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AHA/HRET HEN: Data and Coaching Webinar: Early Elective Deliveries

AHA/HRET HEN: Data and Coaching Webinar: Early Elective Deliveries. Data Review June 7, 2012 1:00 – 2:00 PM, CDT. Welcome and Overview. Welcome, thank you for joining us today! Housekeeping: This webinar is being recorded and will be archived.

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AHA/HRET HEN: Data and Coaching Webinar: Early Elective Deliveries

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  1. AHA/HRET HEN:Data and Coaching Webinar:Early Elective Deliveries Data Review June 7, 2012 1:00 – 2:00 PM, CDT

  2. Welcome and Overview • Welcome, thank you for joining us today! • Housekeeping: • This webinar is being recorded and will be archived. • You will receive a PDF of today’s presentation, later this week, as well as a link to fill-out the evaluation, a summary of Q&A and a link for the recording. • For questions: please reach out to your state lead – or email us: HEN@aha.org. • Agenda: • EED Measures • Content Review • Hospital Story • Teach Back

  3. Polling Questions (#1 and #2)How Many of You are Joining Us From: Hospital type? A. General Medical / Surgical B. Teaching C. Rural D. Children’s E. Long-term Care F. Psychiatric Hospital size? A. CAH B. Not CAH, <100 beds C. Not CAH, 100-299 beds D. Not CAH, 300+ beds

  4. Objectives: EED and Measures • Review data requirements • Discuss measures listed in the HRET Encyclopedia of Measures • Review measure definitions and interpretation examples • Discuss options for organization-defined measures

  5. Introductions • Shannon McDonnell, MPH, HRET • Kim Werkmeister, RN, BA, Cynosure Health • Charisse Coulombe, MS, MBA, HRET • Steve Tremain, MD, Cynosure Health

  6. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Elliott Main, MDChair, California Quality Care Collaborative (CMQCC)Chair, Department of Obstetrics and Gynecology, California Pacific Medical Center, San Francisco www.CMQCC.org www.marchofdimes.com/medicalresources_39weeks.html

  7. Elimination of Non-medically Indicated (Elective) Deliveries Prior to 39 Weeks Funding • Federal Title V block grant from the California Department of Public Health; Maternal, Child and Adolescent Health Division • California Maternal Quality Care Collaborative • March of Dimes Can be downloaded at: www.cmqcc.orgor www.marchofdimes.com

  8. Key Points • Research has shown that early elective delivery without medical or obstetrical indication is linked to neonatal morbidities with no benefit to the mother or infant. • There are numerous maternal and fetal indications for deliveries PRIOR to 39 weeks gestation • In addition… this toolkit… is not meant to imply that elective deliveries AFTER 39 weeks have been proven to be without risks for mothers and infants.

  9. Terminology Term The “New” Term Late Preterm Early Term First day of LMP 0 20 0/7 340/7 37 0/7 39 0/7 416/7 Week # Preterm Post term Modified from Drawing courtesy of William Engle, MD, Indiana University Raju TNK. Pediatrics , 2006;118 1207. Oshiro BT Obstet Gynecol 2009;113:804

  10. Scheduled Delivery <39 wks in an Uncomplicated Pregnancy • Since 1979, ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication (Committee Opinion #22) • ACOG has also noted that “a mature fetal lung maturity test result before 39 weeks of gestation, in the absence of appropriate clinical circumstances, is not an indication for delivery”.(Committee Practice Bulletins #97 and #107)

  11. Change in Distribution of Births by Gestational Age: United States, 1990-2006 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2009.

  12. The Gestational Age that Women Considered it “Safe to Deliver” Obstet Gynecol 2009;114:1254

  13. Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks • Increased NICU admissions • Increased transient tachypnea of the newborn (TTN) • Increased respiratory distress syndrome (RDS) • Increased ventilator support • Increased suspected or proven sepsis • Increased newborn feeding problems and other transition issues See Toolkit for more data and full list of citations Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997

  14. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes • 13,258 elective repeat cesarean births in 19 large centers • 35.8% done <39 weeks gestation • Increased risk of neonatal morbidity • Respiratory, hypoglycemia, sepsis, NICU admissions, hospitalization > 5 days • Even among babies delivered between 38 and 39 weeks Tita AT, et al, NEJM 2009;360:111

  15. Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Odds Ratios Tita AT, et al, NEJM 2009;360:111

  16. Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Absolute Risk Tita AT, et al, NEJM 2009;360:111

  17. New Concept: U-Shaped Curve for near-term Neonatal Outcomes • Neonatal outcomes at 37 and 38 weeks are very similar (or worse) than those at 41 and 42 weeks… • Best outcomes are at 39 and 40 weeks!

