risk appropriate maternal and neonatal …...3c. improve access to and utilization of first...
TRANSCRIPT
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RISKAPPROPRIATEMATERNALANDNEONATALCARE:
Evidencebasedstrategytoreduceinfantmortality
M.KathrynMenardMDMPH
• ViceChairforObstetricsDirectorofMaternalFetalMedicine,UNCSchoolofMedicine
• MedicalDirector,NCPregnancyMedicalHomeProgram
• PastPresident,SocietyforMaternalFetalMedicine
• President,NCObstetricsandGynecologicSocietyMarch6,2018
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STUDYLEVELSOFMATERNALANDNEONATALRISKAPPROPRIATECARE:HB741ANDSB311
Supportastudybilltoassesstimelyandequitableaccesstohighqualityrisk-appropriatematernalandneonatalcare;studytoresultinactionablerecommendations.
CFTFtoadministrativelysupportedstudy(additionalfundswouldneedtobemadeavailable)
PassedHouselastyear;requestcontinuedsupport
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NORTHCAROLINA,2014
66%ofchildhooddeathswereinfants
860infantdeaths
593deathswithinthefirst28daysoflife 187duetoprematurityandLBW 125duetomaternalfactors/complications
Theseleadingcausesofneonataldeathdisproportionatelyaffectminorities
Earlyandriskappropriateprenatalcarecanmakeadifference
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3.IMPROVETHEQUALITYOFPRENATALCARE
3C.Improveaccesstoandutilizationoffirsttrimesterprenatalcare3E.Ensurethatallpregnantwomenandhigh-riskinfantshaveaccesstotheappropriatelevelofcarethroughawell-establishedregionalperinatalsystem
1.Decreasethe%ofVLBWandhigh-riskbabieswhoarebornatLevel1andLevel2hospitals
2.Define,identifyandpromotecentersofexcellenceforVBAC(vaginalbirthaftercesarean)
3.AssessthelevelsofneonatalandmaternitycareservicesforhospitalsusingtheconsensusrecommendationsoftheAmericanAcademyofPediatrics(AAP),theAmericanCollegeofObstetriciansandGynecologists(ACOG),andtheSocietyforMaternal-FetalMedicine(SMFM)
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RISKAPPROPRIATEMATERNALANDNEONATALCARE
Earlyonsetprenatalcare Riskassessmentandinterventionformodifiableriskfactors Tobaccocessation Optimalmanagementofmedicalcomplicationsofpregnancy Aspirintopreventpre-eclampsia 17hydroxyprogesteronetopreventrecurrentpretermbirth Caremanagementforthosewhowillbenefitmost
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PMHPROVIDERNETWORK:PARTICIPATION
Providerparticipation:380practicesparticipateinthePMHprogram,representing>1,700providersandmorethan90%ofmaternitycareprovidedtoMedicaidpatients.95of100NCcountieshaveaPMH.
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EARLYANDRISKAPPROPRIATEPRENATALCARE
Whoisavailabletoprovideprenatalcare? Whataretheypreparedtomanage? Whatistheircapacitytoseewomeninatimelymanner? Whatifmoreadvancedcareisneeded?Whatisthesystemforreferral?Dowomenacceptreferral?
Whydoonly65%ofMedicaidrecipientsreceiveprenatalcareinthefirsttrimester?
Ruralcounties:69% Metropolitan:65%
Wherearetheservicegaps?Howcantheybefilled?
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RISKAPPROPRIATEMATERNALANDNEONATALCARE
Whenpretermdeliveryisinevitable Antenatalsteroids Maternaltransfertohospitalwithappropriateresourcesforneonatalcare
VLBWnewbornsare1.8Xmorelikelytodieifbornoutsideofaregionalcenter
Lasswell, Barfield, Rochat, Blackmon. JAMA 2010
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2012AAPLEVELSOFNEONATALCARE
LevelI(Basic)
>35wkswhoarestable
Stabilizeandtransfer<35weeks
LevelII(SpecialtyCare)
≥32 wks or ≥1500 gms who have physiological immaturity
Provideconvalescent care after intensive care; Assisted ventilation for ≤24 hours or CPAP
LevelIII(SubspecialtyCare)
Continuouslifesupport;Care<32wksand<1500gms
Advancedimagingw/interpretationonanurgentbasis(CT,MRI,echocardiography):Promptaccesstofullrangeofpediatricmedicalandsurgicalsubspecialistsonsiteorbypre-arrangedconsultativeagreements
LevelIV SeeLevelIII
Capabilitytoprovidesurgicalrepairofcomplexcongenitalorpostnatalconditions;Immediateat-siteaccesstopediatricsubspecialists,pediatricsurgeonsandpediatricanesthesiologists
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AreNorthCarolina’highestriskinfantsborninfacilitieswithresourcestoprovidethebestcare?
