PowerPoint Presentation · % With Only GHTN or Pre-E Without Severe Linear (% With Only GHTN or...

PQCNC 2015

Making North Carolina the best place to give birth and be born!

Martin J McCaffrey, MD, CAPT USN (Ret) Professor of Pediatrics, UNC Chapel Hill School of Medicine

Director of the Perinatal Quality Collaborative of North Carolina martin_mccaffrey@med.unc.edu

984 974-7852

Accomplishing the Mission

•Create value through time limited statewide perinatal QI projects • Best evidence, reduce variation • Partnership with patients and families • Resource optimization

•Projects developed and led by Expert Teams with Members from multiple hospitals

•Work conducted by local Perinatal Quality Improvement Teams facilitated/supported by PQCNC core team

Hospitals (62) Participating in PQCNC Initiatives

• Cape Fear Valley • Carolinas Medical Center • CMC-Pineville • Columbus • Cleveland • Duke • Granville • New Hanover • Novant Forsyth • Novant Huntersville • Novant Presbyterian • Rex • UNC • Vidant (ECU) Greenville • Womack • WakeMed • Caromont • Catawba Valley • Central Carolina • CMC-NorthEast • FirstHealth - Moore • Grace • McDowell • Mission • Onslow • Transylvania • Women's - Cone Health Greensboro • Durham Regional • Blue Ridge Regional Hospital • NH Camp Lejeune • Pardee Women & Children's Center

• Albemarle Women's Center • Granville Medical Birthing Center • Halifax Regional Medical Center • Maria Parham Medical Center Maternity Services • Nash Health Care Special Care Nursery • Nash Health Care Women's Center • Wilson Medical Center • Carteret General Hospital Brady Birthing Center and

Nursery • Outer Banks Hospital • Bladen County Hospital Birth Center • Johnston Health Women's Pavilion • Wake Med Cary • Southeastern Regional Women's Healthcare • Vidant Edgecombe • Alamance Regional Medical Center • Brenner Children's Hospital • Davis Regional • Morehead Memorial Hospital • Randolph Hospital • CMC – Lincoln • Grace Hospital • High Point Regional Culp Women's Center • Iredell Memorial Hospital • Novant-Matthews • Rowan Regional Medical Center • Stanly Regional Medical Center • Lenoir Memorial Hospital • Watauga Medical Center • Wilkes Regional Medical Center

2015 PQCNC Initiatives

• Neonatal Abstinence Syndrome (NAS) (Nursery and NICU in 25 Hospitals) • 49% of deliveries in the state

• Phase 2 Conservative Management of Preeclampsia (CMOP) (23 Hospitals) • 21 hospitals with 45% of deliveries in the state

• Screening for Critical Congenital Heart Disease (CCHD) • Website has registered 72 hospitals submitting data

• Webinar based improvement series

NAS

• Standardization of protocol within the hospital • Observation for 4-7 days if scored

• Who is screened

• Single first line pharma

• Standardize Scoring • Modified Finnegan

• Modular training for all scoring staff

• Inter-rator reliability testing

• Optimal room for hospitalization

• Encouraging breastfeeding

ALOS for All NAS Infants

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ALOS for All Infants

ALOS overall reduced by 2 days…14%

ALOS for Pharma Treated Infants

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ALOS for Pharma Treated Infants

ALOS reduced from 23 days to 16 days …30% reduction

% of NAS Infants Pharma Treated

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% of All Infants Pharma Treated

Increase in pharma treatment for reported infants of 15%

Why Has % Pharma Treated Infants Increased?

