A8 B8 Idealized Designof Perinatal Care

A8/B8: Idealized Design of Perinatal Care
Perinatal Session at
Forum 2005
Frank Federico
Peter Cherouny, MD
Frank Mazza, MD
Patricia Constanty, CNS
$23.8m award in childbirth lawsuit

2 doctors faulted at Mass. General
By Scott Allen, Globe Staff | May 11, 2005
http://www.boston.com/business/articles/2005/05/1
1/238m_award_in_childbirth_lawsuit/
1
Why focus on perinatal

care?
• Rate of claims is low; payment if high
• Good science exists
• Significant variability in process
© 2005 Institute for Healthcare Improvement
What is Idealized Design

of Perinatal Care
• Idealized design enables the system to do
better in the future than the best it can do
today.
• Idealized Design ™ has been developed
by the Institute for Healthcare Improvement
(IHI) to bring together organizations that are
committed to comprehensive system
redesign.
2
What is Idealized Design

of Perinatal Care
• “If we were to deliver ideal perinatal care,
what would the system of care look like?”
• “What processes are components of the
ideal perinatal care system?”
• Clinical processes (special attention to
high risk whether physiological, legal,
psychological)
• Communication and teamwork
• Mother and family preferences
Design Targets
• Reduce neonatal harm to 3.3 per 1000 births or

less
• Patients state that 95% of the time their wishes
are known to the entire team and respected
• The care team reports that a 50% improvement
in culture survey score.
• All claims or allegations may be defended
because 95% or more of claims meet each
institution’s internal standards for defense (e.g.,
consistent documentation, no lapses in
documentation, no lapses in communication)
3
Woman and family as the source of control

Productive
conversations
Prepared and activated teams

RELIABLE PROCESSES
Prepared and
Informed & ready
activated receiving unit;
mom EVALUATE
FIRST SECOND Stabilized mom
ADMIT STAGE STAGE BIRTH and baby
LABOR LABOR
PREVENT IDENTIFY MITIGATE
APPROPRIATE INFRASTRUCTURE
What does this have to

do with reliability?
• What: Best science for the care we deliver
– Research and expert opinion
• How: the method we use deliver that care
– this is the focus of our work- discovering the way to
reliably deliver the best care every time
• Way: use of reliable design and an articulated
goal for each of the processes of care that we
think will make the most difference and are
outlined in the model
4
Our work
Phase I Phase II
• Common language • Common Interpretive
• Elective Induction Construct
Bundle • Reliability
• Augmentation Bundle • Patient Preference
• Application of • Harm measure: OB
reliability model trigger tool
• Communication and • Identification of risk
Teamwork Training
Quality Care in Obstetrics

Peter Cherouny, M.D.
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
University of Vermont College of Medicine
5
Quality Care in
Obstetrics
• What we say
– Priorities for Action were chosen based upon
national indicators or data sets chosen by
AHRQ, NQF, and/or other national safety
organizations. Excellence in these priority
areas...
– The strategy calls for an individual ministry to
develop that blueprint, pilot the spread to four
or five Beta sites, and then lead the
dissemination of the strategy/change
package…
Quality Care in
Obstetrics
• What we hear
– Blah blah blah blah quality blah blah blah blah

outcomes blah blah blah blah blah blah blah
blah blah blah blah blah blah blah blah blah
blah blah blah quality blah blah blah
outcomes blah blah blah blah blah blah blah
blah blah
6

Birth Trauma
• Definition
– Cases of birth trauma per 1,000 liveborn births.
• Numerator
– Discharges with ICD-9-CM code for birth trauma in
any diagnosis field per 1,000 liveborn births.
• Denominator
– All liveborn births.
– Exclude infants with a subdural or cerebral hemorrhage (subgroup of birth trauma coding)
and any diagnosis code of pre-term infant (denoting birth weight of less than 2,500 grams
and less than 37 weeks gestation or 34 weeks gestation or less).
– Exclude infants with injury to skeleton (7673, 7674) and any diagnosis code of osteogenesis
imperfecta (75651).
Birth Trauma
Definition
• We know it when we see it
7
Birth Trauma
Definition
• Most birth trauma is self limited with an

eventual favorable outcome
• Difficult to separate traumatic birth injury from
hypoxic-ischemic injury

Birth Trauma
• Frequency
– Rate: 6.34 per 1,000 population at risk
– Accounts for less than 2% of neonatal deaths
and stillbirths
– Bias: Did not undergo empirical testing of bias
8

Birth Trauma
• Rate
– Coding validity. A study of newborns who had a
discharge diagnosis of birth trauma found that only
25% had sustained a significant injury to the head,
neck, or shoulder.
• Reliability (S/N ratio)

– proportion of the total variation across hospitals that is
truly related to systematic differences (signal) in
hospital performance rather than random variation
(noise)

