Perinatal Quality: Making NC the Best Place to be Born!

SIVB II Learning Session 2 October 9, 2012

What is PQCNC?
Perinatal Quality Collaborative of North Carolina

A community of organizations, agencies and individuals committed to making North Carolina the best place to be born.

PQCNC Mission
Promote high value perinatal care
Spread best practice and reduce variation Partner with families and patients Optimize resources

PQCNC Table
Family Members Perinatal providers Doctors (OB, MFM, Neos, Peds, FP) Nurses (Peds, NICU, & OB) Midwives Hospital Administrators Payers (Medicaid, BCBSNC) State Legislators DPH State Hospital Association Others (Malpractice insurers)

PQCNC Initiatives
39 Weeks CABSI Exclusive Human Milk (EHM) NICU EHM Well Baby Support for Intended Vaginal Birth (SIVB) NCABSI

Maternal Quality Initiatives

39 Week Project Supporting Intended Vaginal Birth (SIVB)

39 Weeks Project

Decrease of 43%

SIVB: Supporting Intended Vaginal Birth

Improve the rate of vaginal birth among first-time mothers PQCNC's goal was to increase the rate of vaginal birth in this population by 25% by January 2012. Each participating hospital set its own site-specific goal.

Carolinas Medical CenterPineville Gaston Memorial Granville Health System Cape Fear Valley Medical Center Carolinas Medical Center Onslow Memorial Hospital Carolinas Medical Center NorthEast Carteret General Hospital Catawba Valley Medical Center Central Carolina Hospital Columbus Regional Healthcare System FirstHealth Moore Regional Hospital

Presbyterian HospitalMain Presbyterian HospitalMatthews Forsyth Medical Center Mission Hospital Nash General Hospital New Hanover Regional Medical Center Pitt County Memorial Hospital Presbyterian Hospital Huntersville Rex Health Stanly Regional Medical Center University of North Carolina Hospitals Forsyth Medical Center

SIVB in North Carolina

Data on forty patients were collected from each hospital Inclusion Criteria: Nulliparous Singleton Pregnancy Vertex 37 weeks or more Live fetus Exclusion Criteria: Placenta previa Vaso previa Previous Myomectomy Cord Prolapse Active Herpes Infection HIV (with viral load >1000 copies) Diabetic with EFW > 4500 grams Non-Diabetic with EFW > 5000 grams
*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries

CESAREAN RISK FACTORS

Diabetes (any type) IUGR Maternal age greater than/equal to 35 Hypertensive disease Macrosomia (EFW greater than 4000g) Obesity

28.8% of all patients had at least one risk factor

14.00%

12.00%

11.48%

11.33%

10.00%

Risk Factor Prevalence

8.00%

6.00%

5.45% 4.02% 2.52% 0.86%

4.00%

2.00%

0.00%

Diabetes

IUGR

AMA

HTN

Macrosomia

Obese

OVERALL PRIMARY C/S RATE OVER TIME ALL FACILITIES

50.00% 45.00% 40.00% 35.00% 30.00%

Overall C/S

25.11% 24.12% 23.99% 23.67% 23.54% 22.80% 25.00% 22.16% 21.98% 21.26% 21.02% 20.37% 19.05%
20.00% 15.00% 10.00% 5.00% 0.00%

GOAL = 18.83%

In nine months we saw a 15% increase in the likelihood of first-time mothers delivering vaginally in 24 participating centers

INITIATIVE-WIDE CESAREAN RATES

50.00% 45.00% 40.00% 35.00% 30.00%
25.11% 38.01%

OVERALL C/S RATE C/S RATE - NO C/S RISK FACTORS C/S RATE - 1+ C/S RISK FACTORS
36.34% 34.62% 34.07% 30.20% 29.74% 28.00% 23.99% 24.12% 23.67% 22.80% 21.02% 20.37% 19.11% 20.74% 18.47% 18.27% 18.83% 16.95% 16.59% 35.06%

Linear (OVERALL C/S RATE)

32.60% 30.41% 26.42% 27.62% 23.95% 21.29%

25.00% 20.00% 15.00% 10.00% 5.00% 0.00%

22.16%

21.98%

20.25% 18.23%

19.32%

18.66%

19.06%

19.19%

AVERAGE C/S RATE BY FACILITY: Baseline - December

50.0% 45.0%

40.0%

Average facility c/s rate

35.0% 31.2% 30.0% 25.0% 23.9% 21.7% 20.0% 25.4% 23.0% 26.8% 24.9% 23.5% 27.6% 24.7% 23.9% 23.1% 23.1% 25.0% 23.4% 21.6% 18.8% 16.9% 14.7% 16.5%

20.8% 17.4%

18.5%

15.0%

10.0%

5.0%

0.0% 110 200 210 300 320 330 350 380 390 391 392 400 420 430 490 500 510 530 540 640 650 660 680

% OF PATIENTS IN LABOR AT ADMISSION

70.00%

% of pts in labor at

60.00%

% of paPents in labor

53.40% 52.78% 52.26% 51.30% 51.23% 50.80% 50.00% 49.88% 49.78% 48.77% 48.57% 47.77% 50.00%

40.00%

30.00%

CESAREAN RATE FOR PTS NOT IN LABOR AT ADMISSION: 31.70% CESAREAN RATE FOR PTS IN LABOR AT ADMISSION: 14.61%

20.00%

10.00%

0.00%

BOTTOM LINE!
Labor is Important
Cesarean rate for patients in labor at admission 0-3 cm 4+ cm 18.38% 10.86%

Cesarean rate for induction patients 0-3 cm 4+ cm 31.34% 28.42%

*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries

SIVB-2 Data
A focus on Labor!

*Phase 2 involves 31 hospitals and has collected data on more than 6,000 deliveries

GOAL = 18.83%

Nulliparous*C,sec/on*Rate*,*Total* 35%$ 30%$ 25%$ 20%$ 15%$ 10%$ 5%$ 0%$

N$=$3192$ N$=$3034$ N$=$6226$

33%$

24%$

In$Labor$ NOT$in$Labor$ Total$

15%$

This is less prominent than SIVB I results

Drilling down on the data! Obesity Hypertension Diabetes

Mothers may have more than one risk factor

BMI 30 OR last maternal weight 200 lbs

BMI 30 OR last maternal weight 200 lbs

Includes gestational diabetes well or poorlycontrolled; preexisting Type II or Type 1 diabetes

Includes chronic hypertension, gestational hypertension, preeclampsia, eclampsia, HELLP syndrome

Very conservative estimate

Many mothers carry more than one risk factor Obesity is a poor indication for induction of labor

BOTTOM LINE!
Labor is Important
Cesarean rate for patients in labor at admission 0-3 cm 4+ cm 18.38% 10.86%

Cesarean rate for induction patients 0-3 cm 4+ cm 31.34% 28.42%

*Phase I involves 23 hospitals and has collected data on more than 10,000 deliveries

What do we do next?

1. Do you have a physician or team of physician champions? 2. Do you have adequate time, space, and/or expertise to diagnosis labor? 3. Are your patients educated with respect to the importance of labor? 4. Do you have multiple mechanisms to support a patients labor? 5. Does your institution track vaginal delivery rate and report it back to the providers specifically in nulliparous patients? 6. Do you have an induction protocol for Nulliparous patients? 7. Do you Track and review elective nulliparous inductions less than 41 wk?

Faces of PQCNC

Thank you! QuesPons?

James deVente MD/PhD Associate Professor, Dept. OB/Gyn Medical Director of Labor and Delivery East Carolina University Brody School of Medicine Pager: 252-413-4153 (please page me)