A8b8idealizeddesignofperinatalcare

A8/B8: Idealized Design of Perinatal Care

Perinatal Session at Forum 2005 Frank Federico Peter Cherouny, MD Frank Mazza, MD Patricia Constanty, CNS

$23.8m award in childbirth lawsuit 2 doctors faulted at Mass. General By Scott Allen, Globe Staff | May 11, 2005 http://www.boston.com/business/articles/2005/05/1 1/238m_award_in_childbirth_lawsuit/

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A8/B8: Idealized Design of Perinatal Care

Why focus on perinatal care? • Rate of claims is low; payment if high • Good science exists • Significant variability in process

© 2005 Institute for Healthcare Improvement

What is Idealized Design of Perinatal Care • Idealized design enables the system to do better in the future than the best it can do today. • Idealized Design ™ has been developed by the Institute for Healthcare Improvement (IHI) to bring together organizations that are committed to comprehensive system redesign. © 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

What is Idealized Design of Perinatal Care • “If we were to deliver ideal perinatal care, what would the system of care look like?” • “What processes are components of the ideal perinatal care system?” • Clinical processes (special attention to high risk whether physiological, legal, psychological) • Communication and teamwork • Mother and family preferences © 2005 Institute for Healthcare Improvement

Design Targets • Reduce neonatal harm to 3.3 per 1000 births or less • Patients state that 95% of the time their wishes are known to the entire team and respected • The care team reports that a 50% improvement in culture survey score. • All claims or allegations may be defended because 95% or more of claims meet each institution’s internal standards for defense (e.g., consistent documentation, no lapses in documentation, no lapses in communication) © 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Woman and family as the source of control Productive conversations

Prepared and activated teams RELIABLE PROCESSES

Prepared and activated mom EVALUATE ADMIT

PREVENT

FIRST STAGE LABOR

SECOND STAGE LABOR

IDENTIFY

Informed & ready receiving unit; Stabilized mom BIRTH and baby

MITIGATE

APPROPRIATE INFRASTRUCTURE © 2005 Institute for Healthcare Improvement

What does this have to do with reliability? • What: Best science for the care we deliver – Research and expert opinion

• How: the method we use deliver that care – this is the focus of our work- discovering the way to reliably deliver the best care every time

• Way: use of reliable design and an articulated goal for each of the processes of care that we think will make the most difference and are outlined in the model

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Our work Phase I • Common language • Elective Induction Bundle • Augmentation Bundle • Application of reliability model • Communication and Teamwork Training

Phase II • Common Interpretive Construct • Reliability • Patient Preference • Harm measure: OB trigger tool • Identification of risk

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Peter Cherouny, M.D. Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology University of Vermont College of Medicine

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics • What we say – Priorities for Action were chosen based upon national indicators or data sets chosen by AHRQ, NQF, and/or other national safety organizations. Excellence in these priority areas... – The strategy calls for an individual ministry to develop that blueprint, pilot the spread to four or five Beta sites, and then lead the dissemination of the strategy/change package… © 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics • What we hear – Blah blah blah blah quality blah blah blah blah outcomes blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah quality blah blah blah outcomes blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah blah © 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Definition – Cases of birth trauma per 1,000 liveborn births.

• Numerator – Discharges with ICD-9-CM code for birth trauma in any diagnosis field per 1,000 liveborn births.

• Denominator – All liveborn births. – –

Exclude infants with a subdural or cerebral hemorrhage (subgroup of birth trauma coding) and any diagnosis code of pre-term infant (denoting birth weight of less than 2,500 grams and less than 37 weeks gestation or 34 weeks gestation or less). Exclude infants with injury to skeleton (7673, 7674) and any diagnosis code of osteogenesis imperfecta (75651).

© 2005 Institute for Healthcare Improvement

Birth Trauma Definition

• We know it when we see it

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Birth Trauma Definition

• Most birth trauma is self limited with an eventual favorable outcome • Difficult to separate traumatic birth injury from hypoxic-ischemic injury

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma

• Frequency – Rate: 6.34 per 1,000 population at risk – Accounts for less than 2% of neonatal deaths and stillbirths – Bias: Did not undergo empirical testing of bias

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Rate – Coding validity. A study of newborns who had a discharge diagnosis of birth trauma found that only 25% had sustained a significant injury to the head, neck, or shoulder.