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DeliveriesatNorthCarolinaFacilitiesbyVolume
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NCVLBWBIRTHBYHOSPITALTOTALBIRTHVOLUME,2014
1853VLBWbirths
1487(80%)borninhospitalswithbirthvolume>3,000
228bornw/1000–2,999birth
138(5%)bornw/<1000births
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RISKAPPROPRIATEINTRAPARTUMCARE
Arethehighestriskbabiesborninfacilitieswithresourcesandpersonneltoprovideappropriatecare? Whatarethecapabilities/LevelofneonatalcareforNCmaternityhospitals? HowisLevelofcaredesignated? Whatsystemsareinplaceformaternaltransport,whenindicated? Whatsystemsareinplaceforoutreacheducationandsupportforqualitymonitoringandimprovement?
Whyare20%ofbabies<1500gramsborninhospitalswithlowdeliveryvolume?Arethematernalandneonatalresourcesappropriate? Wherearetheservicegaps?Howcantheybefilled?
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WHATABOUTTHEMOM?
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DEFININGLEVELSOFMATERNALCARE
Tointroduceuniformdesignations,withstandardizeddefinitionsforlevelsofmaternalcarethatarecomplementarybutdistinctfromlevelsofneonatalcare
Toprovideconsistentguidelinesaccordingtolevelofmaternalcareforuseinqualityimprovementandhealthpromotion
Tofosterthedevelopmentandequitablegeographicdistributionoffull-servicematernalcarefacilitiesandsystemsthatpromoteproactiveintegrationofrisk-appropriateantepartum,intrapartum,andpostpartumservices
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Providenationallyapplicableuniformdefinitionsdescribingcapabilityoffacilitiestoprovideincreasingcomplexityofcaretopregnantwomen
LEVELS OF MATERNAL CARE
Jointly published by ACOG and SMFM
Endorsementandsupportfrom• AmericanAssociationofBirthCenters• AmericanCollegeofNurseMidwives• AssociationofWomen’sHealthObstetricand
NeonatalNurses• CommissionfortheAccreditationofBirth
Centers• AmericanAcademyofPediatrics• AmericanSocietyofAnesthesiologists» SocietyofObstetricAnesthesiaand
Perinatalogy
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LEVELSOFMATERNALCARE(LOMC)
NOTaboutclosingsmallorruralmaternitycarecenters
ISaboutroleofLevelIII/IV(Regional)Centerstosupporteducationandqualityimprovementamongtheirreferringfacilities
ISaboutbuildingacultureofcollaboration
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LOMC:DEFINITIONS/EXAMPLESBirthCenter
Low-riskw/uncomplicatedsingletontermpregnancies,vertexpresentation;Expectedtohaveuncomplicatedbirth
Term,singleton,vertex
LevelI
Uncomplicatedpregnancies;Detect,stabilize,andinitiatemanagementofunanticipatedproblemsthatoccurduringantepartum,intrapartum,orpostpartumuntiltransfer
TermtwinsUncomplicatedcesareanPreeclampsiaw/oseverefeatures
LevelII LevelIfacilitypluscareofappropriatehigh-riskconditions,bothdirectlyadmittedandtransferredfromanotherfacility.
Severepre-eclampsiaPlacentapreviaw/noprioruterinesurgery
LevelIII LevelIIfacilitypluscareofmorecomplexmaternalmedicalconditions,obstetriccomplications,andfetalconditions
Placentaaccreta/percreta;ARDS;Expectantmanagementseverepreeclampsia<34wks
LevelIV LevelIIIfacilityplusonsitemedicalandsurgicalcareofthemostcomplexmaternalconditionsandcriticallyillwomenandfetuses
SeverecardiacconditionsorpulmonaryhtnRequiresneurosurgery
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3.IMPROVETHEQUALITYOFPRENATALCARE
3C.Improveaccesstoandutilizationoffirsttrimesterprenatalcare3E.Ensurethatallpregnantwomenandhigh-riskinfantshaveaccesstotheappropriatelevelofcarethroughawell-establishedregionalperinatalsystem
1.Decreasethe%ofVLBWandhigh-riskbabieswhoarebornatLevel1andLevel2hospitals
2.Define,identifyandpromotecentersofexcellenceforVBAC(vaginalbirthaftercesarean)
3.AssessthelevelsofneonatalandmaternitycareservicesforhospitalsusingtheconsensusrecommendationsoftheAmericanAcademyofPediatrics(AAP),theAmericanCollegeofObstetriciansandGynecologists(ACOG),andtheSocietyforMaternal-FetalMedicine(SMFM)
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RECOMMENDATION:INFORMEDACTIONPLAN
CommissionabroadlyrepresentativetaskforcetostudydegreetowhichNCwomenreceiveriskappropriatematernalandneonatalcareWhoisavailabletoprovideprenatalcare?Where?
Whydoonly65%ofMedicaidrecipientsreceiveprenatalcareinthefirsttrimester?
Arethehighestriskbabiesborninfacilitieswithresourcesandpersonneltoprovideappropriatecare?Whyare20%ofbabies<1500gramsborninhospitalswithlowdeliveryvolume?
Arematernityhospitalsequippedforsafematernalcare?Dothehighestriskmothershaveaccesstonecessaryresourcesforhighqualitycare/
Wherearetheservicegaps?Howcantheybefilled?