Elizabeth Herlihy, BSN, MS NYSDOH Immunization Program Promoting Universal Hepatitis B Birth Dose Policy through LQA Hospital Reviews in New York State Elizabeth Herlihy, BSN, MS NYSDOH Immunization Program

LQA Hospital Review Lot Quality Assurance: A method to evaluate compliance with Perinatal Hepatitis B Prevention Program in upstate New York. A type of quality control developed in the manufacturing industry.

LQA Methodology LQA: Sampling of a “lot” - in this case medical records from a six month birth cohort. Records are reviewed for “deficiencies” (e.g. failure to record maternal HBsAg status in the maternal or infant record).

LQA Methodology con’t NYS PHL mandates testing, reporting, and recording of maternal HBsAg status 100% of the records reviewed must contain HBsAg status in both maternal and infant record “Certificate of Excellence” awards for 100% compliance and birth dose policy

Advantages of LQA Review Takes less time - fewer records reviewed Review performed by DOH staff rather than hospital staff Quality Assurance activity - systematic review of perinatal hepatitis B activities for the hospital

Advantages con’t Ensures compliance with PHL Valuable educational opportunity Opportunity for local DOH to interface with local hospital Provides opportunity to promote universal hepatitis B birth dose policy!

Birth Dose Survey In April 2001, birth dose survey mailed to 118 upstate New York birthing hospitals: Only 12% had re-instituted a universal birth dose policy! 25% gave birth dose per provider preference 63% did not have a hepatitis B birth dose policy!

Recommendations Document maternal HBsAg in BOTH the maternal and infant record Use “maternal HBsAg” terminology in records Include date of test, as well as result Include hard copy of HBsAg lab results in hospital record

Recommendations con’t Re-test high risk mothers in late pregnancy or at time of delivery Must have “stat” testing capability for “unknowns” Use MMR instead of single antigen rubella for mothers with negative or equivocal titer

Recommendations con’t Document vaccines administered thoroughly and share VIS with parents Provide vaccination record for parents Share current immunization information with all parents Establish process to inform PCPs about vaccines administered in hospital

Recommendations con’t Establish process to inform PCPs and county LHDs about high risk infants Establish a written policy for perinatal hepatitis B prevention Establish universal hepatitis B birth dose policy!

LQA Results 87 LQA visits have been conducted at 68 birthing hospitals 20 of the hospitals have had one or more deficiencies and required a repeat visit following corrective actions Only 5 of the hospitals have adopted a universal birth dose policy following LQA review

Goals for 2003 Continue LQA reviews - target hospitals not yet visited as well as those found to be out of compliance with PHL Provide free hepatitis B vaccine to all upstate birthing hospitals that adopt a universal hepatitis B birth dose policy!