• Reliability (S/N ratio) – proportion of the total variation across hospitals that is truly related to systematic differences (signal) in hospital performance rather than random variation (noise) © 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma

• What do we do to babies? – Soft tissue injuries • • • • • •

Caput succedaneum Cephalohematoma (90% may be misdiagnosed) Subgaleal hematoma Abrasions and lacerations Intraperitoneal bleeds Hepatic rupture

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma

• What do we do to babies? – Nerve injuries • Brachial plexus injury • Cranial nerve injury • Spinal cord injury

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma

• What do we do to babies? – Bone injuries • Clavicular fracture • Long bone fracture • Epiphyseal dysplasia

© 2005 Institute for Healthcare Improvement

Birth Trauma

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Can we reduce birth trauma? – Estimated that about 50% is potentially avoidable through anticipation

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma • Causation – Large fetuses – Operative vaginal deliveries (esp midpelvic & combined) – Vaginal breech delivery – Inappropriate use of pitocin – Abnormal/excessive traction

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • How do we reduce birth trauma?

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma • Reducing birth trauma – Don’t deliver large babies – Don’t do operative vaginal deliveries (esp midpelvic) – Don’t do vaginal breech delivery – Don’t use pitocin – Be gentle; avoid abnormal/excessive traction

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Don’t deliver large babies – Offer cesarean section for diabetic fetuses greater than 4500 gms or nondiabetic fetuses greater than 5000 gms – The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold's maneuvers) Fetal Macrosomia. ACOG Practice Bulletin #22, November 2000 © 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma

• Don’t deliver large babies – With an estimated fetal weight greater than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery – Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes Fetal Macrosomia. ACOG Practice Bulletin #22, November 2000 © 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Operative vaginal deliveries – Be comfortable with fetal and pelvic assessment • • • • •

Position Presentation Engagement Asynclitism Clinical Pelvimetry

– Midpelvic deliveries should be rare, while setting up cesarean room Operative Vaginal Delivery. ACOG Practice Bulletin #17, June 2000 © 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma Don’t do vaginal breech delivery – As a result of the findings of the study, planned vaginal delivery of a term singleton breech may no longer be appropriate

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356:1375–1383

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Don’t use Pitocin – Know everything about the drug – Have a well established policy for Pitocin use and follow it

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics Birth Trauma • Be gentle; avoid abnormal/excessive traction – Manage shoulder dystocia in a standard fashion – Don’t use fundal pressure – Break the bed down – Have adequate help around – Practice this emergency © 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Quality Care in Obstetrics Birth Trauma • Process measures • Team based care • Quality review – Don’t wait for the problem – Review all at risk procedures – Use it as an educational tool – Someone is watching

© 2005 Institute for Healthcare Improvement

Seton Experience Dr. Frank Mazza, MD

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A8/B8: Idealized Design of Perinatal Care

The SETON Healthcare Network • 8 Acute Care Hospitals (5 Urban, 2 Rural, 1 Psychiatric) – Serves population of 1.4 million from 11 counties – Level II Trauma Center, dedicated Children’s facility, full range of services, e.g., Cardiac (and other) Transplantation – Magnet Nursing designation for 4 ‘Austin Hospitals’

• Obstetrics Care Performed in Four Facilities – SMC - tertiary care referral center - offers high risk OB care – level 3 nursery – Brackenridge – teaching facility – offers high risk OB care – level 3 nursery – SNW – medium sized – level 2 nursery – SSW – small, semi-rural – level 1 nursery – Total 8,300 deliveries per year

© 2005 Institute for Healthcare Improvement

Induction Rate by Physician Seton Healthcare Network 100%

90%

80%

70%

60%

Rate

n11

50%

40%

m8 n4 n8

UCL

n6 n2 n15

n1 m16

30%

Mean = 30.0%

n12 n9

n14

2s n10

n7

1s m20

m2

m17

n3 m22

20%

10%

m7 m9 m15 m10 m1

m23 m3

m4 m12

m11 m18m25

m5 n5

m21n13 m24 m19

m14

1s 2s

m13 LCL m6

0%

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Instrumented Delivery Rate By Physician Seton Healthcare Network 25%