  18. NICU Admissions By Weeks Gestation Deliveries Without Complications, 2000-2003 NICU Admissions Oshiro et al. Obstet Gynecol 2009;113:804-811.

  19. RDS By Weeks GestationDeliveries Without Complications, 2000-2003 RDS Oshiro et al. Obstet Gynecol 2009;113:804-811.

  20. Ventilator Usage By Weeks GestationDeliveries Without Complications, 2000-2003 Ventilator Use Oshiro et al. Obstet Gynecol 2009;113:804-811.

  21. Examples of Successful Programs to Reduce Non-medically Indicated (Elective) DeliveriesBefore 39 weeks of Gestation • Magee Women’s Hospital (Pittsburg) • Intermountain Healthcare (Utah) • Hospital Corporation of America (HCA) • Ohio State Department of Health

  22. Magee Women’s Experience with Guidelines “Voluntary”: educational program and dept. recommendations “Enforced”: Department standard requiring approval by the Perinatal Committee Chair before scheduling non-standard indications for inductions Fisch et al ObstetGynecol 2009;113:797

  23. Magee Women’s Experience “The importance of strong physician and nursing leadership cannot be overstated. The change in the induction scheduling process that began to enforce the guidelines strictly in late 2006 was spearheaded by the OB Process Improvement Committee, whose members included the hospital’s Vice President for Medical Affairs, the Medical Director of the Birth Center, and the nursing leadership for the Birth Center.” Fisch et al Obstet Gynecol 2009;113:797

  24. Intermountain Healthcare’s Experience • Intermountain Healthcare is a vertically integrated healthcare system that operates 21 hospitals in Utah and Southeast Idaho and delivers approximately 30,000 babies annually. • Computerized L&D system. • MFMs hired by system, but OBs are independent. • January 2001: 9 urban facilities participated in a process improvement program for elective deliveries. • 28% of elective deliveries were occurring before 39 completed weeks of gestation. Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

  25. % Non-medically Indicated Deliveries<39 Weeks, January 1999 – December 2005 Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

  26. Stillbirths Before and After Implementation of Guidelines at Intermountain Healthcare Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

  27. HCA Trial of 3 Approaches for Reduction of Elective Deliveries <39 weeks Hard Stop Soft Stop/Peer Rev EducationOnly Consistent reduction in every hospital Clark SL. et al. Am J Obstet Gynecol 2010;203:449.e1-6

  28. Common Themes • All started with education provided to obstetricians regarding ACOG guidelines and best practices. • Modest change at most, until physicians were held accountable, nurses were empowered, and guidelines were enforced (“Hard stop”). • Medical leadership important.

  29. Clinician and/or Patient Desire to Schedule a Non-medically Indicated (Elective) Induction or Cesarean Section Clinician, Staff & Patient Education Public Awareness Campaign Reduce Demand Induction / Cesarean Scheduling Process Elective Delivery Hospital Policy QI Data Collection & Trend Charts Case NOT Scheduled if Criteria Not Met Physician Leadership A. Enforce policy B. Approve exceptions

  30. Engagement of Providers and Patients Framing: Data is clear about baby risks: 37-38wks >> risk than 41-42 weeks Get local Neonatologists involved, +local data Medical/Obstetric leader(s) a must Senior Administrator leadership is KEY! Hospital policy on EED is a good crutch for practicing OB’s Patient education materials/consents/MOD

  31. Steps for QI Make the case—involve Pediatrics early How many 37/38 weekers are transferred to the NICU? Collect baseline data Joint Commission measure specifications Work-out collection issues 3 distinct QI sub-projects Documentation Coding Practice

  32. How Do You Measure Elective Deliveries <39 weeks? The Joint Commission Measure Definition(NQF endorsed and utilized by others, including LeapFrog, CMS, AMA-PCPI, and many payers) https://manual.jointcommission.org/bin/view/Manual/WebHome

  33. First Steps (Fundamentals) • Gather baseline data of <39wk scheduled deliveries and outcomes • Implement list of “approved” indications • Have departmental criteria for making certain diagnoses (e.g. hypertensive complications of pregnancy) • Identify strong medical leadership to handle “appeals” for exceptions • This list DOES NOT imply that all folks with these diagnoses SHOULD be delivered before 39 weeks • Implement criteria for establishing gestational age >39 weeks

  34. ACOG Checklist • New ACOG form (November 2011) • To be revised locally, modeled after many in current use • Need to ensure that the indication is well charted

  35. Reference Guide • Used in Doctor’s offices when scheduling cases • To be revised locally, modeled after many in current use

