Eliminating Elective Early Term Deliveries at University Hospital - PowerPoint Presentation

Slide1

Eliminating Elective Early Term Deliveries at University Hospital

Robyn Horsager M.D.

Patricia Santiago-Munoz M.D.

Slide2

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

California Toolkit to Transform Maternity Care

Slide3

Netherlands: Timing of Elective Cesarean Deliveries

Wilmink

et al, Am J

Obstet

Gynecol

, 2010

Slide4

Increased Adverse Neonatal Outcomes at 370

-38

6

Weeks of Gestation

Neonatal death

NICU admission

Newborn sepsis

Respiratory distress syndrome

Transient

tachypnea of the newbornTreated hypoglycemiaHyperbilirubinemia

Tita et al, N Eng J Med, 2009

Wilmink

et al, Am J

Obstet

Gynecol

, 2010

Slide5

Neonatal Death Rates per 1000

L

ivebirths

Zhang et al, J

Pediatr

, 2009

Slide6

Neonatal Complications: NICU Admission Rate

Oshiro

et al, Am J

Obstet

Gynecol

, 2009

Slide7

Neonatal Complications: Need for Ventilator

Oshiro

et al, Am J

Obstet

Gynecol

, 2009

Slide8

Netherlands: Adverse Neonatal Outcomes After Elective Cesarean Delivery

Wilmink

et al, Am J

Obstet

Gynecol

, 2010

Percent

Slide9

Maternal Outcomes Associated with Labor Induction

Increased cesarean section rate for failure to progress in

nulliparous

women with unfavorable cervix

Increased cesarean section rate for fetal distress

Increased post-partum hemorrhage >500

mL

Prolonged maternal hospital stay

Oshiro

et al, Am J Obstet Gynecol, 2009Baud et al, Am J

Obstet Gynecol ,2011

Slide10

Cognitive Development and Early Term Birth: Long-term Consequences

Scotland: Increased risk for “special education need”

Denmark: Increased reading and spelling difficulties at age 10

Belarus: Lower IQ test scores at age 6

United States: Lower standardized math and English/language arts scores in third grade

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Slide12

University Hospital Obstetrical Service

2010: 1440 deliveries

897 by community physicians

543 by UT Southwestern Medical Center employed physicians

12

Slide13

Frequency of Births at 370

- 38

6

Weeks

National Vital Statistics

Report

, 2010

Slide14

University Hospital Experience: Labor Induction Rate at 37

0

-38

6

Weeks

Slide15

Our Team

Robyn

Horsager

MD*

Chief OB/

Gyn

, University Hospital

Patricia Santiago-Munoz MD*

Maternal-Fetal Medicine

Melissa Tarango RN Labor and DeliveryCatherine VanBeek BSN, WHCNP Epic Analyst

John Morris CS&E Facilitator

* CS&E Course participant

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Aim Statement

The aim of this project is to

eliminate

electiv

e deliveries between 37 weeks 0 days and 38 weeks 6 days over the next 5 months. This project is important because delivery at this gestational age is associated with increased neonatal morbidity and healthcare costs and there is increasing public reporting of this measure by hospitals.

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2009 Leapfrog Data: Dallas Area

HOSPITAL

ELECTIVE DELIVERIES AT 37-39 WEEKS

Baylor

4.8%

Medical City Dallas

29.8%

Methodist Charlton

11.2%

Methodist5.3%

Presbyterian Dallas25%Doctors Hospital

13.5%

Presbyterian Plano

4.7%

Medical Center Plano

11.4%

17

Slide18

CS&E Project Checklist



Revise AIM statement (all)

Write policy (RH &MT)

Outside speaker with similar experience



Speaker (RH)



Room/breakfast (RH &PSM)



CME (RH)



CEU (MT)



Create Clarity report (CV)



Change scheduling log in L&D (MT)



Mailing to physicians (RH&PSM)



Find a “face” to the story (PSM)



Obtain patient list



Review charts



Patient and nursing materials (all)



Obtain



Distribute



Gather previous data (RH)



2005-2008



2009-2010

Create run chart (RH & PSM)