20%

n7

m 16 n12 m3

15%

m 14 b3 m 13 s1 m 17 m 10 m12 m6 m24 m2

10%

2s

m25 n4 m21 m15 m7

Mean = 8.6%

5%

UCL b6

1s

m8 n3 m11 m18 n9 b5 m1m22 n6

m19m20 m4

m5

1s b2 n5 n2 n8

s3

2s b7 n13 b1 b4 m23n14

n1 m9

LCL n10 n11

s2

s4 n15

0%

© 2005 Institute for Healthcare Improvement

Forming the Work Group • Interdisciplinary team • Commitment to ‘High Reliability’ (alpha site for Ascension Health) • ‘Evidence-Based’

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

The Oxytocin Innovation Bundle Elective Induction Bundle • Gestational Age >/= 39 weeks • Reassuring Fetal Status • Pelvic Exam prior to the start of Oxytocin • Absence or management of Hyperstimulation with increases in Oxytocin

Augmentation Bundle • Documentation of Estimated Fetal Weight • Reassuring Fetal Status • Pelvic Exam prior to the start of Oxytocin • Absence or management of Hyperstimulation with increases in Oxytocin

© 2005 Institute for Healthcare Improvement

Elective Induction Bundle Seton Northwest Hospital

Seton Medical Center

Seton Southwest Health Center

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Augmentation Bundle Seton Northwest Hospital

Seton Medical Center

Seton Southwest Hospital

Seton Brackenridge Hospital

© 2005 Institute for Healthcare Improvement

Elective Inductions Prior to 39 Weeks Seton Healthcare Network FY05-Q1 FY05-Q2 FY05-Q3 FY05-Q4 FY06-Q1

N um ber of C ases

35 30

27

29 25

25

22

20 15 10 5

10 4 5

0

SMC

1

0 0

SNW

4 3 2

0 1

SSW

0 0 0 0 0

BH

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Seton Healthcare Network Birth Injury Rate 7/1/2000--6/30/2005

1%

0.46% 0.43% 0.40% 0.37% Mean = 0.31% 0.32%

0.41% 0.24% 0.23% 0.22%

0.31%0.33% 0.32% 0.30%

0.25% 0.26%

0.14%

F Y 05-Q 3

F Y 05-Q 2

F Y 04-Q 4

F Y 04-Q 3

F Y 04-Q 2

F Y 04-Q 1

F Y 03-Q 4

F Y 03-Q 3

F Y 03-Q 2

F Y 03-Q 1

F Y 02-Q 4

F Y 02-Q 3

F Y 02-Q 2

F Y 02-Q 1

F Y 01-Q 4

F Y 01-Q 3

F Y 01-Q 2

F Y 01-Q 1

F Y 05-Q 1

0.11% Mean = 0.06%0.05%

0%

UCL 2s 1s 0.05% 1s LCL F Y 05-Q 4

0.34%

© 2005 Institute for Healthcare Improvement

Lessons Learned • Use small tests of change • OB Units already highly standardized – Took advantage of existing documents – “Make it easy to do the right thing”

• Documentation of estimated fetal weight was an early success. • Hyperstimulation element of bundle remains a challenge. © 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Thomas Jefferson University Hospital Experience Patricia Constanty, CNS

Augmentation Bundle

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Elective Induction Bundle

© 2005 Institute for Healthcare Improvement

Physician Engagement • Physician Champion • Agreed to test sticker • Proactive work with resident group

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

TJUH Success Stories • Inductions -Compliance with gestational age, pelvic adequacy and documentation of fetal reassurance prior to oxytocin • Augmentations – Compliance with fetal weight, pelvic adequacy and fetal reassurance prior to oxytocin

© 2005 Institute for Healthcare Improvement

© 2005 Institute for Healthcare Improvement

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A8/B8: Idealized Design of Perinatal Care

Challenges at TJUH • Agreement with both nurses and physicians – definition of hyperstimulation • Agreement with intervention when hyperstimulation occurs

© 2005 Institute for Healthcare Improvement

Questions

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A8/B8: Idealized Design of Perinatal Care

For more information visit www.IHI.org

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