Transcript Document

Philadelphia OB Project
Improving Patient Safety, the Quality
of Care and Reducing Liability
in a Metropolitan Obstetrical Population through
Inter-Institutional Collaboration
Guiding Principles and Checklists for
6 University Obstetrical Practices
Owen Montgomery M.D. FACOG
Chairman Department of Obstetrics and Gynecology
Drexel University College of Medicine
Philadelphia OB Project
US News and World Report
6 Top Ranked Hospitals in Philadelphia
ranked amongst the best in US/ region
#1 Hospital of the University of Pennsylvania
#2 Thomas Jefferson University Hospital
#3 Temple University Hospital
#4 Hahnemann University Hospital
#4 Pennsylvania Hospital
#8 Einstein Medical Center
All 6 have Obstetrical Residency Programs
Philadelphia OB Project
• The University of Pennsylvania is
the oldest and one of the finest
medical schools in the United
States.
• Founded in 1765 Penn prides
itself on educating the leaders of
tomorrow in patient care,
biomedical research, and
medical education.
• among the top five in US
research-oriented medical
schools.
• 4500 deliveries
• 26.2% C/S rate
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• Founded in 1824, Jefferson
Medical College has awarded
more than 27,000 medical
degrees and has more living
graduates than any other
medical school in the nation.
• Jefferson Medical College is
recognized for its balanced
approach to medical education,
and approximately one out of
four to one out of five applicants
throughout the U.S. apply to
Jefferson.
• 2500 deliveries
• 32.3% C/S rate
Philadelphia OB Project
Temple University School of
Medicine is recognized as an
institution that offers an exceptional
clinical education to a diverse and
socially-conscious student body.
10,000 living medical graduates are
practicing in the fifty states and
other parts of the world.
Temple University School of
Medicine ranks fifth in the nation in
African American medical school
graduates
4000 deliveries
32.2% C/S rate
Philadelphia OB Project
Drexel University College of
Medicine is merger of two of the
earliest medical colleges in the
United States Medical schools
Hahnemann Medical College 1848
Woman’s Medical College of
Pennsylvania 1850
Woman’s was the very first medical
school for women in the world.
DUCOM has the largest medical
student enrollment of any private
medical school in the nation.
National Center of Excellence in
Women’s Health
2500 deliveries
24.3% C/S rate
Philadelphia OB Project
• Pennsylvania Hospital, “the
nation’s first hospital”, is a 515bed acute care facility that
provides a full range of
diagnostic and therapeutic
medical services and functions
as a major teaching and clinical
research institution.
• The hospital was founded in
1751 by Benjamin Franklin and
Dr. Thomas Bond to care for the
“sick-poor and insane of
Philadelphia.”
• 5000 deliveries
• 35.3% C/S rate
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Einstein Medical Center’s is rooted
in healing, caring and learning.
Philadelphia's largest independent
Academic Medical Center with 7 (8)
hospitals a distinguished history
extending back to 1866
Started a gynecological clinic in 1896
Albert Einstein gave permission to
use his name for the new medical
center 1951
Einstein hospital has provided care
for the disadvantaged of north-east
Philadelphia for over one-hundred
years
4000 deliveries (not including new
Montgomery site)
31.9% C/S rate
Philadelphia OB Project
• SUMMARY: Hospital OB units in Pennsylvania
• Statewide, 1997 = 147
• Statewide, 2009 = 103
• Number of Closures = 44
• Number of Openings = 3
• Net Loss Statewide = 41
• % change = 29.9%
• SUMMARY: Hospital OB units Southeast PA
• SEPA, 1997 = 41
• SEPA, 2009 = 23
• Number of Closures = 19
• Number of Openings = 2
• Net Loss = 17
• % change = 43.9%
Philadelphia OB Project
MATERNITY UNITS CLOSED
(Southeastern PA)
Bucks
Warminster (2000)
Chester
Brandywine Hospital (2008)
Delaware
Mercy Fitzgerald Maternity Unit (2003)
Montgomery
