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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 [email protected]
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
0
2
4
6
8
10
12
14
16
18
Feb'14
Mar'14
Apr'14
May'14
Jun '14 Jul '14 Aug'14
Sep'14
Oct'14
Nov'14
Dec'14
Jan '15 Feb'15
Mar'15
Apr'15
May'15
Jun '15 Jul '15 Aug'15
Sep'15
Oct'15
Nov'15
Dec'15
ALOS for All Infants
ALOS overall reduced by 2 days…14%
ALOS for Pharma Treated Infants
0
5
10
15
20
25
30
Jan'14
Feb'14
Mar'14
Apr'14
May'14
Jun'14
Jul '14 Aug'14
Sep'14
Oct'14
Nov'14
Dec'14
Jan'15
Feb'15
Mar'15
Apr'15
May'15
Jun'15
Jul '15 Aug'15
Sep'15
Oct'15
Nov'15
Dec'15
ALOS for Pharma Treated Infants
ALOS reduced from 23 days to 16 days …30% reduction
% of NAS Infants Pharma Treated
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Feb'14
Mar'14
Apr'14
May'14
Jun'14
Jul '14 Aug'14
Sep'14
Oct'14
Nov'14
Dec'14
Jan'15
Feb'15
Mar'15
Apr'15
May'15
Jun'15
Jul '15 Aug'15
Sep'15
Oct'15
Nov'15
Dec'15
% 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
0
10
20
30
40
50
60
70
80
90
100
Jan'14
Feb'14
Mar'14
Apr'14
May'14
Jun'14
Jul '14 Aug'14
Sep'14
Oct'14
Nov'14
Dec'14
Jan'15
Feb'15
Mar'15
Apr'15
May'15
Jun'15
Jul '15 Aug'15
Sep'15
Oct'15
Nov'15
Dec'15
% 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
0
10
20
30
40
50
60
70
80
90
Jan'14
Feb'14
Mar'14
Apr'14
May'14
Jun'14
Jul '14 Aug'14
Sep'14
Oct'14
Nov'14
Dec'14
Jan'15
Feb'15
Mar'15
Apr'15
May'15
Jun'15
Jul '15 Aug'15
Sep'15
Oct'15
Nov'15
Dec'15
% 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)
0
20
40
60
80
100
120
Feb'14
Mar'14
Apr'14
May'14
Jun'14
Jul '14 Aug'14
Sep'14
Oct'14
Nov'14
Dec'14
Jan '15 Feb'15
Mar'15
Apr'15
May'15
Jun'15
Jul '15 Aug'15
Sep'15
Oct'15
Nov'15
Dec'15
% of Maternal Heroin Use
72% Increase in NAS Cases With Maternal Heroin Exposure
Center 1540 % Cases With Maternal Heroin Use
0
5
10
15
20
25
30
35
40
Feb '14 Mar'14
Apr '14 May'14
Jun '14 Jul '14 Sep '14Oct '14 Nov'14
Dec'14
Jan '15Feb '15 Mar'15
Apr '15 May'15
Jun '15 Jul '15 Aug'15
Sep '15Oct '15 Nov'15
Dec'15
% 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
0
10
20
30
40
50
60
70
80
90
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%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
Mar '14 Apr '14 May'14
Jun '14 Jul '14 Aug '14 Sep '14 Oct '14 Nov '14 Dec '14Mar '15 Apr '15 May'15
Jun '15 Jul '15 Aug '15 Sep '15 Oct '15 Nov '15 Dec '15
% 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%
2.0%
2.5%
3.0%
3.5%
4.0%
Mar '14 Apr '14 May'14
Jun '14 Jul '14 Aug '14 Sep '14 Oct '14 Nov '14 Dec '14 Mar '15 Apr '15 May'15
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
