Perinatal Hepatitis B Program Evaluation Department of Public Health Immunization Program Pat Hoskins-Saffold, RN, MSN and Steven Terrell-Perica, MA, MPH, MPA April 23, 2008

Overview  Hospital recruitment  Mailings  Volunteer recruitment  Sampling methodology  Hospital audits  Feedback sessions  Results

Hospital Record Reviews  Chicago Demographics  Population size: 2,896,016*  Number of birthing hospitals: 24  Number of live births: 47,958*  Expected HBsAg births: 286†  Identified HBsAg births: 141‡ * US Census, 2000 † CDC, 2004 ‡ CDPH, 2004

Chicago Birthing Hospitals N=24

Timeline February 1, January 15, 2007 Week 1: Identified delivery hospitals Week 2: Mailed CDC’s audit packets to 5 hospitals Week 3: Mailed CDPH packets to 24 hospitals Week 4: Recruited volunteer auditors and scheduled audits Week 5: Trained auditors Week 6: Hospital audits began

Timeline-Cont’d  March 5 - August 24, 2006  Hospital audits  August 1, January 5, 2007  Data entry  September 26, January 15, 2007  Feedback sessions

February: Week #1  CDPH clerical staff contacted 24 Chicago hospitals:  Determined if Labor & Delivery units were still open  Obtain current information on the maternal child health (MCH) administrative teams Chief Obstetricians and Pediatricians Nursing Directors Infection Control Practitioners (ICPs)

February: Week #2 Began CDC Audits  CDC’s National Audit:  Chicago: 5 participating hospitals  25 mother-baby pairs  250 records total  CDC and CDPH worked together to modify the data abstraction tools  Mailed CDC’s packets

February: Week #3 Mail, and faxes  Notifications sent on “Official CDPH letterhead” to 24 ICP’s and MCH Nursing Directors  Letter contents: CDPH objectives Policy survey HIPAA disclosure Participants’ roles and expectations during the chart audit 2005 ACIP Childhood Hepatitis B Recommendations

February: Week #4  Recruited auditors:  Within CDPH Immunization Program  volunteers  Began scheduling hospital audits:  CDC’s 5 participants  Chicago participants

March: Week #5  Training Auditors  Auditors from various programs within the Immunization Division were trained to review and abstract information from medical records 2 groups Morning Afternoon  Several private sessions

March: Week #6  Began chart audits:  2-3 days prior to scheduled visits, appointments were confirmed for readiness: Audit dates, times, space & locations, parking availability, and completion of the Policy Surveys Policy Surveys were picked up on the day of the audit Extended deadlines were discussed and arranged between nursing administration or their delegates and the PHB Coordinator

Sample  Sample Selection:  October 2005 to present  The first 60 pairs, beginning October 1 st, 2005 to current date, audits ended August 2006  Sample Size:  Maternity wards prepared a delivery list  Health Information Management (HIM) often pulled the charts  60 mother-baby medical pairs (120 records per hospital)  1,453 chart pairs reviewed for 24 birthing hospitals

Data Collection Tool*  Mother datasets  Demographics: DOB, Admit date and time, Race/Ethnicity, and Insurance information  Prenatal Testing: Provider and type HBsAg/HIV screening and results, date, and time  Admission testing: Provider and type HBsAg/HIV screening and results, date, and time *Screening Assessment Tally Sheets (SATS) were used to collect data.

Data Collection Tool-Cont’d  Infant datasets  Delivery: Date/time/weight Documentation of maternal HBsAg/HIV results  Medications: Documentation of HBV-1 dose and/or HBIG, when needed Time/date  Reasons for not Vaccinating: <2000gms Infant medically unstable Mother Refused, etc.

Audit Time Needed at Hospitals:  Between 2-6 hours, depending on…  Sample Size (i.e., 60 record pairs)  Number of available auditors  Appropriateness of the sample Correctness of the review period Completeness of the sample Appropriate mother-baby pairs

Staffing  6 auditors recommended for 60 chart pairs  1 auditor per 12 record pairs (Approx. 2-3 hours with appropriate sample preparations)  1 coordinator Assessing the sample to ensure the sample review period is correct and mother-baby pairs are matching (approx. 15 to 30 minutes). Troubleshooting problems, i.e., call medical records for mismatched records, locating a document, or selecting and replacing pairs (approx. 10 to15 minutes). Reviewing audit forms for completeness and accuracy Covering breaks (15 or 30 minute)

Time Consumers!!!  Hardcopy files  Electronic medical records  Hospitals in transition of changing to an electronic medical records system

Hard Copy Files  7-12 minutes per record:  Records may not be matched or in the appropriate sequence  Difficult searching through admission profiles, physician orders, laboratory reports, L/D & OB records, progress notes, etc.  Concerns with legibility and readability (i.e., Hand written vs. typed documents)  Medically unstable infant charts contained more records and took longer to review

Electronic Medical Records  7-15 minutes (per record):  Omitted data must be retrieved from hard copy files  Baby not linked to mother via her Medical Record Number (MRN)  Maternal screening results (HBsAg) were not always entered on the computer laboratory page but was embedded in admission profiles  Hepatitis B vaccine and HBIG administrations were frequently documented in the L/D, OB or nursing pages, rather than on the medication page

Transitioning Hospitals  minutes:  Waiting around System clearance Access codes  Records may have been in “the data entry process” Could not be located, waiting to be processed Critical information often omitted during the data entry process

Feedback to Hospitals  Time between audits and hospital feedbacks averaged 6-7 months  Audit results were mailed 2-3 weeks prior to scheduled feedback sessions  Permitting hospitals time to review results and validate current practices  Discuss concerns with staff and ancillary teams (i.e., CNE, ICP’s, QA management, obstetricians, pediatricians, and the pharmacists).  Prepare relevant questions for the feedback session

Feedback Session Invitations  Invitations mailed to MCH nursing directors  Invited policy makers  Chief Obstetricians  Chief Pediatricians  OB and L/D Nurse Administrators  Infection Control Coordinators  Quality Assurance Managers  Pharmacists  Clinical Nurse Educators

Feedback Session Content  Results of the chart audit and policy surveys  Recommendations for the areas needing improvements:  Practice issues  Policy issues  Access to “free” vaccine  Vaccine For Children (VFC) was introduced and enrollment encouraged for hospitals not currently signed up

What did CDPH Learn?

2006-Chart Audit Findings  Improvements (4 years later)  16% increase in prenatal HBsAg screening documentation  2% increase in screening on admission for women with no prenatal screening  49% increase in maternal screening results documented in infant records  22% increase in infants receiving the first dose of hepatitis B vaccine before leaving the hospital

Hospital Policy Survey Results, 2006 Maternal PolicyStanding Order Review HBsAg status on admission67%42% Screen on admission if no prenatal screening 67%50% Repeat HBsAg screening for high risk mothers 25%0% Infant Document maternal HBsAg status in infant chart 63%0% Universal birth dose79%83% HBsAg-positive, HBIG/HepB, within 12 hrs79%83% HBsAg-unknown, HepB, within 12 hrs67% N=24 hospitals, response rate 100%

Percentage of Infants Receiving Hepatitis B Vaccine before Discharge “Many hospitals expressed surprise at falling behind other hospitals in their area. Hospitals were pleased CDPH did the audit. Hospitals with low percentages promised to improve perinatal hepatitis B prevention services.”

Challenges Conducting the Reviews  Lacked coordinating secondary contacts who understood the records review process  Policy surveys were incomplete  Inadequate health department staff  Sample:  Records did not coincide with the record review period  Incomplete documentation  Illegible documentation  Unavailable records (i.e., records stored off site)