TipQC—Tennessee initiative for perinatal quality Care

Mission Tennessee Initiative for Perinatal Quality Care (TIPQC) seeks to improve health outcomes for mothers and infants in Tennessee by engaging key stakeholders in a perinatal quality collaborative that will identify opportunities to optimize birth outcomes and implement data- driven provider- and community-based performance improvement initiatives.

Goals of Tipqc Establish a statewide perinatal database Foster state-wide quality improvement initiatives to reduce mortality and morbidity associated with premature birth and low birth weight Promote system changes by provider organizations to increase use of evidence based clinical practices for obstetric and NICU patients

Maternal arm Reduction of elective deliveries before 39 weeks Breastfeeding Promotion—delivery and post partum Obstetric hemorrhage

Infant Arm NICU temperature project Golden Hour Central line infection Human milk for NICU Antenatal steroids Neonatal abstinence syndrome project Hospital acquired infection NICU nutrition and growth

Why Invest Time and money?? Improves health of mothers and infants Saves healthcare dollars Gives hospitals tools to standardize important measures Idea sharing and collaboration It is the right thing to do

Breastfeeding and neonatal mortality Chen and Rogan 2004 Breastfeeding showed reduction of mortality for infants 28 days-1 year Longer breastfeeding had lower risk Ware in 2016 is involved in a study which is confirming this data. Chen A, Rogan W. Breastfeeding and the Risk of Postnatal Death in the United States. Pediatrics 2004. 113:5.

Breastfeeding and neonatal mortality Promoting breastfeeding has the potential to save 720 neonatal deaths in the US each year

Breastfeeding and Neonatal mortality Cochrane Review of 11 papers Early initiation of breastfeeding reduced risk Initiating breastfeeding after first hour doubled risk of mortality Exclusively breastfed neonates had lower risk of mortality than partially breastfed neonates Khan, J. Timing of Breastfeeding Initiation and Exclusivity of Breastfeeding During the First Month of Life: Effects on Neonatal Mortality and Morbidity--A Systematic Review and Meta-analysis. Maternal and Child Health Journal. March 2015, 19:3, 468-79.

Breastfeeding and Neonatal mortality Pneumonia is the leading cause of child mortality in children <5. Optimal breastfeeding had greatest reduction of risk. Lamberti L. Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health 2013. 13:3.

Breastfeeding promotion Project—TipQC 2009 2009 the obstetrical community voted to develop a project to promote breastfeeding Joint commission perinatal core measure 05—exclusive breastmilk feeding at discharge as the project outcome measure—goal to increase by 10% Project in 3 parts: antenatal, hospital, and postnatal

Quality Improvement Why do we care? How do we improve? Attitude that says we have room for improvement How do we improve? By being perpetually curious and looking for the next step not the whole answer Small behavior changes can have ripple effects

UT/St. Francis A primary care residency clinic that provides full- spectrum care for patients—this includes OB and pediatric care Faculty include 11 family medicine physicians, 2 OB/GYNs, 2 pharmacists and 1 therapist 24 1st-3rd year residents

Our multidisciplinary team--Bridgette Erasmus, MA, Katosha Muse-resident, Andrea Green lpn, Lisa Canon RN, and myself

Importance of Early intervention Studies have shown 50-90% of pregnant women decide how they will feed their child either before becoming pregnant or very early in their pregnancy5 Breastfeeding intentions appear to be significant predictors of breastfeeding initiation and duration6

Comparing rates Source: CDC Breastfeeding Report Cart—United States, 2009. St. Francis patient info from deliveries June 1, 2009-Nov 30, 2009 three month info actually 2 month info.

Demographics for Breastfeeding Behaviors5 Women who breastfeed for longer durations tend to be: Caucasian Older Married Better educated Have higher incomes

Demographics of St. Francis Patients

Demographics of St. Francis Patients

Demographics of St. Francis Patients

Demographics of St. Francis Patients INSURANCE Tenncare 88.1% BlueCross 5% Cigna 4% Other 3%

Baseline Rates

AIM The aim of this project is to improve the health of infants and mothers in Tennessee by increasing initiation and duration of breastfeeding through systematically promoting breastfeeding at prenatal care visits. While barriers to successful breastfeeding exist in multiple settings, we will focus on high reliability (>90%) implementation of processes that promote breastfeeding in the prenatal clinic. Thus, we seek to increase the fraction of infants who are fed breast milk at the maternal post-partum visit by 50% by March 2012.   Caption for the following 7 slides

PROJECT PLAN (LAUNCHED 11.1.11)   Provide at first provider visit: “ Breastfeeding vs. Bottle feeding” handout Document on ACOG blue sheet At 1 hour GTT office visit: Patient will view a breastfeeding DVD Provide at GBS visit: MALCA handout “Breastfeeding: Hints to a Good Start” handout “Prescription for Breastfeeding” for provider to dispense / discuss Continue to conduct six week PP visit infant feeding survey For baseline and outcome measurement

FIRST TRIMESTER SECOND TRIMESTER THIRD TRIMESTER Gave “Breastfeeding vs. Bottle Feeding” Gave USDHHS book Date­­­­______ Signature____________________________ Viewed Breastfeeding DVD at GTT visit Gave “101 Reasons to Breastfeed” Date______ Signature_______________________ Gave MALCA Trifold Gave “Breastfeeding Hints” Date_______ Signature_________________________ Physical Exam of Breasts Discuss benefits of breastfeeding Discuss exposure to breastfeeding and barriers Barriers:____________________________ ___________________________________ Breastfeeding Plans: Breast/Formula/ Undecided Duration: _______Months Date___________ Discuss breastfeeding plans and address barriers Breast/Formula Date__________ Gave ”Rx to Breastfeed” Discuss skin to skin contact at delivery and importance of initiating breastfeeding immediately Discuss plans for rooming in PROVIDER SIGNATURE (AS REQUIRED)­­­ ______________________________________________________

UT Medical Group, Inc. Family Medicine - St Francis Prescription: At least six months of Breast Milk for Baby________________ Start date: At Birth Benefits for baby: • Lower risk of: • Sudden Infant Death Syndrome (SIDS), • Being severely overweight (obese), • Infections, asthma, diabetes, ear infections, and allergies • Higher IQ (on average, compared to babies who are only formula fed) • Breast milk is easier for baby to digest than formula • Breast milk has all the nutrients, calories, growth factors, & fluids a baby needs to be healthy Benefits for Mom: • Releases body hormones that promote mothering behavior • Saves money and time (breast milk is free and always ready and available!) • Help lose the “baby” weight • Help prevent postpartum depression • Lower risk of breast and ovarian cancer • Lower risk of osteoporosis (weak bones) _______________________________________, MD Flip over for more  Prescription to breastfeed is intended for educational purposes only

OUTCOME MEASUREMENT Six Week PP Visit: Infant Feeding Assessment: How is baby currently fed? Check one:  Breast milk only (breastfeeding and/or pumped breast milk) Breast milk and formula  Formula only Has baby been readmitted to the hospital? Yes No  

Project Data (as of 2/24/12)

Breastfeeding Promotion Outcomes 11 hospitals joined project by 2012 Increased exclusive breastfeeding at discharge from 37-42% which is a relative increase of 13.5% In 2013 the project teams voted to continue to work to implement the 10 steps to successful breastfeeding

Why Invest Time and money?? Improves health of mothers and infants Saves healthcare dollars Gives hospitals tools to standardize important measures Idea sharing and collaboration It is the right thing to do