1. Texas Center for Quality and Patient Safety Eliminating Elective Deliveries Before 39 Weeks (EED) DENNIS W. COOK, MSN, RN Senior Director/Texas Center for Quality and Patient Safety dcook@tha.org www.texashospitalquality.org www.tha.org

2. Citation The information in the presentation has been taken from: Improving Perinatal Safety: The Elimination of Elective Deliveries Before 39 Weeks. Health Research & Educational Trust. Chicago: February 2012. Accessed at www.hpoe.org

3. Why Reduce EED? Decrease the possibility of adverse neonatal outcomes: • ICU Admissions • Transient Tachypnea • Respiratory Distress Syndrome • Sepsis • Feeding Problems

4. Medical Reasons to Induce Labor • Placenta Abruption • Post-term Pregnancy (>/= 41 weeks) • Maternal conditions • preeclampsia • hypertension • diabetes • chronic renal disease • Fetal Problems • insufficient growth • congenital anomalies • prior stillbirth • fetal demise • Psychosocial

5. Texas Law Under a 2011law, Texas Medicaid will not reimburse hospitals for elective deliveries occurring prior to 39 weeks’ gestation when not medically necessary.

6. How to Eliminate EED • Form a team • Analyze the current situation • Set a primary goal • Create guidelines • Collaborate with staff • Implement coordination • Educate physicians • Track progress

7. How to Eliminate EED • Step 1: Form a team • Involve all who have a stake in the planning and outcomes process: • Physicians • Administrators • Operations analysts • Quality department • Executive leadership

8. How to Eliminate EED • Step 2: Analyze the current situation • Analyze EED rates by facility, year, and physician to find trends. • Calculate outcome metrics • Compare rates to state and national trends

9. How to Eliminate EED Step 3: Set a primary goal Aim to eliminate EED within a realistic time period

10. How to Eliminate EED Step 4: Create guidelines In a team setting, draft sample guidelines for review

11. How to Eliminate EED • Step 5: Collaborate with staff • Present the primary analysis to participating clinical and administrative staff • Discuss sample guidelines and request feedback for improvement • Review potential solutions to reach primary goal

12. How to Eliminate EED Step 6: Implement coordination Pilot new guidelines to identify gaps. Revise plan before it goes into a policy.

13. How to Eliminate EED • Step 7: Educate physicians • Develop educational materials that cover the new guidelines for physicians with less exposure to the implementation plan. • Develop educational materials for physicians to give to patients describing the health risks associated with EED.

14. How to Eliminate EED • Step 8: Track progress • Measure outcome and process metrics to gauge improvement and recognize challenges. • Disseminate and discuss metrics with team and all involved staff for feedback.

15. Partnership for Patients Metrics For TCQPS HEN: Process Metric Numerator: Number of elective deliveries between 37-39 weeks Denominator: Number of elective deliveries Outcome Metric Numerator: Number of injuries using ICD-9-CM codes in any diagnosis fields Denominator: Number of elective deliveries between 37-39 weeks

16. Essentials for Success • Leadership Buy-in • Physician Adherence • Patient Education • Documented Process

17. Case Study Presentation • Seton Family of Hospitals (Ascension Health) implemented “Journey to Zero” in 2003. • Impact: There has been no elective inductions before 39 weeks within the system. • Birth trauma rates decreased from 30/10,000 to 2/10,000 since 2007 (93% reduction). • Zero NICU admission attributed to EED for more than six years. • NICU charges declined from $4mil to $186,000/yr. • Webinar on this effort will be held in May 2012. Date and Time TBD.

18. Serving Texas Hospitals/Health Systems