INTEGRIS Canadian Valley Hospital

Every Week Counts Collaborative

Terminology

First day of LMP

0Week # 37 0/7 416/7

Preterm Post term

340/7

Term

Modified from Drawing courtesy of William Engle, MD, Indiana University

20 0/7

Raju TNK. Pediatrics , 2006;118 1207. Oshiro BT Obstet Gynecol 2009;113:804

39 0/7

Late Preterm Early Term

The “New” Term

Change in Distribution of Births by Gestational Age: United States, 1990-2006

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for 2006. National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics. 2009.

U.S. Cesarean Section and Labor Induction Rates Singleton Live Births by Week of Gestation,1992 and 2002.

Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April 2006.

2002 Induction

2002 C-S

1992 C-S

1992 Induction

Early Term

Percent of singleton births by gestational age at delivery: Oklahoma, 1991-2008

6Source: Oklahoma Vital Statistics

12/1/2010 1/1/2011 2/1/2011 3/1/20110

10

20

30

40

50

60

70

80

Rate of Scheduled C-Sections by Gestational Age - as percentage of Total Scheduled C-Sections

Rate of Scheduled C-Sections >39 weeks

Rate of Scheduled C-Sections <39 Weeks - Indicated

Rate of Scheduled C-Sections <39 Weeks - NOT Indicated

Impact of Cost

• Average length of stay in L&D for nulliparous women in large, urban hospital of 8,000 birth/year– Induction of labor = 18.7 hours (intensive nursing

care and increased amount of resources)– Spontaneous labor = 11.2 hours

• Average postpartum LOS– C/S after failed induction = 4.2 days– Repeat C/S = 3.8 days– Vaginal birth = 2.0 days Simpson, 2010, J Perinat Neonat Nurs 8

Timing of Fetal Brain Development

• Cortex volume increases by 50% between 34 and 40 weeks gestation. (Adams Chapman, 2008)

• Brain volume increases at rate of 15 mL/week between 29 and 41 weeks gestation.

• A 5-fold increase in myelinated white matter occurs between 35-41 wks gestation.

• Frontal lobes are the last to develop, therefore the most vulnerable.

(Huttenloher, 1984; Yakavlev, Lecours, 1967; Schade, 1961; Volpe, 2001).

A tool to educate patients

marchofdimes.com© 2007 Bonnie Hofkin

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

Mean IQ Scores in 6 yo Children from Healthy Term Pregnancies

13,824 healthy term infants followed for an average of 6.5 years. IQ scores adjusted for multiple factors including: sex, birthweight for gestational age, maternal height and age at birth, smoking and drinking during pregnancy, parental marital status, number of children in the household, parental education and occupation.

Yang et al. Am J Epidemiol 2010;171:399-406

Cerebral Palsy among Term and Postterm Births

Norwegian birth cohort of 1,682,441 singleton term births without congenital anomalies followed for a minimum of 4 years (maximum of 20 years) with identified CP in the National Health Insurance Registry.

Moster et al. JAMA 2010;304:976-982.

CP is 2.3x higher at 37wks and 1.5x higher at 38 wks than at 39-41 wks

Caveats on CNS Outcomes…

• Best outcomes are at 40 weeks.• Note that these studies are associations and

can not show NOT causation.• Nonetheless, the onus is on us to show that

earlier birth is better…

Support for this Initiative comes from across the board

• ACOG strong support• National Quality Organizations

– Joint Commission, Leapfrog, NQF measures• March of Dimes• Many state collaboratives• State Medicaid programs are exploring options

– “Do not pay”, withholds, incentives, pre-auths– Commercial Insurance has acted in other states

JC Core Measure Set

NQF National Consensus Standards for Perinatal Care 2008 (17 measures—9 OB)

• Episiotomy rate• Elective delivery prior to 39 weeks• Cesarean rate for low-risk first births• Prophylactic antibiotics for Cesarean birth• DVT prophylaxis for women having a Cesarean birth• Exclusive breastfeeding at hospital discharge• Birth trauma rate (limited ICD9 codes) • Rate of antenatal steroids for under 34 week births• Infants under 1500g (VLBW) not delivered at

Level III center

OB/Mom

OB/Baby

Leapfrog Group Measures

=Measures that are highest value (Quality + Savings)

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

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;113:804-811.

