Trifecta for Change: Enhancing Antenatal Care in Ontario

TEC Talk

May 27th, 2013

Mari TeitelbaumMichael Pluscauskas, Sandra Dunn, Tracy Carr, Brenda Bonner, Douglas Cochen

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BORN Ontario

The best possible beginnings for lifelong health

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Facilitation of Care: Access to Information

• Sarah, from Toronto, is having a weekend away with friends, she is 34 weeks pregnant

• Delivers unexpectedly at the London Health Sciences Centre

• How will the delivering obstetrician access her pregnancy health records?

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Pregnancy in Ontario140k women

Midwife Family doctor Community

obstetrician High risk obstetrician Nurse practitioner

LMP

TransmitForms toHospital

Newborn Screeningwithin 48 hrs of

birth

UltrasoundGBS

Screening

Pregnancy Care Reminders

PrenatalEducation

PrenatalScreening

Plan labour& birth

DiabetesScreening

Cared for by: Delivering:

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Antenatal Forms Consistent care Facilitates

communication Gold standard

✗ Up to 10% of the time the forms are missing – early delivery, unexpected location or lost

✗ Practices associated with the pathway change regularly

6Prenatal Genetic Investigations

First Visit(s): Early Prenatal Care

Ultrasound2nd Test: Hb, ABO/Rh, Repeat ABS

Fetal anatomy / morphology

18-20 wks Dating scan 11-14 wks (early if larger than dates) If 2 U/S, use 1st for EDB

IPS FTS NT

MSS

1 hr GCT

CVS / amnio

declined or twins

MSAFP

Diagnostic and Screening Tests

First Visit (s): Identify Risk Factors and Management Plan

Adjust EDB

Pregnancy SummaryLMP:Certain Y/N

Cycle q:Regular Y/N

Contraceptive TypeLast Used

GravidaTermPrematureAbortusesLiving

EDB by dates:

Dating Method: Dates T1 US T2 US ART (e.g. IVF)

Final EDB:

Obstetrical HistoryNo.YearSex M/FGest. Age (weeks)

Birth WeightLength of LabourPlace of BirthType of Delivery

Comments re: pregnancy and birth

Current PregnancyBleeding Y/N Occup / Environ Risks Y/NNausea, vomiting Y/N Dietary restrictions Y/NSmoking___cig/day Y/N Calcium adequate Y/NAlcohol, street drugs Y/N Preconceptual folate Y/N

Infectious DiseaseVaricella Susceptible Y/N

STDs / HSV / BV Y/N

Tuberculosis risk Y/N

Other Y/N

PsychosocialPoor social support Y/N Family violence Y/NRelationship problems Y/N Parenting concerns Y/NEmotional / Depression Y/N Relig. / Cultural issues Y/NSubstance abuse Y/N Family violence Y/N

Family History: At risk population Y/N

SOGC guidelines for screening options

Repeat 1hr GCT in high risk -ve

2 hr GCT

Value 7.8-10.3

Administer Rh-IG

Physical ExaminationHt BMI Wt BPThyroid N / AbN External Genitalia N / AbNChest N / AbN Cervix, vagina N / AbNBreasts N / AbN Uterus N / AbNCardiovascular N / AbN Size: _____ weeksAbdomen N / AbN Adnexae N / AbNVaricosities / Extrm. N / AbN Other N / AbN

High risk1 hr GCT

Second trimester screening (Quad)

10-13+6 wks

0- 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

WEEK

Medical History Genetic HistoryHypertension Y/N Surgery Y/N At risk population Y/NEndocrine Y/N Blood Transfusion Y/N Family History:Urinary tract Y/N Anaesthetic compl. Y/N Developmental delay Y/NCardiac/Pulmonary Y/N Psychiatric Y/N Congenital anomalies Y/N

Liver, hepatitis, GI Y/N Epilepsy / Neurological Y/N Chromosomal disorders Y/N

Gynaecology / Breast Y/N Other Genetic disorders Y/NHem/Immunology Y/N

Subsequent Visits: Ongoing Prenatal Care (see next page)

Soft Markers for Aneuploidy

(see box above)

Establish Risk + Counsel

Previous C-Section: Consider VBAC vs. Repeat C-Section

Laboratory Investigations

Urine C&SHIVHBsAgABO

VDRLSickle CellRh

GC/ChlamydiaRubella ImmuneMCV

Last PapAntibody ScreenHb

Rh -ve

Give Rh-IG (28wks)

If father known, consider Rh test

Father +ve

Glucose intolerance

Follow Canadian Diabetes

Association Guidelines

Diagnose Gestational Diabetes

1 AbN test

Glucose Level AbN

Placental Edge

Overlap

Abnormal Cervical Length Change

Fetal Structural Anomaly

EICF

Soft Markers for Aneuploidy:

establish risk + counsel

Single umbilical

artery

Enlarged cysterna magna

pelvis ≥ 5mm

pyelectasis

pelvis >10mm

3rd trimester scan

Mild ventriculomegaly

Fetal anatomy review

Neonatal u/s

Grade 2, 3 echogenic

bowel

Expert review + further

evaluation

Choroid plexus cysts

35+ or MSS +ve or other soft markersIsolated

+ risk > 1/600

Fetal karyotyping

Expert review

Other

Thickened nuchal fold

Adjust EDB

> 5 days discrepancy with LMP estimate

> 10 days discrepancy with LMP date

Finalize EDB

If 1st visit

14-20+6 wks

AbN level maternal serum marker

SOGC Guidelines Consult OB to establish fetal

surveillance plan

2nd trimester screen for open neural tube defects

3rd Trimester exam and follow-up re:

need for C-Section

Consult with specialist and genetic counselor

Refer to tertiary ultrasound unit

Repeat U/S, consider further imaging

Assess preterm birth risk

Value >10.3

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A1A2 Pilot Project• Launched in 2011, partnership between E-Health Ontario

and BORN, the project had 3 Goals1. Improve practitioner use of high quality clinical practice guidelines (CPGs)

and pathways for antenatal care. (partnership of BORN and Centre for Effective Practice)

2. Automate the flow of data collected on A1/A2 to facilitate care to women who may arrive at an Ontario birthing hospital without an antenatal record

3. Enhance the quality of data available to support QI, system planning and surveillance of pregnancy and birth

• Participants– 1 EMR Vendor (OSCAR)– 4 family health teams– 3 hospitals

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Clinical Input

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EMR Enhancements

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System Enhancements

BORNRegistryBORN

Registry

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System Impact

BORNRegistryBORN

Registry

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Trifecta: Pregnancy Pathway

Value to the provider beyond what is in their

chart

Trusted & Authoritative

Connection to the individual patient – clinical impact and

outcomesPatient information available when and where it

is needed

Clinical pathway embedded in primary care practice

Created by clinicians and subject matter experts using

OMA standard forms

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Pilot Learning

• 573 records in the BORN Information System• Preliminary evaluation findings: ‘Good’*

– Integration & Coordination of Care– Evidence-based Care & Patient Safety– Workflow Efficiency

• Critical Success Factors– Well defined scope– Governance– The Trifecta

• Many new opportunities!

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So many to Thank

• eHealth Ontario

• Participating family health teams

• OSCAR

• Perinatal Services BC

• Centre for Effective Practice

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Questions