern Pennsylvania since 1997.

The largest decrease is in Philadelphia with 13 closures leaving only 6 hospitals in the city with Obstetrical Units

Number of births in the city not changed

1996-23,706 births 2010- 23,508 births. Of the 23,000 deliveries 99% are performed by

physicians or midwives employed by hospitals. The “practice” of Obstetrics and Gynecology by self

employed physicians in Philadelphia is extinct.


Philadelphia Health Commissioner Task Force •Sharing “quality outcome data” and “Quality Initiatives” between institutions

impossible•Absence of peer review protection by the Health Commissioner.•Each of the 6 remaining institutions use different Electronic Health Records or no EHR for Obstetrics•This makes sharing of data impractical and/or

prohibited by institutional legal counsel.


Deputy Mayor/Health Commissioner Chairs of all 6 University OB/GYN Programs Hospital Association of Pennsylvania all working together but

NO significant improvement in the reimbursement and medical liability situation.

To assure quality care and patient safety with increasing volume of patients:

It is necessary for all remaining Obstetrical Units to

work together to find new ways to insure quality care

while reducing liability.


MATERNITY UNITS REMAINING OPEN

Philadelphia County

Albert Einstein Medical Center

Hahnemann University Hospital

(Drexel University College of Medicine)

Hospital of the University of Pennsylvania

Pennsylvania Hospital

Temple University Hospital

Thomas Jefferson University Hospital


The Philadelphia OB Chairs are concerned about their continued ability to provide quality, safe obstetrical care.

Group formed in 2008 to meet with the City Health Commissioner:

low reimbursement high medical liability costs closure of 14 obstetrical units in the last 10 years 5 units in the past 5 years. increased and unplanned volume in the remaining 6 units major unpredicted fluctuations in volume from day to day regular safe staffing by nurses, physicians very difficult.


The Philadelphia OB Chairs agree to work with the Health Commissioner to develop a city wide RHIO for all Obstetrical patients in Philadelphia.Improve care for patients who come to an Obstetrical Unit without access to their OB record (10- 15% throughout city, 33% at TEMPLE)Improve efficiency in obtaining diagnoses and previous laboratory dataImprove outcomes while reducing costs

Develop a central de-identified city data base for: continuous quality improvement and outcomes data research.

•


Philadelphia OB Chairs Response

The Philadelphia OB Chairs have agreed to the following initiatives to maintain the highest level of quality care and patient safety:

Continue to provide the highest level of obstetrical care to all women in the City of Philadelphia Provide 24/7 coverage of the remaining Obstetrical Units with a Board Certified or eligible OB/GYN Physician The OB Physician will work for a maximum of 24 hoursThe OB Physician will have No other patient duties during the 24 hoursThe OB Physician will have No patient duties after the 24 hours of OB unit coverageThe OB Physician will supervise the care of all patients without regard to insurance coverage or site of Prenatal care


Number 526 May 2012

Standardization of Practice to Improve OutcomesProtocols and checklists have been shown to improve patient safety through standardization and communication.

Standardization of practice to improve quality outcomes is an important tool in achieving the shared vision of patients and their health care providers

Philadelphia OB ProjectGuidelines for Single (national) standard for induction of

labor and timing of Cesarean Sections.

•ACOG and March of Dimes Campaign:•NO Elective Deliveries before 39 completed weeks•Hard Stop for Inductions and Scheduled Cesarean Sections•Leepfrog Quality Indicator

Philadelphia OB Project• Guidelines for Standardization of Interpretation and

Management of Fetal Heart Rate recordings

• Agree to a single standardized ACOG national nomenclature for interpretation of fetal heart rate tracings

• Decrease variability in care from provider to provider and institution to institution.• Mandate for all Obstetrical Providers: • Attendings, Midwives, Resident Physicians and Obstetrical Nurses

12 hour on line advanced course in Fetal Heart Rate Interpretation• APS or GE are ACOG approved as on line courses


Guidelines for Standardization of Education and Management of Shoulder Dystocia

•Mandatory Formal Educational Program for all Obstetrical Providers: Attendings, Midwives, Residents, Labor Nurses•Regular Team Training and Drills for Shoulder Dystocia •Simulation training •ACOG Standard Forms for recording maneuvers and timing•Documentation and Certification•Staff privilege requirement


Guidelines for Standardization of Post Partum Discharge Requirements Instructions for Follow up•Screening for Post Partum Depression and Intimate Partner Violence•Smoking Cessation , Immunization, Contraception, Breast Feeding •Post partum visits and testing for HTN , GDM•Instructions for specific concerns: chest pain, headache bleeding, fever•Self care and Neonate care

Maternal Mortality in New Jersey

Safe Motherhood in Massachusetts

Pregnancy-associated injury deaths: Violence, substance abuse, and

motor vehicle collisions, 1990-1999

Massachusetts Department of Public HealthPublic Health Council MeetingMay 28, 2002

Distribution of injury and medical causes of pregnancy-associated death 1990-1999

n=80n=152

66%

34%

Medical Injuries

n=80

n=152

•There were 232 pregnancy-associated deaths.•Over one-third were injury-related.

