Perinatal HIV Chart Review - Florida Please include the title of your presentation, your full name and affiliations (including your role within the AETC, if applicable). JoNell Potter, PhD Robert Lawrence, MD Sheryl Carney, RN

Background- Why Did We Do This? Review of cases (missed opportunities) from DOH data; Developed a chart review tool headed by Rivero & Potter; Met with Florida Perinatal Nurse Coordinators at Annual Florida AETC meeting in October 2012 to engage & inform about the process; January 29, 2013: Letter to RPICC Medical Directors from DOH announcing the plan for a quality review of perinatal HIV (9 Centers in Florida); Some sites resistant - no outside reviewers, need IRB approval, no response from some, logistics complicated at some sites (multiple providers).

Plan: What We Did & How We Did It Develop & Refine Perinatal Chart Review Tool Pilot Tool in S. Florida (WPB, Broward, Miami-Dade) Host a Statewide Summit for Key Stakeholders DOH & AETC to Co-Host: Invite & Engage RPICC Medical Directors & Florida Perinatal Nurse Coordinators DOH to Present Data on History of Perinatal HIV in the State and on New Perinatal HIV cases AETC to Present Summary of Findings from South Florida Perinatal Chart Reviews Develop a Strategic Plan for the Future

Regional Perinatal Intensive Care Centers (RPICC) Centers in Florida Tampa General Hospital - Tampa, FL Shands Teaching Hospital - Gainesville, FL Shands -Jacksonville - Jacksonville, FL Jackson Memorial Hospital, Jackson Health System - Miami, FL Sacred Heart Hospital - Pensacola, FL Winnie Palmer Hospital at Arnold Palmer Med. Center - Orlando, FL All Children’s Hospital - St. Petersburg, FL Bayfront Medical Center - St. Petersburg, FL St. Mary’s Medical Center - West Palm Beach, FL Broward General Medical Center - Ft. Lauderdale, FL Memorial Regional Medical Center - Hollywood, FL Lee Memorial Health System - Ft. Myers, FL

Significant Findings from Pilot Perinatal Record Reviews Lack of communication and consistent documentation between HIV providers, prenatal providers, L&D providers & pediatric providers; EMRs on different operating systems & not available to all providers across disciplines, clinics & hospitals.

From Our Reviews: Specific Guidelines Not Being Followed Vaccinations in pregnancy; Tuberculosis screening; Hepatitis testing – A, C in particular; Accurate history of cART use in previous pregnancies; VL done 2-4 weeks after initiating or changing cART; VL at 34-36 weeks gestation to guide decisions for delivery mode; Documented resistance testing – prior, current, and in patients with elevated VL despite therapy; Accurate documentation in L&D notes of cART used during pregnancy, last dose (date & time) once admitted to L&D; Documentation of whether the mother received a prescription or the actual medication (ZDV) for the infant before discharge.

Significant Findings from Pilot Perinatal Record Reviews Little documentation of appropriate standard counseling of risks associated with cART during pregnancy, the impact of poor adherence & risk to sexual partners/neonates, pre-mastication, & follow-up care for mother & newborn. Gaps in communication regarding pertinent data on mother (VL at/prior to delivery, no PNC, etc.) to create a strategic plan for management in L&D & an emergency consultation to pediatrics for evaluation of risk and “does this baby need more than ZDV?”

Problems to be Addressed with Non-Compliance with Guidelines Problem- Inappropriate Management Issues Solution- Engage providers & offer education & training through F/C AETC; Problem-Despite education and training, individual providers not willing to accept intervention/education and/or follow guidelines, placing women & neonates at risk; Solution- How can this be addressed appropriately & by whom?

Proposed Ideas for the Future Use of a Perinatal Chart Review Tool - Use as a Quality Measure or use components as individual - Performance Measures to review practice and improve performance Tracking - Reporting of HIV positive deliveries at time of delivery or earlier - Reporting and Tracking of HIV exposed infants thru DOH Data Management / Exchange / Communication - Standard information to be reported - Electronic record and exchange of information overseen by DOH Local Perinatal HIV Transmission Prevention Team  Best Practices Model - Reproduce the model in each area around the state - Adapt the model to specific issues in different locales

Perinatal Chart Review Tool Subject #: Reviewer: Review Date: Demographics - SECTION 1 1. Mother’s Age at 1st Visit 2. Race: 1. African American/Black 2. White 3. Asian 4. American Indian/Alaska Native 5. Native Hawaiian/ Pacific Islander 3. Hispanic, Latino, or Spanish Origin? O Yes O No 4. Primary Language:_______ Translator O Yes O No

Perinatal Chart Review Tool 5. Payment Source: 1. Medicaid 2. Private Payer 3. Self Pay 4. SSI 5. Medicare 6. Other ______

Perinatal Chart Review Tool Comments:

Perinatal Chart Review Tool HIV Management in Pregnancy – SECTION 2

Perinatal Chart Review Tool Yes No N/A Comments:

Perinatal Chart Review Tool Monitoring During Pregnancy – SECTION 3 Comments:

Perinatal Chart Review Tool Baseline Labs/Testing – SECTION 4

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Perinatal Chart Review Tool Vaccines and TB Screening – SECTION 5

Perinatal Chart Review Tool Hepatitis – SECTION 6 Comments:

Perinatal Chart Review Tool CD4 – SECTION 7 Comments:

Perinatal Chart Review Tool Viral Load – SECTION 8 Comments:

Perinatal Chart Review Tool Resistance Testing – SECTION 9 Comments:

Perinatal Chart Review Tool Opportunistic Infections – SECTION 10 Comments:

Perinatal Chart Review Tool Initiation of ARV Therapy – SECTION 11

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Perinatal Chart Review Tool Antepartum ARV Therapy – SECTION 12

Perinatal Chart Review Tool

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Perinatal Chart Review Tool Labor and Delivery – SECTION 13

Perinatal Chart Review Tool Delivery Information – SECTION 14

Perinatal Chart Review Tool Testing/Care of Infant if Mother’s HIV Status is Unknown SECTION 15

Perinatal Chart Review Tool Follow Up: Mother – SECTION 16

Perinatal Chart Review Tool Infant Antiretroviral Prophylaxis – SECTION 17

Perinatal Chart Review Tool

Perinatal Chart Review Tool Follow Up: Baby – SECTION 18