• Increased awareness • Umbilical Cord screening

• Turn around quicker

• Lower sensistivity levels

• Stringent screening criteria • Keeping infants recommended 4-7 days vice 2-3 days

•Standardization of scoring

•More mothers with multiple drug exposures • Require more intensive treatment

•Rising heroin use

% of Infants Hospitalized in NICU

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% of Infants Hospitalized in NICU

20% Reduction in NAS Infants Hospitalized in NICU

Days to Reach Peak Pharma Dose

Pharma Treatment Escalations

% of Infants Solely Formula Fed

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% of NAS Infants Solely Formula Fed

20% Increase in Infants Receiving Breastmilk

Maternal Drug Use for NAS Babies in 2013

Maternal Narcotic Use

% NAS Cases With Maternal Heroin Use (St. Louis)

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% of Maternal Heroin Use

72% Increase in NAS Cases With Maternal Heroin Exposure

Center 1540 % Cases With Maternal Heroin Use

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% of Cases With Heroin Exposure

Summary NAS

• Enrolled 798 infants in 2015

• 395 infants treated pharmacologically

• Total 9191 hospital days • 6832 for pharma treated infants

• ALOS for pharma treated infants reduced by 7 days

• ALOS for all infants reduced by 2 days

• Annually eliminates 2765 hospital days for pharma treated infants • 1659 in the NICU ($3,318,000)

• 1106 in mother/baby or peds units ($1,106,000)

• An additional 806 hospital days reduced for non-pharm treated infants ($403,000)

• Estimated total cost savings $4,827,000

Conservative Management of Preeclampsia

•Adoption of new definitions for HTN disorders of pregnancy

• Increase accuracy in blood pressure measurement

•Emphasize time to treatment within 1 hour

• Increase antenatal steroid administration rates

•Reduce deliveries of preterm infants with only GHTN or preeclampsia without severe features

CMOP Phase 1 Data (Preliminary) (3/1/15-12/31/15)

•45,406 total deliveries at 21 actively participating sites

•6280 with any HTN diagnosis (13.8% HTN rate) •2442 Cesarean deliveries (39% Cesarean Rate) •1603 delivered < 37 weeks (26% PTD rate) •108 potentially unindicated preterm deliveries

• 52 delivered for gestational hypertension

• 56 delivered for preeclampsia without severe features

Time To Treatment

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Mar '15 Apr '15 May '15 Jun '15 Jul '15 Aug '15 Sep '15 Oct '15 Nov '15 Dec '15 Jan '16

% of BPs Treated Within 1 Hour

25% Increase in Numbers of Women Treated Within 1 Hour

Antenatal Steroid Administration Rates

% All Preterm Deliveries With Sole Indication GHTN or Preeclampsia Without Severe Features

0.00%

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16.00%

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% All Preterm Deliveries With Only Indication GHTN or Preeclampsia Without Severe Features

Series3 Linear (Series3)

50% reduction in these deliveries

Reduction in Preterm Deliveries For GHTN or Preeclampsia Without Severe Features

0.0%

0.5%

1.0%

1.5%

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2.5%

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3.5%

4.0%

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Jun '15 Jul '15 Aug '15 Sep '15 Oct '15 Nov '15 Dec '15

% of All Deliveries Which Are < 37 Weeks With Only GHTN or Pre-E Without Severe Features

% With Only GHTN or Pre-E Without Severe Linear (% With Only GHTN or Pre-E Without Severe)

50% Reduction in these deliveries

CMOP Impact

• 6181 mothers enrolled with hypertension

• Analyzing data for ICU admissions for mothers

• Avoiding estimated 98 non-indicated preterm deliveries per year

• No increase in NICU admits or mortality for infants > 37 weeks

• Range in gestational ages....24-36 weeks

• If presume all 34-36 weeks, estimate cost savings as 2000-2500 gms using Tricare DRG calculator…$686,000

• Improved maternal health • Reduced morbidity and mortality

2016

•Continue CMOP work •Focus on bedside engagement with patients •Time to treatment within 60 minutes

•New Nursery/NICU Project •Selection 1 March at McKimmon Center (0900) •7 projects to be presented •Present to Leadership Team on 22 March •?NAS, ?Antibiotic Stewardship, ?Golden Hour…

•Continue upkeep and refinement of CCHD site

CMOP