Leading causes of pregnancy-associated death 1990-1999

Homicide leading cause overall (n=30) 2 out of 3 were cases of domestic violence

Other leading causes of injury deaths: Motor vehicle collisions (n=21) Drug overdose (n=16) Suicide (n=7)

Leading causes of medical deaths: Cancer (n=28) Acute and chronic respiratory conditions (n=23) Cardiovascular disease and conditions (n=11 ) Peripartum and postpartum cardiomyopathy

(n=8)

Number of injury deaths by cause and period of risk, 1990-1999

0

5

10

15

20

Pregnant 0-41 days 42-179 days 180-364 days

Timing of Death

Num

ber

of d

eath

s

Homicide Suicide Motor Vehicle Substance abuse

Opportunities - Number of provider visits by period of risk, 1990-1999

0

2

4

6

8

10

12

Pregnancy 0-41 days 42-179 days 180-364 days

Num

ber

of V

isit

s

OB Pediatric WIC Primary Care Hospital

• Affects approximately 1.5 million women each year

• Affects as many as 324,000 pregnant women each year

• May be more common than conditions for which pregnant women are routinely screened

• Possibly associated with unintended pregnancy, delayed prenatal care, smoking, alcohol and drug abuse

Facts About Intimate Partner Violence (IPV)

Routinely Screen Every Patient

• At first prenatal visit

• At least once per trimester

• At postpartum checkup

• At routine ob-gyn visits and preconception visits


• Guidelines for Standardization of Post Partum Discharge Instruction in Philadelphia

• Purpose : to assist the medical providers and staff of the Philadelphia Obstetrical Units to cooperatively establish the components of standard postpartum instructions,

• to maximize the ability of the new mother to care for herself and her neonate and to identify potential problems related to her maternal and general health .


Principles:

1)all new mothers should receive prior to

discharge instruction and educational

materials about the following areas of care:

• Self-care and care of the neonate

• Appropriate Rest

• Early Ambulation

• Health and Regular Diet:


• National recommendations: 1800 kcal per day or 550 kcal/day additional

• Vitamins, especially Calcium, Vitamin D, Iron as needed

• Perineal Hygiene

• Routine Care of the Breast, Bladder and Vulva


2) All new mothers should receive the appropriate recommended Immunizations prior to discharge including:

Anti D, Tdap, Rubella

3) All new mothers should receive education and support in the Promotion of Breast feeding

4) All new mothers should receive education

about, access to, and discussion of :

Contraception /Family Planning

with or without breast feeding

•


5) All new mothers should receive support for their psychosocial health and prior to discharge specifically receive

“Screening for Post Partum Depression” using the Edinburgh Depression Screening

or equivalent with appropriate follow-up (appendix supplied).

“Intimate partner violence” screening with community resources


Additionally, new mothers should be instructed on when and how to contact their provider if:

• their depression symptoms last longer than 2

weeks or gets worse,

• they are unable to perform daily activities,

• they have no interest in the baby, or

• they feel they may harm themselves or the

baby.


6) All new mothers should receive educational information and instruction in :

Smoking Cessation (as appropriate)

Dangers of Alcohol and Drug


7) All new mothers should be instructed what signs and symptoms to look for after discharge and when and how to contact their providers.

These conditions include but are not limited to:

Observation of chills or fever of 100.4 or

greater or aches and chills

Excessive bleeding (more than 4 soaked pads

within an hour for 2 hours)

Severe chest or abdominal pain that does not

go away or any other severe pain


Inability to urinating or pain with urination Persistent headache or blurred vision Tenderness, redness, hard areas and pain in

their breast Inability to have a bowel movement or

diarrhea for more than 3 days Swelling, redness, or tenderness in their legs Redness or foul smelling discharge around

stitches or surgical wound


8) All new mothers should receive appropriate

Post-Partum Follow-Up Visits:

Usually this is in 7-14 days for surgical

follow-up and high risk conditions:

PIH, Preeclampsia or medical, obstetrics or

inter-current complications.

Routine Post Partum visits are usually in 4-6

weeks


9) All new mothers should receive appropriate

Home Visits as dictated by :

• their medical condition and

• allowed by state guidelines and

• insurance coverage


References:

Guidelines for Perinatal Care. American Academy of Pediatrics (and) the American College of Obstetricians and Gynecologists, 6th Edition. Copyright© October 2007, by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

J.L. Cox, JM. Holden, F T Sagovsky (1987), Post Partum Depression Screen. British Journal of Psychiatry, June, Vol. 150.

You and Your Baby: Prenatal Care, Labor and Deliver, and Postpartum Care. Patient Education Booklet. Copyright© September, 2011 by the American College of Obstetricians and Gynecologists.

philadelphia ob project improving patient safety, the quality of care and reducing liability in a...

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