Update OB/

Gyn

Best Practices Committee

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Scheduled induction of labor or cesarean delivery is not permitted before 39 weeks of gestation…

Policy Revision

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Data Collection

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Communication

Slide22

Eliminating Elective Delivery < 39 Weeks

Seton’s Experience

Michael Nix , MD

November 2, 2010

Education

Slide23

Slide24

Our Results

November 1, 2010- September 30, 2011

Slide25

Slide26

University Hospital Experience: Elective Inductions* at 37

0

-38

6 Weeks

* Project time period includes elective inductions and scheduled cesarean deliveries

Slide27

Decreased NICU Admissions with Intervention

Based on 2008 rate of elective delivery 4 fewer infants admitted to NICU

Based on 2009 rate of elective delivery 2-3 fewer infants admitted to NICU

Slide28

Cost per 100 Neonates for Treatment of Adverse Outcome

Dollars

Robinson et al, Am J

Obstet

Gynecol

, 2010

Slide29

Potential Revenue Loss without Intervention

In 2009 there were 61 vaginal deliveries

without

medical necessity between 37-39 weeks

Would estimate approximately 30 scheduled repeat cesarean

deliveries

without

medical necessity

at same gestational age

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Professional Fees

61 vaginal deliveries @ $663 per patient= $40,443

30 cesarean sections @ $802 per patient= $24,060

Hospital Stay

61 vaginal deliveries @ $1742 per patient= $106,262

30 cesarean sections @ $2762 per patient= $82,860

Grand Total $253,625

Slide31

Additional Savings

Reduced costs for other neonatal morbidities like treatment and re-admission for

hyperbilirubinemia

Reduced costs for maternal complications

What are costs for educational system long-term?

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What’s Next?

October 1, 2011 “hard stop” for scheduling cases with review by physicians

Determination of “medical necessity” for delivery before 39 weeks of gestation

Slide33

Thank you!

Slide34

References

Baud D,

Rouiller

S,

Hohlfeld

P,

Tolsa

J et al. Am J

Obstet

Gynecol 2011;204:S328.Herson V, Feldman D, Borgida A, Fang YM et al. Full term NICU admission for respiratory morbidity: the role of gestational age. Am J Obstet Gynecol 2011;204:S85.Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age. A California Toolkit toTransform Maternity Care.Induction of labor. ACOG Practice Bulletin No. 107. American College of Obstetricians and Gynecologists. Obstet

Gynecol 2009;114:386-97.Kirkegaard MD, Obel C, Hedegaard M, et al. Gestational age and birth

w

eight in relation to school

p

erformance of 10 year

o

ld

c

hildren: a

f

ollow-up study of children

b

orn

a

fter 32 completed

w

eeks. Pediatrics 2006; 118:1600-1606.

Lipkind

HS,

Slopen

ME, Pfeiffer MR, McVeigh KH. School-age outcomes of late preterm infants. Am J

Obstet

Gynecol

2011;204:S37.

MacKay DF, Smith GCS,

Dobbie

R, et al. Gestational age at delivery and special

e

ducational

n

eed: retrospective

c

ohort

s

tudy of 407,503 schoolchildren.

Plos

Med 7 (6):e1000289.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ et al. Births: final

d

ata for 2008. National Vital Statistics Report 2010;59.

Slide35

References

Oshiro

BT, Henry E, Wilson J, Branch DW et al. Decreasing elective deliveries

before

39

weeks of gestation in an integrated health care system.

Obstet

Gynecol

2009;113:804-811.Robinson CJ, Villers MS, Johnson DD, Sampson KN. Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis. Am J Obstet Gynecol 2010;202:632.e1-6.Tita A, Landon MB, Spong CY, Lai Y et al. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes. N Engl J Med 2009; 360:111-120.Wilmink FA, Chantal WP, Lunshof S, Mol BW et al. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. Am J

Obstet Gynecol 2010;202:250.e1-8.Yang S, Platt RW, Kramer MS. Variation in Child Cognitive Ability by Week of Gestation Among Healthy Term Births. Am J Epidemiol

2010; 171:399-406.

Zhang X, Kramer MS. Variation in mortality and morbidity by gestational age among infants born at term. J

Pediatr

2009;154:358-362.