Maryland Perinatal System Standards, Revised 2004

Summary of Efforts by the Perinatal Clinical Advisory Committee, Department of Health & Mental Hygiene

Maryland Perinatal System Standards, 2004

• Consensus document developed by a 33-member committee representing 16 Maryland professional organizations • 3 rd major updating of Maryland perinatal standards that have been in existence since 1995 • Consistent with

Guidelines for Perinatal Care, 5 th 2002

issued by AAP/ACOG

Edition,

• Consistent with AAP 2004 Policy Statement on

Levels of Neonatal Care

• Standards facilitate consistent service provision, represent professional consensus, informs the public, and permits comparisons for outcomes among institutions 2

Perinatal Standards: National Perspective

• 1972 – March of Dimes formed the Committee on Perinatal Health (COPH) • 1976 – COPH issued Toward Improving the Outcome of Pregnancy (TIOP I) that defined standards for perinatal regionalization • 1985 – Robert Wood Johnson Foundation Report on perinatal regionalization demonstrated improved pregnancy outcomes • 1993 – COPH updated Toward Improving the Outcome of Pregnancy (TIOP II) • 2002 – Guidelines for Perinatal Care, 5 th Edition, issued by AAP and ACOG supports TIOP II standards 3

Perinatal Standards: Maryland’s Perspective

• 1989 – Maryland AAP’s Fetus and Newborn Committee developed nursery guidelines • 1995 – DHMH Secretary’s Perinatal Clinical Advisory Committee issued voluntary Maryland Guidelines for Perinatal Care • 1998 – Perinatal Clinical Advisory Committee updated Maryland Perinatal System Standards – Level III and IV standards adopted by MIEMSS for maternal-neonatal transport purposes and MHCC for certificate of need purposes • 2004 – Perinatal Clinical Advisory Committee updated Maryland Perinatal System Standards 4

Perinatal Outcomes: Maryland

• Infant mortality rate declined by 11% from the early 1990’s to early 2000’s – (9.1/1000 in 92-96 to 8.2/1000 in 97-01) • Neonatal mortality rate declined by 5% • Postneonatal mortality rate declined by 22% • VLBW-specific neonatal mortality rates improved – For all hospitals: 148/1000 to 132/1000 – For Level III & IV hospitals: 142/1000 to 129/1000 – Fewer Level III and IV hospitals now have NMR’s greater than 200/1000 (4 to 1) 5

Birth Weight-Adjusted Neonatal Mortality Rates, By Maryland Level III & IV Hospital

1994-1995 1999-2000

D1 G1 H1 C1 A1 B1 E1 ALL Z K1 T X F1

Birth Weight-Adjusted Neonatal Mortality Rates by Hospital of Birth for Maryland Resident Infants with Birth Weights of 500-1499 Grams Born in Maryland III/IV Hospital, 1994-1995

63.5

89.6

147 134.3

130.2

121.3

117.7

142.2

178.6

209.3

257.5

249.8

241.1

0 100 200

Neonatal mortality rate per 1000 live births

300

Birth Weight Adjusted Neonatal Mortality Rates by Hospital of Birth for Maryland Infants with Birth Weights of 500-1499 Grams Born in Maryland Level III/IV Hospitals, 1999-2000

H1 B1 W K1 F1 E1 D1 ALL V J1 Y G1 A1 C1 X Z 72.2

87.4

68.6

156 155.7

149.8

131.8

147.2

123.7

121.2

114.8

111.2

129.2

187.5

202.7

186.5

0 100 200

Neonatal mortality rate per 1000 live births

300 6

Maryland Perinatal Clinical Advisory Committee, 2004

• American Academy of Pediatrics, Maryland Chapter • American College of Nurse-Midwives, Maryland Chapter • American College of Obstetricians & Gynecologists, Maryland Chapter • Association of Women’s Health, Obstetric & Neonatal Nurses • Association of Social Workers, Maryland Chapter • Department of Health and Mental Hygiene • Maryland Academy of Family Physicians • Maryland Association of County Health Officers • Maryland Health Care Commission 7

Maryland Perinatal Clinical Advisory Committee, 2004

• Maryland Hospital Association • Maryland Institute for Emergency Medical Services Systems • Maryland Commission on Infant Mortality Prevention • Maryland Perinatal Association • Maryland Society of Anesthesiologists • Med-Chi • Obstetrical and Gynecologic Society of Maryland 8

Definitions of Levels of Care, 2004: Level I

• Basic care to pregnant women and infants • Delivery room and normal newborn care for stable infants  35 weeks gestation • Maternal care limited to term and near-term gestations • Other than emergency stabilization, neonatal units do not provide mechanical ventilation • No pediatric subspecialty or surgical specialty services • Do not receive primary infant or maternal referrals 9

Definitions of Levels of Care, 2004: Level IIA

• Specialty care to pregnant women and infants • Delivery room and specialized care for stable infants  1,500 grams or  32 weeks gestation • Maternal care limited to term and preterm gestations • Neonatal units may provide conventional mechanical ventilation only in stabilization situations • No pediatric subspecialty or neonatal surgical specialty services • Do not receive primary infant or maternal referrals 10

Definitions of Levels of Care, 2004: Level IIB

• Specialty care to pregnant women and infants • Delivery room and acute specialized care for stable infants  1,500 grams or  32 weeks gestation • Maternal care limited to term and preterm gestations • Neonatal units may provide conventional mechanical ventilation, limited in technique and duration • May provide limited pediatric subspecialty services • No neonatal surgical specialty services • Do not receive primary infant or maternal referrals 11

Definitions of Levels of Care, 2004: Level IIIA

• Subspecialty care to pregnant women and infants • Acute delivery room & neonatal intensive care unit (NICU) care for infants  1,000 grams or  28 weeks gestation • Maternal care spans the range of normal term gestation care to the management of moderate prematurity and moderately complex maternal complications • Neonatal units provide conventional mechanical ventilation and offer continuous availability of neonatologists • May provide some pediatric subspecialty services • No neonatal surgical specialty services • May provide maternal or neonatal transport 12

Definitions of Levels of Care, 2004: Level IIIB

• Subspecialty care to pregnant women and infants • Acute delivery room and neonatal intensive care unit (NICU) care for infants of all birth weights and gestational ages • Maternal care spans the range of normal term gestation care to the management of extreme prematurity and moderately complex maternal complications • Neonatal units provide multiple modes of neonatal ventilation and offer continuous availability of neonatologists • Provide some pediatric subspecialty services • May provide some neonatal surgical specialty services • May provide maternal or neonatal transport 13

Definitions of Levels of Care, 2004: Level IIIC

• Subspecialty care to pregnant women and infants • Acute delivery room and neonatal intensive care unit (NICU) care for infants of all birth weights and gestational ages • Maternal care spans the range of normal term gestation care to that of highly complex or critically ill mothers • Neonatal units provide advanced modes of neonatal ventilation and life support and offer continuous availability of neonatologists • Extensive pediatric subspecialty services and pediatric subspecialty surgical services are available, including cardiothoracic open-heart surgery and neurosurgery • Provides maternal and neonatal transport 14