Elkins Park (2001)
Central Montgomery Medical Center
(2009)
Philadelphia
Temple East-Northeastern Hospital (2009)
Chestnut Hill Hospital Maternity Unit
(2008)
Jeanes Hospital (2007)
Frankford Hospital (2006)
Parkview (2003)
Methodist (2002)
Mercy Philadelphia Hospital (2002)
Episcopal (2001)
Roxborough Memorial Hospital (1999)
City Avenue (1999)
Germantown (1998)
Nazareth Hospital (1998)
Medical College of Pennsylvania (1997)
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MATERNITY UNITS AND HOSPITALS STILL OPEN
(Southeastern PA)
Bucks
Doylestown Hospital
Grand View Hospital
Lower Bucks Hospital
St. Mary Medical Center
Chester
Chester County Hospital
Jennersville Regional Hospital
Paoli Hospital
Phoenixville Hospital
Delaware
Crozer-Chester Medical Center
Delaware County Memorial Hospital
Riddle Memorial Hospital
Montgomery
Abington Memorial Hospital
Bryn Mawr Hospital
Einstein Montgomery (open 10/2012)
Holy Redeemer Health
System
Lankenau Hospital
Mercy Suburban Hospital (just
closed late 2009 )
Montgomery Hospital Medical
Center (closed 10/2012)
Pottstown Memorial Medical Center
Obstetric Care Availability
Consequence of Liability
 20 Obstetric Units have closed in Southeastern
Pennsylvania since 1997.
 The largest decrease is in Philadelphia with 13
closures leaving only 6 hospitals in the city with
Obstetrical Units
 Number of births in the city not changed
1996-23,706 births
2010- 23,508 births.
 Of the 23,000 deliveries 99% are performed by
physicians or midwives employed by hospitals.
 The “practice” of Obstetrics and Gynecology by self
employed physicians in Philadelphia is extinct.
Obstetric Care Availability
Consequence of Liability
Philadelphia Health Commissioner Task Force
•Sharing “quality outcome data” and “Quality
Initiatives” between institutions
impossible
•Absence of peer review protection by the Health
Commissioner.
•Each of the 6 remaining institutions use different
Electronic Health Records or no EHR for Obstetrics
•This makes sharing of data impractical and/or
prohibited by institutional legal counsel.
Obstetric Care Availability
Consequence of Liability
 Deputy Mayor/Health Commissioner
 Chairs of all 6 University OB/GYN Programs
 Hospital Association of Pennsylvania
all working together but
NO significant improvement in the reimbursement and
medical liability situation.
To assure quality care and patient safety with increasing
volume of patients:
It is necessary for all remaining Obstetrical Units to
work together to find new ways to insure quality care
while reducing liability.
Philadelphia OB Project
MATERNITY UNITS REMAINING OPEN
Philadelphia County
Albert Einstein Medical Center
Hahnemann University Hospital
(Drexel University College of Medicine)
Hospital of the University of Pennsylvania
Pennsylvania Hospital
Temple University Hospital
Thomas Jefferson University Hospital
Philadelphia OB Project
The Philadelphia OB Chairs are concerned about their
continued ability to provide quality, safe obstetrical care.
Group formed in 2008 to meet with the City Health Commissioner:
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low reimbursement
high medical liability costs
closure of 14 obstetrical units in the last 10 years
5 units in the past 5 years.
increased and unplanned volume in the remaining 6 units
major unpredicted fluctuations in volume from day to day
regular safe staffing by nurses, physicians very difficult.
Philadelphia OB Project
The Philadelphia OB Chairs agree to work with the
Health Commissioner to develop a city wide RHIO for
all Obstetrical patients in Philadelphia.
 Improve care for patients who come to an
Obstetrical Unit without access to their OB record
(10- 15% throughout city, 33% at TEMPLE)
 Improve efficiency in obtaining diagnoses and
previous laboratory data
 Improve outcomes while reducing costs
 Develop a central de-identified city data base for:
continuous quality improvement and
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outcomes data research.