Birth Trauma
• What do we do to babies?
– Soft tissue injuries
• Caput succedaneum
• Cephalohematoma (90% may be misdiagnosed)
• Subgaleal hematoma
• Abrasions and lacerations
• Intraperitoneal bleeds
• Hepatic rupture
9

Birth Trauma

Birth Trauma
– Nerve injuries
• Brachial plexus injury
• Cranial nerve injury
• Spinal cord injury
10

Birth Trauma
– Bone injuries
• Clavicular fracture
• Long bone fracture
• Epiphyseal dysplasia
Birth Trauma
11

Birth Trauma
• Can we reduce birth trauma?
– Estimated that about 50% is potentially

avoidable through anticipation

Birth Trauma
• Causation
– Large fetuses
– Operative vaginal deliveries (esp midpelvic &
combined)
– Vaginal breech delivery
– Inappropriate use of pitocin
– Abnormal/excessive traction
12

Birth Trauma
• How do we reduce birth trauma?

Birth Trauma
• Reducing birth trauma
– Don’t deliver large babies
– Don’t do operative vaginal deliveries (esp
midpelvic)
– Don’t do vaginal breech delivery
– Don’t use pitocin
– Be gentle; avoid abnormal/excessive traction
13

Birth Trauma
• Don’t deliver large babies
– Offer cesarean section for diabetic fetuses
greater than 4500 gms or nondiabetic fetuses
greater than 5000 gms
– The diagnosis of fetal macrosomia is
imprecise. For suspected fetal macrosomia,
the accuracy of estimated fetal weight using
ultrasound biometry is no better than that
obtained with clinical palpation (Leopold's
maneuvers)
Fetal Macrosomia. ACOG Practice Bulletin #22, November 2000

Birth Trauma
• Don’t deliver large babies
– With an estimated fetal weight greater than
4,500 g, a prolonged second stage of labor or
arrest of descent in the second stage is an
indication for cesarean delivery
– Suspected fetal macrosomia is not an
indication for induction of labor, because
induction does not improve maternal or fetal
outcomes
Fetal Macrosomia. ACOG Practice Bulletin #22, November 2000
14

Birth Trauma
• Operative vaginal deliveries
– Be comfortable with fetal and pelvic
assessment
• Position
• Presentation
• Engagement
• Asynclitism
• Clinical Pelvimetry
– Midpelvic deliveries should be rare, while setting up
cesarean room
Operative Vaginal Delivery. ACOG Practice Bulletin #17, June 2000


Birth Trauma
Don’t do vaginal breech delivery
– As a result of the findings of the study,
planned vaginal delivery of a term singleton
breech may no longer be appropriate
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
Planned caesarean section versus planned vaginal birth for breech presentation at
term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Lancet 2000;356:1375–1383
15

Birth Trauma
• Don’t use Pitocin
– Know everything about the drug
– Have a well established policy for Pitocin use and
follow it

Birth Trauma
• Be gentle; avoid abnormal/excessive
traction
– Manage shoulder dystocia in a standard
fashion
– Don’t use fundal pressure
– Break the bed down
– Have adequate help around
– Practice this emergency
16

Birth Trauma
• Process measures
• Team based care
• Quality review
– Don’t wait for the problem
– Review all at risk procedures
– Use it as an educational tool
– Someone is watching
Seton Experience
Dr. Frank Mazza, MD
17
The SETON Healthcare

Network
• 8 Acute Care Hospitals (5 Urban, 2 Rural, 1
Psychiatric)
– Serves population of 1.4 million from 11 counties
– Level II Trauma Center, dedicated Children’s facility, full range of
services, e.g., Cardiac (and other) Transplantation
– Magnet Nursing designation for 4 ‘Austin Hospitals’
• Obstetrics Care Performed in Four Facilities

– SMC - tertiary care referral center - offers high risk OB care – level 3
nursery
– Brackenridge – teaching facility – offers high risk OB care – level 3
nursery
– SNW – medium sized – level 2 nursery
– SSW – small, semi-rural – level 1 nursery
– Total 8,300 deliveries per year
Induction Rate by Physician

Seton Healthcare Network
100%
90%
80%
70%
60%
n11
m8
Rate
50% n4
UCL
n6
n8
2s
40% n2 n15 n1
n12 n14
m16 n10
n9 1s
n7
Mean = 30.0% m20
30% n3 m7 m9 m15
m2 m17 m10 m23 m4
m22 m11 m5 1s
m1 m3 m12 m21n13 m24
20% m18m25 n5 m19
m14 2s
m13 LCL
m6
10%
0%
18
Instrumented Delivery Rate By Physician