% Non-medically Indicated Deliveries<39 Weeks, January 1999 – December 2005

Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

% Non-medically Indicated Deliveries<39 Weeks, January 1999 – December 2005

Oshiro, B. et al. Obstet Gynecol 2009;113:804-811.

Superior Outcomes and $1 Million Dollars saved in 2009

Common Themes Noted in Intermountain Healthcare’s Experience

• Education provided to obstetricians regarding ACOG guidelines, best practice.

• Little change until physicians were held accountable, nurses were empowered, and guidelines were enforced.

• Medical leadership important.

Intermountain Healthcare System Initiative

Elective inductions: 28% to >2%

Length of time in labor: decreased by roughly 31 days/year (*this allowed for an additional 1500 births per year without any additional beds or nurses)

Unplanned cesarean sections(with associated costs):reduced to 21% (national average 34%)

Reduction in admissions to Neonatal Intensive Care Unit (and associated costs)

ESTIMATED REDUCTION IN HEALTHCARE COSTS IN UTAH FROM THIS INITIATIVE: $50 MILLION/YRIf applied nationally, would lower healthcare delivery costs by approximately $3.5 billion annually

Magee-Women’s Hospital’s Experience

• Magee-Womens Hospital is the largest maternity hospital in Western Pennsylvania, performing more than 9,300 deliveries in 2007.

• A rise in the use of induction, reaching a high of 28% in 2003, L&D too busy!

• In 2006, a process improvement initiative changed the induction scheduling process and strictly enforced the guidelines.

• “Elective”: not before 39weeks and without cervical ripening agents if 39+0 to 40+6).

Fisch et al Obstet Gynecol 2009;113:797

Magee Women’s Experience with Guidelines

Baseline3mos 2004

Voluntary3mos 2005

Enforced14mos 2006-7

Deliveries 2,139 2,260 10,895

Elective Inductions <39wks (N) Elective Inductions <39wks (rate) (elective inductions <39 / total elective inductions)

2311.8%

2110.0%

304.3%

(p<0.001)

Total Induction Rate 24.9% 20.1% 16.6%

Fisch et al Obstet Gynecol 2009;113:797

“Voluntary”: educational program and dept. recommendations“Enforced”: Department standard requiring approval by the Perinatal Committee Chair

before scheduling non-standard indications for inductions

These are not exhaustive lists!But close… (e.g. prior classical CS)

Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Absolute Risk

Tita AT, et al, NEJM 2009;360:111

0%

2%

4%

6%

8%

10%

12%

14%

16%

Any adverseoutcome or death

Adverserespiratory

outcome(overall)

RDS TTN Admission toNICU

Newborn Sepsis(suspected or

proven)

Perc

ent A

ffec

ted

37+ Weeks

38+ Weeks

39+ Weeks

Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Odds Ratios

Tita AT, et al, NEJM 2009;360:111

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Any adverseoutcome or death

Adverserespiratory

outcome(overall)

RDS TTN Admission toNICU

Newborn Sepsis(suspected or

proven)

Treatedhypoglycemia

Hospitalization >5 days

Odd

s Ra

tios

37+ Weeks38+ Weeks39+ Weeks

Lots of Pressures onObstetricians

Clin Obstet Gynecol 2006;49:698-704

Physician Convenience Guarantee attendance at birth

(“co-dependency”) Avoid scheduling conflicts Reduce being woken at night

…what’s the harm? Bad outcomes are unrecognized and rare The NICU handles these issues just fine

Limit my risk of a bad pregnancy outcome And…payment pressures to deliver own pts

Suspected Fetal Macrosomia(Non-Diabetic Population)

•Does not reduce risk of shoulder dystocia•Doubles risk of cesarean section•262 pregnancies EFW>90%•Elective group:

• 57% cesarean section rate• 5.3% shoulder dystocia

•Spontaneous labor group:• 31% cesarean delivery rate• 2.5% shoulder dystocia

Physicians• Convenience

• Economics• Pt.

