Washington State Perinatal CollaborativeUpdate on Quality Improvement Initiatives

Elective Deliveries 37-<39 wks Episiotomies Breast Milk Feeding

Thomas Benedetti, MD, MHA University of Washington Medical Center

Department of Obstetrics and Gynecology and

Jean O’Leary, MPH, RDNutrition Consultant

Washington State Department of HealthWIC Nutrition Program

November 19, 2013Presented at Washington State Hospital Association Safe Table 11/19/2013

90% reduction in Early Elective Deliveries between 37 to 39 weeks.$5 million in cost savings. Over 1,900 fewer early deliveries!

Percentage of Hospitals Under 5% by QuarterBaseline: 16%

Q1 2011: 35.5%Q2 2011: 44.4%Q3 2011: 51.2%Q4 2011: 54.9%Q1 2012: 69.5%Q2 2012: 66.7%Q3 2012: 69.1%Q4 2012: 88.5%Q1 2013: 88.2%

2003 2004 2005 2006 2007 2008 2009 2010 2011 201222%

23%

24%

25%

26%

27%

28%

29%

26.7%26.9%

27.6%27.8% 27.8%

27.1%

26.7% 26.7%

24.9%

24.5%

Washington State Percent of All Term Births >= 37 wks Gestation that were 37-38 wks

37-3

8 w

k bi

rth

% o

f all

term

>=3

7 w

ks

Presented at Washington State Hospital Association Safe Table 11/19/2013

2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

0.25

0.5

0.75

1

1.25

1.5

1.75

2

2.25

Washington State Stillbirths by Gestational Age Rates per 1,000 Ongoing Pregnancies

37 wks 38 wks 39 wks 40 wks 41 wks

Stillb

irths

per

1,0

00 O

ngoi

ng P

regn

anci

es

Presented at Washington State Hospital Association Safe Table 11/19/2013

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 201312%

14%

16%

18%

20%

22%

24%

26%

28%

Washington State Trends Percent of All Term Births >= 37 wks Gestation that were 37-38 wks

NTSV Cesarean rate Primary Term Singleton Vertex Cesarean rate

37-38wks % of all term >=37wks CY NTSV C-section % SFYPrimary TSV C-section % SFY

Presented at Washington State Hospital Association Safe Table 11/19/2013

Optimizing Episiotomy Rates ReviewMethods and Components 2012-2013

Statewide voluntary project Regionally promoted by WSPC, WSHA-Partnership for

Patients, PRN coordinators and physician champion Measure: Episiotomy rate for spontaneous vaginal deliveries (National Quality Forum-based Measure; excludes shoulder dystocia, forceps, vacuum)

Distribute baseline vs. blinded hospital peer 2011 data to hospitals (WSHA Nov 2012: data source CHARS)

Hospitals will validate baseline data 2012-2013 Target rate < 5% (Note: target rate is Not 0%)

Quarterly 2012-2013 hospital rates provided by WSHA Hospitals encouraged to track related episiotomy rate with

instrument and third and fourth degree perineal lacerations

Presented at Washington State Hospital Association Safe Table 11/19/2013

0% 5% 10% 15% 20% 25%

-1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

f(x) = 0.212422390738303 x + 0.0111393550213229R² = 0.391500088628643

2011 Washington State Episiotomy Rates vs. 3rd & 4th Degree Lacera-tion Rates for Spontaneous Vaginal Delivery

Episiotomy Rate

Lace

ratio

n Ra

te

Correlation Coefficient (r) = 0.628Moderately Strong Association

Presented at Washington State Hospital Association Safe Table 11/19/2013

Baseline 2011 (48,563)

Q1-2 2012 (23,302)

Q3 2012 (12,914) Q4 2012 (11,740) Q1 2013 (11,484)0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

6.52%5.93%

5.27%5.90%

4.96%

Episiotomy Rate for Vaginal Deliveries without Forceps/Vacuum

Target Rate < 5%All WA Hospitals (Partnership for Patients (PFP) and non-PFP)

Time Period (Denominator)

23.9% decrease from CY 2011 baseline

Presented at Washington State Hospital Association Safe Table 11/19/2013

Baseline 2011 (48,563)

Q1-2 2012 (23,302) Q3 2012 (12,914) Q4 2012 (11,740) Q1 2013 (11,484)0%

10%

20%

30%

40%

50%

60%

70%

48.5% 54.0% 54.8%51.7%

61.0%

34.8%

27.0%

25.8%

28.3%25.4%

Episiotomy rate without forceps or vacuum Proportion of Hospitals with rates < 5% and > 8%

All WA hospitals (both PFP and non-PFP)

% of Hospitals < 5% % of Hospitals > 8%

Time Period (Denominator)

Presented at Washington State Hospital Association Safe Table 11/19/2013

Baseline 2011 (3,167)

Q1-2 2012 (1,381)

Q3 2012 (681) Q4 2012 (980) Q1 2013 (943)0%

10%

20%

30%

40%

29.5% 28.0% 28.4% 27.4%29.7%

Episiotomy rate for vaginal delivery with forceps and vacuum

All WA hospitals (both PFP and non-PFP)

Presented at Washington State Hospital Association Safe Table 11/19/2013

Baseline 2011 (48,563)

Q1-2 2012 (23,302) Q3 2012 (12,914) Q4 2012 (11,740) Q1 2013 (11,484)0%1%2%3%4%5%

2.4% 2.3% 2.2% 2.1% 2.1%

Third and Fourth Degree Laceration Rate for Vaginal Delivery without forceps or vacuum

All WA hospitals (both PFP and non-PFP)

Time Period (Denominator)

Baseline 2011 (3,167)

Q1-2 2012 (1,381) Q3 2012 (681) Q4 2012 (980) Q1 2013 (943)0%

10%

20%

30%

40%

16.9% 16.0% 14.0% 16.5% 17.7%

Third and Fourth Degree Laceration Rates for Vaginal De-livery with forceps or vacuum

All WA hospitals (both PFP and non-PFP)

Time Period (Denominator)

Presented at Washington State Hospital Association Safe Table 11/19/2013