Philadelphia OB Project
Philadelphia OB Project
Philadelphia OB Chairs Response
The Philadelphia OB Chairs have agreed to the following initiatives to
maintain the highest level of quality care and patient safety:
 Continue to provide the highest level of obstetrical care to all
women in the City of Philadelphia
 Provide 24/7 coverage of the remaining Obstetrical Units with a
Board Certified or eligible OB/GYN Physician
 The OB Physician will work for a maximum of 24 hours
 The OB Physician will have No other patient duties during the 24
hours
 The OB Physician will have No patient duties after the 24 hours of
OB unit coverage
 The OB Physician will supervise the care of all patients without
regard to insurance coverage or site of Prenatal care
Philadelphia OB Project
Number 526 May 2012
Standardization of Practice to Improve Outcomes
Protocols and checklists have been shown to improve patient safety
through standardization and communication.
Standardization of practice to improve quality outcomes is an
important tool in achieving the shared vision of patients and their
health care providers
Philadelphia OB Project
Guidelines for Single (national) standard for induction of
labor and timing of Cesarean Sections.
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ACOG and March of Dimes Campaign:
NO Elective Deliveries before 39 completed weeks
Hard Stop for Inductions and Scheduled Cesarean Sections
Leepfrog Quality Indicator
Philadelphia OB Project
• Guidelines for Standardization of Interpretation and
Management of Fetal Heart Rate recordings
• Agree to a single standardized ACOG national nomenclature for
interpretation of fetal heart rate tracings
• Decrease variability in care from provider to provider and
institution to institution.
• Mandate for all Obstetrical Providers:
• Attendings, Midwives, Resident Physicians and Obstetrical Nurses
12 hour on line advanced course in Fetal Heart Rate Interpretation
• APS or GE are ACOG approved as on line courses
Philadelphia OB Project
Guidelines for Standardization of Education and
Management of Shoulder Dystocia
• Mandatory Formal Educational Program for all Obstetrical
Providers: Attendings, Midwives, Residents, Labor Nurses
• Regular Team Training and Drills for Shoulder Dystocia
• Simulation training
• ACOG Standard Forms for recording maneuvers and timing
• Documentation and Certification
• Staff privilege requirement
Philadelphia OB Project
Guidelines for Standardization of Post Partum
Discharge Requirements Instructions for Follow up
• Screening for Post Partum Depression and Intimate Partner
Violence
• Smoking Cessation , Immunization, Contraception, Breast
Feeding
• Post partum visits and testing for HTN , GDM
• Instructions for specific concerns: chest pain, headache
bleeding, fever
• Self care and Neonate care
Maternal Mortality in New Jersey
Safe Motherhood in Massachusetts
Pregnancy-associated injury deaths:
Violence, substance abuse, and
motor vehicle collisions, 1990-1999
Massachusetts Department of Public Health
Public Health Council Meeting
May 28, 2002
Distribution of injury and medical
causes of pregnancy-associated
death 1990-1999
34%
n=80
n=152
n=80
n=152
Medical
Injuries
66%
•There were 232
pregnancyassociated deaths.
•Over one-third
were injury-related.
Leading causes of pregnancyassociated death 1990-1999
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Homicide leading cause overall (n=30)
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Other leading causes of injury deaths:
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Motor vehicle collisions (n=21)
Drug overdose (n=16)
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Suicide (n=7)
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2 out of 3 were cases of domestic violence
Leading causes of medical deaths:
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Cancer (n=28)
Acute and chronic respiratory conditions (n=23)
Cardiovascular disease and conditions (n=11 )
Peripartum and postpartum cardiomyopathy
(n=8)
Number of injury deaths by cause and
period of risk, 1990-1999
Number of deaths
20
15
10
5
0
Pregnant
0-41 days
42-179 days
180-364 days
Timing of Death
Homicide
Suicide
Motor Vehicle
Substance abuse
Opportunities - Number of provider
visits by period of risk, 1990-1999
Number of Visits
12
10
8
6
4
2
0
Pregnancy
OB
0-41 days
Pediatric
WIC
42-179 days
Primary Care
180-364 days
Hospital
Facts About Intimate Partner Violence
(IPV)
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Affects approximately 1.5 million women each
year
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Affects as many as 324,000 pregnant women
each year
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May be more common than conditions for
which pregnant women are routinely screened
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Possibly associated with unintended
pregnancy, delayed prenatal care, smoking,
alcohol and drug abuse
Routinely Screen Every Patient
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At first prenatal visit
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At least once per trimester
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At postpartum checkup
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At routine ob-gyn visits and
preconception visits
Philadelphia OB Project
• Guidelines for Standardization of Post Partum
Discharge Instruction in Philadelphia
• Purpose : to assist the medical providers and
staff of the Philadelphia Obstetrical Units to
cooperatively establish the components of
standard postpartum instructions,
• to maximize the ability of the new mother to
care for herself and her neonate and to
identify potential problems related to her
maternal and general health .