Satisfaction

Patients•Convenience

• Comfort• Scheduling

Babies

?Hospital

sCost

Liability Risk

Safety

Board Issues

1. “Of course, why not? Make it policy immediately”

2. What precedent are we setting by elevating this quality assessment item above all the other things we routinely evaluate?

3. For the Board of Governors (mostly non-physicians) to make a policy that limits physicians’ autonomy regarding clinical decision making requires a very high standard. Does this issue pass the test for scientific and clinical need?

Team Members

•Physician Champion•Executive Leader•Day to Day Leader•Technical Expert•Pediatrician Champion•Risk Management•Quality - CNS•Childbirth Educator•Unit Nursing Leadership

•Scheduled initial committee meeting

•Established agenda:• Overview• Data• Implementation Strategies

• Hard stop/Soft stop• Policy

•Time Frame•Team Discussion

Scheduling Algorithm

Complete “ICVH Procedure/Scheduling” form and mail, deliver, or fax to Women’s Center with current

completed prenatal record

EDD Verified (by criteria) No

Yes

> 39 Wks?

NO

Yes

Indicated ? (by criteria)

Indicated? (by criteria) No

Yes

No

For patients with unconfirmed dates

and without a medical indication:

•Patient is not scheduled

Or•If estimated

gestational age >39 wks, pt is

tentatively scheduled for C-section pending results of lung

maturity amnio.

Do not schedule. Refer to Director

or Physician Leader.

Scheduling physician may

appeal decisions through

established appeal process.•Scheduler evaluates request with respect to room

availability, staffing, and completed form.•Pt is tentatively scheduled.

•Final scheduling contingent upon updated prenatal record week of procedure.

•Scheduler will contact office to verify date and time of procedure.

INTEGRIS Canadian Valley Hospital Procedure/Scheduling Form

Patient Name___________________________________________Phone_________________________

OB Provider_________________________________________ G/P__________________________

Scheduled: Induction C/S Desired Date/Time______________/______________________

Non-scheduled: Induction Spontaneous labor C/S Admission Date/Time____________/________

EDC_________________Gestational Age at Date of Induction/C/S___________________________

EDC Based on: US < 20 weeks Doppler FHT + for 30 weeks + hCG for 36 weeks

Other dating criteria (describe)__________________________________________________________

Elective Induction of Labor ≥ 39 wks Patient choice/social Distance Macrosomia Other ________________

Scheduled Cesarean Birth ≥ 39 weeks Prior C/S Prior classical C/S* Prior myomectomy* (* may be < 39 weeks with FLM test) Breech presentation Other malpresentation Patient choice Twin w/o complication (OK ≥ 38 weeks) other: ________________________________________

Indications for Induction of Labor or Scheduled Cesarean Birth (if less than 39 weeks)

Maternal Placenta Abruption Placenta Previa Chorioamnionitis PROM/SROM HTN: gestational preeclampsia

eclampsia chronic Diabetes requiring insulin:

gest. I II Heart disease Renal disease Pulmonary disease Coagulopathy/ Thrombophilia Liver Disease HIV Infection

Fetal IUGR Fetal malformation Fetal demise: current prior Oligohydramnios Polyhydramnios Isoimmunization Twin with complication Non-reassuring fetal status

Form competed by: ______________________________________Date/Time:___________________

Physician Signature:_____________________________________Date/Time:___________________

Other:_______________________________________________________________________________________________________________________________________________________________________

SCHEDULING OFFICE USE ONLY……………………………………………………………..

Updated Prenatal Record with request? ______ Updated PNR within 7 days of admit?_______

Procedure Scheduled? By:___________________ Confirmed with __________________

Date/time confirmed:______________ Faxed confirmation date/time _____________________

Unresolved Challenges

1. Appeal Process: not local doctor to doctor or nurse to doctor. Who exactly and how do they get paid?

2. Exact wording of the policy.