AHA/HRET HEN: Data and Coaching Webinar: Early Elective Deliveries Data Review June 7, :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. – 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 us: Agenda: – EED Measures – Content Review – Hospital Story – Teach Back 2

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, beds D. Not CAH, 300+ beds 3

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 4

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

Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Elliott Main, MD Chair, California Quality Care Collaborative (CMQCC) Chair, Department of Obstetrics and Gynecology, California Pacific Medical Center, San Francisco

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: or

1)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. 2)There are numerous maternal and fetal indications for deliveries PRIOR to 39 weeks gestation 3)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. 8 Key Points

Terminology First day of LMP 0 Week # 37 0/7 41 6/7 PretermPost term 34 0/7 Term Modified from Drawing courtesy of William Engle, MD, Indiana University 20 0/7 Raju TNK. Pediatrics, 2006; Oshiro BT Obstet Gynecol 2009;113: /7 Late PretermEarly Term The “New” Term

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)

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

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

Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks See Toolkit for more data and full list of citations Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997 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

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 Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes Tita AT, et al, NEJM 2009;360:111

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

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

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! New Concept: U-Shaped Curve for near-term Neonatal Outcomes

NICU Admissions By Weeks Gestation Deliveries Without Complications, NICU Admissions Oshiro et al. Obstet Gynecol 2009;113:

RDS By Weeks Gestation Deliveries Without Complications, RDS Oshiro et al. Obstet Gynecol 2009;113:

Ventilator Usage By Weeks Gestation Deliveries Without Complications, Ventilator Use Oshiro et al. Obstet Gynecol 2009;113:

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

Magee Women’s Experience with Guidelines Baseline 3mos 2004 Voluntary 3mos 2005 Enforced 14mos Deliveries2,1392,26010,895 Elective Inductions <39wks (N) Elective Inductions <39wks (rate) (elective inductions <39 / total elective inductions) % % % (p<0.001) Total Induction Rate24.9%20.1%16.6% “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 Obstet Gynecol 2009;113:797

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

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:

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

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

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

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.

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

Engagement of Providers and Patients Framing: Data is clear about baby risks: 37-38wks >> risk than 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

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

How Do You Measure Elective Deliveries <39 weeks? Perinatal Core Measure: PC-01 v2012B (latest for 2012) Denominator37+0 to 38+6 week births without a STANDARD (listed) Medical or OB complication NumeratorInductions and CS NOT in Active Labor or with ROM Benchmark?? <5% The Joint Commission Measure Definition (NQF endorsed and utilized by others, including LeapFrog, CMS, AMA-PCPI, and many payers)

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

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

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

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

Questions?

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

Why is OB/EED Data 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

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

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)

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 weeks gestation receiving antenatal steroids prior to delivering preterm newborns DVT Prophylaxis - C-Section (OB)

Early Elective Deliveries The 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

Early Elective Deliveries The 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 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

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

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

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)

Early Elective Deliveries The 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

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

Scenarios Angela was induced and delivered in the 37 th 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 38 th 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 38 th 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 39 th 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

Polling Question #2 Has your hospital selected your OB/EED outcome measure(s)? – A. Yes, selected and actively tracking – B. Yes, the measure has been selected – C. No, still researching which measure to select

What happens if the hospital collects an OB/EED measure that isn’t in the Encyclopedia of Measures? Data system allows the hospital to create an organization-defined measure – Hospital specifies the numerator and denominator definitions in addition to entering their data

Polling Question #3 What type of challenges does your hospital have related to collecting data on OB/EED? – A. Collecting birthing data from a manual log – B. Chart review for all OB data is only option – C. Billing data not processed in a timely fashion – D. OB/EED data not given to front-line staff/team in a timely fashion (within 20 days of close of month) – E. All of the Above – F. Combination of A, B, C, D

Polling Question #4 Who is currently reviewing OB/EED data on a monthly basis? – A. Board of Directors/Quality Committee of Board – B. Senior Leadership of your hospital/system (e.g. CEO, VPs) – C. OB Team and/or OB physicians – D. Interdisciplinary OB Team – E. All of the Above – F. Combination of A, B, C, D

What OB/EED Data is Submitted? – Baseline Timeframe flexible Can submit 1 year, 6 months, 1 month, etc. Data set that will be used for comparison to the measurement period(s) – Measurement (2 years) Submitted in monthly increments Data set that will be compared to the baseline to determine if improvement is occurring

OB/EED Data Collection & Submission – Current: Hospital directly enters all OB/EED data into CDS – In Progress: State-level data warehouse OB/EED data gets uploaded to CDS by HRET – Notes: Only collecting aggregate hospital-level data (not unit level, or patient level)

Questions?