Philadelphia OB Project
Principles:
1) all new mothers should receive prior to
discharge instruction and educational
materials about the following areas of care:
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Self-care and care of the neonate
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Appropriate Rest
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Early Ambulation
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Health and Regular Diet:
Philadelphia OB Project
• National recommendations: 1800 kcal per day
or 550 kcal/day additional
• Vitamins, especially Calcium, Vitamin D, Iron
as needed
• Perineal Hygiene
• Routine Care of the Breast, Bladder and Vulva
Philadelphia OB Project
2) All new mothers should receive the
appropriate recommended Immunizations prior
to discharge including:
Anti D, Tdap, Rubella
3) All new mothers should receive education
and support in the Promotion of Breast feeding
4) All new mothers should receive education
about, access to, and discussion of :
Contraception /Family Planning
with or without breast feeding
Philadelphia OB Project
5) All new mothers should receive support for
their psychosocial health and prior to discharge
specifically receive
“Screening for Post Partum Depression” using
the Edinburgh Depression Screening
or equivalent with appropriate follow-up
(appendix supplied).
“Intimate partner violence” screening with
community resources
Philadelphia OB Project
Additionally, new mothers should be instructed
on when and how to contact their provider if:
• their depression symptoms last longer than 2
weeks or gets worse,
• they are unable to perform daily activities,
• they have no interest in the baby, or
• they feel they may harm themselves or the
baby.
Philadelphia OB Project
6) All new mothers should receive educational
information and instruction in :
Smoking Cessation (as appropriate)
Dangers of Alcohol and Drug
Philadelphia OB Project
7) All new mothers should be instructed what
signs and symptoms to look for after discharge
and when and how to contact their providers.
These conditions include but are not limited to:
Observation of chills or fever of 100.4 or
greater or aches and chills
Excessive bleeding (more than 4 soaked pads
within an hour for 2 hours)
Severe chest or abdominal pain that does not
go away or any other severe pain
Philadelphia OB Project
 Inability to urinating or pain with urination
 Persistent headache or blurred vision
 Tenderness, redness, hard areas and pain in
their breast
 Inability to have a bowel movement or
diarrhea for more than 3 days
 Swelling, redness, or tenderness in their legs
 Redness or foul smelling discharge around
stitches or surgical wound
Philadelphia OB Project
8) All new mothers should receive appropriate
Post-Partum Follow-Up Visits:
Usually this is in 7-14 days for surgical
follow-up and high risk conditions:
PIH, Preeclampsia or medical, obstetrics or
inter-current complications.
Routine Post Partum visits are usually in 4-6
weeks
Philadelphia OB Project
9) All new mothers should receive appropriate
Home Visits as dictated by :
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their medical condition and
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allowed by state guidelines and
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insurance coverage
Philadelphia OB Project
References:
Guidelines for Perinatal Care. American Academy of Pediatrics (and) the
American College of Obstetricians and Gynecologists, 6th Edition.
Copyright© October 2007, by the American Academy of Pediatrics and the
American College of Obstetricians and Gynecologists.
J.L. Cox, JM. Holden, F T Sagovsky (1987), Post Partum Depression
Screen. British Journal of Psychiatry, June, Vol. 150.
You and Your Baby: Prenatal Care, Labor and Deliver, and Postpartum
Care. Patient Education Booklet. Copyright© September, 2011 by the
American College of Obstetricians and Gynecologists.