  36. Example QI Worksheet Note: OFIs can be used for OPPE for re-credentialling

  37. Questions?

  38. OB/EED Data Management Strategy Charisse Coulombe Data Director, HRET

  39. Why is OB/EEDData Needed? • Measures are used to assess the impact of changes • To demonstrate hospitals have reduced their rates of harm over the 2 year period • To monitor that interventions to reduce OB Adverse Events/Early Elective Deliveries are working • Part of the PDSA cycle

  40. What OB/EED Data is Needed? • At a minimum, 1 process measure and 1 outcome measure • Process: Measures interactions between healthcare practitioner and patient; a series of actions, changes, or functions bringing about a result • Outcome: measures change or the end result of healthcare intervention

  41. Encyclopedia of Measures • Technical manual to ensure the hospital's measure definitions align with the comprehensive data system (CDS) • Comprehensive details about measure characteristics • Topic • Measure Name • Definition • Numerator, Denominator • Calculation specifications • Source(s)

  42. OB/EED Process Measures • Elective Deliveries at >=37 Weeks and <=39 Weeks (JC PC 1) • Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed • Antenatal Steroids (JC PC 3) • Patients at risk of preterm delivery at 24-32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns • DVT Prophylaxis - C-Section (OB)

  43. Early Elective DeliveriesThe Joint Commission Definition • Patients with elective vaginal deliveries or c-sections at >=37 and <39 weeks of gestation completed • Numerator: Patients with elective deliveries • Includes patients with ICD-9 codes for medical induction of labor (induced labor – ruptured membrane, surgical infection labor NEC); c-section while not in active labor (regular uterine contractions with cervical change before medical induction and/or cesarean section) or experiencing spontaneous rupture of membranes

  44. Early Elective DeliveriesThe Joint Commission Definition • Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation completed • Excludes • Patients with ICD-9-CM Principal Diagnosis Code or ICD-9-CM Other Diagnosis Codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07 • E.g. Preeclampsia, eclampsia, hypertension, twin/triplets, amniotic infection, fetal distress, stillborns • Less than 8 years of age • Greater than or equal to 65 years of age • Length of stay > 120 days • Enrolled in clinical trials

  45. Polling Question #1 • Has your hospital selected your OB/EED process measure? • A. Yes, selected and actively tracking • B. Yes, the measure has been selected • C. No, still researching which measure to select

  46. OB/EED Outcome Measures • C-Section Delivery Rate (JC PC 2) • Elective <39 Week Births Admitted to NICU (March of Dimes) • 5 Minute APGAR <7 Among All Deliveries >39 weeks • 5 Minute APGAR <7 in Early Delivery Newborns • Adverse Outcome Index (OB) • Birth Trauma - Injury to Neonate (AHRQ PSI 17)

  47. OB/EED Outcome Measures • C-Section Delivery Rate (AHRQ IQI 21) • Health Care-Associated Bloodstream Infections in Newborns (JC PC 4) • Infants Under 1500g Not Delivered in Level III NICU Hospital • Neonatal Mortality Rate (AHRQ NQI 2) • OB Trauma - C-Section (AHRQ PSI-Exp-2) • OB Trauma - Vaginal Delivery with Instrument (AHRQ PSI 18) • OB Trauma - Vaginal Delivery without Instrument (AHRQ PSI 19)

  48. Early Elective DeliveriesThe March of Dimes Definition • Number of infants admitted to the NICU or transferred to another hospital for care after a scheduled elective induction/ cesarean section between 37 0/7 and 38 6/7 weeks gestation. • Numerator: Number of infants admitted to the NICU (or transferred to another hospital) • Denominator: Number of singleton births by elective delivery (scheduled induction or cesarean section) between 37 0/7 and 38 6/7 weeks

  49. What week is delivery counted in? • Baby is born in the 36th week and 6/7th day • Baby’s gestational age is 36 weeks • Baby is born in the 38th week and 6/7th day. • Baby’s gestational age is 38 weeks • Baby is born in the 39th week and 1/7th day • Baby’s gestational age is 39 weeks

  50. Scenarios • Angela was induced and delivered in the 37th week and did not have any medical conditions • The birth is counted as an early elective delivery since the timeframe is greater than or equal to 37 weeks • Alyssa was induced and delivered in the 38th week and she has preeclampsia • The birth is not counted as an early elective delivery as preeclampsia counts as a medical condition • 65 year old Joan was induced and delivered in the 38th week • The birth is not counted as an early elective delivery as age of 65 or older is not counted in the rate • Rita was induced and delivered in the 39th week and did not have any medical conditions • The birth is not counted as an early elective delivery as the baby is not within the >=37 week through <39 weeks

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