AHA/HRET HEN: Data and Coaching Webinar: Early Elective Deliveries Coaching Session June 7, :00 – 3:00 PM, CDT

Welcome and Overview 59 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 us: Agenda: – Content Review – Hospital Story – Teach Back 59

Objectives Discuss best practices in reducing early elective deliveries Lean how other hospitals have implemented tests of change and lessons learned Identify improvement strategies to test in your organization 60

Introductions Shannon McDonnell, MPH, HRET Kim Werkmeister, RN, BA, Cynosure Health Steven Tremain, MD, Cynosure Health Karen Malone, RN, Missouri Baptist Medical Center Alanna Bejsovec, RNc, Rapides Women’s and Children’s Hospital 61

Polling Question #1 Regarding the set up of a hard stop to prevent EEDs: A.We already have one and it works much of the time B.We have one but it is generally ignored C.We are thinking about developing one but don’t know how to get the OB’s engaged D.The OB’s are not interested and threaten to leave if we set one up

Collaborative Care to Eliminate Elective Deliveries Prior to 39 Weeks Gestation Missouri Baptist Medical Center

Missouri Baptist Medical Center Labor and Delivery

12 bed Labor and Delivery Unit – 4 bed APU – 4 bed Pregnancy Assessment Unit – 2 Operating Rooms/ 2 Recovery Rooms Approximately 4,200 deliveries a year Level 3A NICU 170 area physician utilize MBMC

WHAT WERE OUR BARRIERS? o Physicians lacked acceptance of new evidence based best practice for no elective deliveries prior to 39 weeks o Patients lacked informed consent of near term infants o Loss of revenue for the hospitaldue to: Decreased admissions to the NICU Physicians opting to schedule deliveries prior to 39 weeks at other facilities o Lack of collaborative care between nursing and physicians

How Did We Overcome These Barriers? Physician, Staff, and Patient Education – Physicians Used best practice to support delivery decision Recognition of insufficient evidence to support delivery – Charge Nurses Part of a collaborative team with physicians Empowered charge nurses in decision making – Patients Given information on best practice for deliveries Informed consent received through proper patient education

How Did We Overcome These Barriers? Developed and implemented a Policy and Procedure for Elective Delivery prior to 39 weeks  Supportive Director of the Women and Infants Department and the Executive Team  Chief of OB Leadership  Enforcement of policy  Approval of any exceptions to policy  Chief of services supportive to nursing staff  Education of OB Physicians

OUR INDUCTION SUCCESS January January 2006 o 666 inductions performed o 209 prior to 39 weeks o % rate of inductions prior to term January January 2012 o 739 inductions performed o 45medically indicated induction done prior to term o 0 % rate of non medically inductions prior to term

CESAREAN SECTION SUCCESS CESAREAN SECTIONS WERE ALSO REGULATED TO ONLY 39 WEEKS UNLESS MEDICALLY INDICATED. CURRENT RATE IS 0%

What can you learn from our journey? Education is critical Firm enforcement of policy is necessary Empowerment of your Nursing staff-huge benefit Developing a strong chain of command for any variance that may occur for the 39 week delivery policy is extremely important

Feel Free to Contact Us: Lisa Parker, Director of Women and Children’s Services – – Karen Malone, Assistant Nurse Manager – –

State of Louisiana Department of Health & Hospitals Birth Outcomes Initiative 39 Week Initiative Rapides Women’s and Children’s Hospital Alexandria, Louisiana

1 of 3 birthing facilities in Central Louisiana, with over 64% of births at Rapides.

Polling Question #2 The key barrier we face in prevention of EED’s is A.Lack of understanding of the science. B.Lack of physician engagement. C.Lack of administrative leadership and cover. D.Lack of knowledge of the details of implementation.

Women’s Services: > 2400 Deliveries Annually 10 LDR’s 2 NST Clinic Rooms 5 OR’s Day Surgery & PACU 26 Bed Post Partum Unit Well Baby Nursery Level III Regional NICU 24 hr NICU Transport Team

Team Rapides

If you can’t measure it, you can’t manage it. unknown

Add Text Subtitle Add Text, Graph, Picture Blinded Provider Numbers

DHH Birth Outcomes Initiative  March of Dimes Toolkit  Birthing Centers of Excellence  Institute for Healthcare Improvement: Reliable Design Data Measures  Elective delivery rate prior to 39 weeks (TJC PC.01)  Gestational Age Reliability  Cases between elective deliveries < 39 weeks  Cesarean Rate for low risk first birth women (TJC PC.02)  Transfer to higher level of care

2011 Key Strategies Decrease process variability (Hard Stop Policy, admits, orders, standardized documentation of indications) Dedicated Admissions Nurse Continued data sharing with staff and physicians Tying process improvement to outcomes Education, Education, Education, Education

Blinded Provider Numbers

Elective Delivery Rate prior to 39 weeks (TJC PC.01) % pts electively delivered newborns >= 37 and < 39 wks of gestation completed

Polling Question #3 Regarding physician champions: A.The leader is engaged an dis slowly engaging others. B.The leader is engaged but can’t seem to engage others. C.One of the OB’s is engaged but is not a leader and isn’t getting much traction. D.No OB’s are engaged.

87 Questions? 87 ?

Wrap Up and Next Steps Next TOC Reminder: Visit the HRET HEN website: for information, resources and events, such as the additional topic-specific Data and Coaching webinars throughout June and July. Thank you for joining us! 88