25%
20%
n7
m 16
n12
m3
m 14 b3
m 13 s1
15%
m 17
m 10
m12 UCL
m6 m24 m2
b6
m25 n4 m21 2s
10% m15 m7 1s
m8
Mean = 8.6%
n3 m11
m18 n9 b5 m1m22
n6
m19m20 m4
m5 1s
b2 n5 n2
n8
s3 2s
5% b7 n13 b1 b4
m23n14 LCL
n1 m9
n10 n11
s2
s4
n15
0%
Forming the Work Group
• Interdisciplinary team
• Commitment to ‘High Reliability’ (alpha
site for Ascension Health)
• ‘Evidence-Based’
19
The Oxytocin Innovation Bundle
Elective Induction Augmentation Bundle

Bundle
• Documentation of
• Gestational Age >/= 39 Estimated Fetal Weight
weeks • Reassuring Fetal Status
• Reassuring Fetal Status • Pelvic Exam prior to the
• Pelvic Exam prior to the start of Oxytocin
start of Oxytocin • Absence or management
• Absence or management of Hyperstimulation with
of Hyperstimulation with increases in Oxytocin
increases in Oxytocin
Elective Induction Bundle

Seton Northwest Hospital Seton Medical Center
Seton Southwest Health Center
20
Augmentation Bundle
Seton Northwest Hospital Seton Medical Center
Seton Southwest Hospital Seton Brackenridge Hospital
Elective Inductions Prior to 39 Weeks

FY05-Q1 FY05-Q2 FY05-Q3 FY05-Q4 FY06-Q1
35
29
30 27
N um ber of C ases
25
25 22
20
15
10
10
4 5 4 3
5 1 2
0 0 0 1 0 0 0 0 0
0
SMC SNW SSW BH
21

Birth Injury Rate
7/1/2000--6/30/2005
1%
0.46%
0.43% 0.40% 0.41%
Mean = 0.31% 0.37%
0.32% 0.34%
0.31%0.33%
0.32% 0.30%
0.24% 0.23% 0.22% 0.25% 0.26% UCL
2s
0.14% 1s
0.11%
Mean = 0.06%0.05% 0.05%
0% 1s
LCL
F Y 01-Q 1
F Y 01-Q 2
F Y 01-Q 3
F Y 01-Q 4
F Y 02-Q 1
F Y 02-Q 2
F Y 02-Q 3
F Y 02-Q 4
F Y 03-Q 1
F Y 03-Q 2
F Y 03-Q 3
F Y 03-Q 4
F Y 04-Q 1
F Y 04-Q 2
F Y 04-Q 3
F Y 04-Q 4
F Y 05-Q 1
F Y 05-Q 2
F Y 05-Q 3
F Y 05-Q 4
Lessons Learned
• Use small tests of change
• OB Units already highly standardized
– Took advantage of existing documents
– “Make it easy to do the right thing”
• Documentation of estimated fetal weight
was an early success.
• Hyperstimulation element of bundle
remains a challenge.
22
Thomas Jefferson
University Hospital
Experience
Patricia Constanty, CNS
Augmentation Bundle
23
Elective Induction
Bundle
Physician Engagement
• Physician Champion
• Agreed to test sticker
• Proactive work with resident group
24
TJUH Success Stories

• Inductions -Compliance with gestational
age, pelvic adequacy and documentation
of fetal reassurance prior to oxytocin
• Augmentations – Compliance with fetal

weight, pelvic adequacy and fetal
reassurance prior to oxytocin
25
Challenges at TJUH
• Agreement with both nurses and
physicians – definition of hyperstimulation
• Agreement with intervention when
hyperstimulation occurs
Questions
26
For more information visit
www.IHI.org
27

A8 B8 Idealized Designof Perinatal Care

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A8/B8: Idealized Design of Perinatal Care

$23.8m award in childbirth lawsuit

By Scott Allen, Globe Staff | May 11, 2005

Why focus on perinatal

© 2005 Institute for Healthcare Improvement

What is Idealized Design

© 2005 Institute for Healthcare Improvement

What is Idealized Design

• Reduce neonatal harm to 3.3 per 1000 births or

© 2005 Institute for Healthcare Improvement

Woman and family as the source of control

Prepared and activated teams

PREVENT IDENTIFY MITIGATE

© 2005 Institute for Healthcare Improvement

What does this have to

© 2005 Institute for Healthcare Improvement

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

– Blah blah blah blah quality blah blah blah blah

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

• We know it when we see it

© 2005 Institute for Healthcare Improvement

• Most birth trauma is self limited with an

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

– Bias: Did not undergo empirical testing of bias

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

• Reliability (S/N ratio)

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

• Can we reduce birth trauma?

– Estimated that about 50% is potentially

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

• How do we reduce birth trauma?

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

Quality Care in Obstetrics

Quality Care in Obstetrics

Operative Vaginal Delivery. ACOG Practice Bulletin #17, June 2000

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics

© 2005 Institute for Healthcare Improvement

Quality Care in Obstetrics