Washington State Perinatal Collaborative Update on Quality Improvement Initiatives

 Elective Deliveries 37-<39 wks  Episiotomies  Breast Milk Feeding

Thomas Benedetti, MD, MHA

University of Washington Medical Center Department of Obstetrics and Gynecology and

Jean O’Leary, MPH, RD

Nutrition Consultant Washington State Department of Health WIC Nutrition Program November 19, 2013 Presented at Washington State Hospital Association Safe Table 11/19/2013

90% reduction in Early Elective Deliveries between 37 to 39 weeks.

$5 million in cost savings.

Over 1,900 fewer early deliveries!

Percentage of Hospitals Under 5% by Quarter

Baseline: 16% Q1 2011: 35.5% Q2 2011: 44.4% Q3 2011: 51.2% Q4 2011: 54.9% Q1 2012: 69.5% Q2 2012: 66.7% Q3 2012: 69.1% Q4 2012: 88.5% Q1 2013: 88.2%

Washington State Percent of All Term Births >= 37 wks Gestation that were 37-38 wks 29% 28% 27% 26,7% 26,9% 27,6% 27,8% 27,8% 27,1% 26,7% 26,7% 26% 24,9% 25% 24% 23% 24,5% 22% 2003 2004 2005 2006 2007 2008 2009 2010

Presented at Washington State Hospital Association Safe Table 11/19/2013

2011 2012

Washington State Stillbirths by Gestational Age Rates per 1,000 Ongoing Pregnancies 0,75 0,5 0,25 0 2,25 2 1,75 1,5 1,25 1 2003 37 wks 2004 2005 38 wks 2006 39 wks 2007 2008 40 wks 2009 41 wks 2010 2011 >=42 wks 2012

Presented at Washington State Hospital Association Safe Table 11/19/2013

28% Washington State Trends Percent of All Term Births >= 37 wks Gestation that were 37-38 wks NTSV Cesarean rate Primary Term Singleton Vertex Cesarean rate 26% 24% 22% 20% 18% 16% 14% 12% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 37-38wks % of all term >=37wks CY NTSV C-section % SFY Primary TSV C-section % SFY

Presented at Washington State Hospital Association Safe Table 11/19/2013

Optimizing Episiotomy Rates Review

Methods and Components 2012-2013

 Statewide voluntary project  Regionally promoted by WSPC, WSHA-Partnership for Patients, PRN coordinators and physician champion  Measure: Episiotomy rate for spontaneous vaginal deliveries (National Quality Forum-based Measure; excludes shoulder dystocia, forceps, vacuum)  Distribute baseline vs. blinded hospital peer 2011 data to hospitals (WSHA Nov 2012: data source CHARS)  Hospitals will validate baseline data  2012-2013 Target rate < 5 % (Note: target rate is Not 0%)  Quarterly 2012-2013 hospital rates provided by WSHA  Hospitals encouraged to track related episiotomy rate with instrument and third and fourth degree perineal lacerations Presented at Washington State Hospital Association Safe Table 11/19/2013

8% 7% 6% 5% 4% 3% 2% 1% 0% 0% 2011 Washington State Episiotomy Rates vs. 3rd & 4th Degree Laceration Rates for Spontaneous Vaginal Delivery R² = 0.3915

Correlation Coefficient (r) = 0.628

Moderately Strong Association 5% 10% Episiotomy Rate 15%

Presented at Washington State Hospital Association Safe Table 11/19/2013

20% 25%

Episiotomy Rate for Vaginal Deliveries without Forceps/Vacuum Target Rate < 5% All WA Hospitals (Partnership for Patients (PFP) and non-PFP) 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 6,52% 5,93% 5,27% 5,90% 23.9% decrease from CY 2011 baseline 4,96% Baseline 2011 (48,563) Q1-2 2012 (23,302) Q3 2012 (12,914) Q4 2012 (11,740) Q1 2013 (11,484) Time Period (Denominator)

Presented at Washington State Hospital Association Safe Table 11/19/2013

Episiotomy rate without forceps or vacuum Proportion of Hospitals with rates < 5% and > 8% All WA hospitals (both PFP and non-PFP) 70% 60% 50% 40% 30% 20% 10% 0% 48,5% 34,8% 54,0% 27,0% 54,8% 25,8% 51,7% 28,3% 61,0% 25,4% Baseline 2011 (48,563) Q1-2 2012 (23,302) Q3 2012 (12,914) Time Period (Denominator) Q4 2012 (11,740) % of Hospitals < 5% % of Hospitals > 8% Q1 2013 (11,484)

Presented at Washington State Hospital Association Safe Table 11/19/2013

Episiotomy rate for vaginal delivery with forceps and vacuum All WA hospitals (both PFP and non-PFP) 40% 30% 29,5% 28,0% 28,4% 27,4% 29,7% 20% 10% 0% Baseline 2011 (3,167) Q1-2 2012 (1,381) Q3 2012 (681) Q4 2012 (980) Q1 2013 (943)

Presented at Washington State Hospital Association Safe Table 11/19/2013

Third and Fourth Degree Laceration Rate for Vaginal Delivery without forceps or vacuum All WA hospitals (both PFP and non-PFP) 4% 2% 0% 2,4% 2,3% 2,2% 2,1% 2,1% Baseline 2011 (48,563) Q1-2 2012 (23,302) Q3 2012 (12,914) Time Period (Denominator) Q4 2012 (11,740) Q1 2013 (11,484) 40% 30% Third and Fourth Degree Laceration Rates for Vaginal Delivery with forceps or vacuum All WA hospitals (both PFP and non-PFP) 20% 10% 16,9% 16,0% 14,0% 16,5% 0% Baseline 2011 (3,167) Q1-2 2012 (1,381) Q3 2012 (681) Time Period (Denominator) Q4 2012 (980) 17,7% Q1 2013 (943)

Presented at Washington State Hospital Association Safe Table 11/19/2013