Transcript Slide 1

ELECTIVE DELIVERY LESS THAN 39
WEEKS GESTATION
THE HCA EXPERIENCE
Steven Holt, MD, FACOG
Chair Department of OB/GYN
Rose Medical Center
7/31/09
HCA 2007 Study
 Hospital Corporation of America –
114 obstetric facilities in 21 states.
 225,000 annual deliveries.
HCA 2007 study
 Population sampled: All deliveries between
May 1, 2007 and July 31, 2007 in 27
facilities in 14 states. (Included three
Virginia hospitals and one Colorado
hospital.)
 Facilities chosen to be representative of
entire population – geographic and delivery
volume.
 Comprehensive data collection for all
women undergoing planned delivery at 37
weeks and 0 days or greater.
Methods
 Planned delivery = patient entered hospital
for delivery admission not in labor, or with
ruptured membranes.
 Planned deliveries = indicated + elective.
 Indicated = any indication noted by the
admitting physician or by the nurse
providing OB care.
 Indications tallied, but not questioned
Methods
Probably more elective deliveries than
claimed because on spurious
indications, there was no questioning
done.
For example: If a patient was listed as
having hypertension, but the admitting
BP was 120/60, the patient was listed as
having a medical reason for the planned
delivery and was not listed in the
“elective” group.
NQF National Voluntary Consensus
Standards for Perinatal Care
 Exclusions: Many of these are referenced in the
ACOG Technical Bulletin #10 November, 1999
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Post-dates (645)
Oligohydramnios (658.0)
Maternal Cardiac Disease (648.8)
Previous Stillbirth (648.5)
Maternal Renal Disease (646.7 & 646.0)
Multiple gestation (652)
Maternal Coagulopathy (656.4)
Ruptured Membranes ((649.3)
Acute Fatty Liver of Pregnancy (656.1)
Unspecified Antenatal Hemorrhage (646.2)
IUGR (656.5
Hypertension (642)
Diabetes (648.0)
Placental Abruption (648.6)
Placenta Previa (641)
Isoimmunization (656.2)
Fetal Demise (657)
Hydramnios (658.1)
Malpresentation (656.1)
Results
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17,794 deliveries
14,955 at 37 weeks of greater
6562 were planned term deliveries 44% of term deliveries
4645 were elective planned term delivery 71% of planned
term deliveries
 31% of all term deliveries were elective
 16% of all deliveries were elective inductions of labor
 11% of all term deliveries were elective and prior to 39
completed weeks gestation
NICU Admissions following Elective
Delivery
 37.0 – 37.6 weeks: 17.8%
 38.0 – 38.6 weeks: 8.2%
 > 39 weeks: 4.6%
 All differences highly significant (p<0.001)
 2/3 were direct NICU admits, 1/3 were admitted later after
initial normal newborn admission.
– As a note, the delivery provider may not realize the baby went to
the NICU after the initial admission.
 Mean NICU stay for these infants was 4.5 days.
Planned Inductions and C-Section
Rates
60
Nulliparous
Multiparous
Cesarean Section Rate (%)
50
40
30
20
10
0
0
1
2
3
4
5
Cervical Dilatation at the time of Induction (cm)
Conclusions
 11% of all term deliveries are elective and performed prior to 39 weeks
gestation, in violation of longstanding ACOG/AAP recommendations.
 Given the nature of many “indications”, the actual rate is probably
higher.
 Such infants experience significant morbidity.
 For all Planned Inductions, the cesarean delivery rate is directly related
to initial cervical dilatation.
 Elective induction of labor with an unfavorable cervix also increases
the risk of cesarean delivery.
39 Week Elective Deliveries in HCA
Institutions
 Greater than 30 perinatal services have
implemented a policy.
 40 perinatal services are somewhere in the
process of implementation
 Other perinatal services are just beginning
discussions
 Do what works best for your institution, your
practitioners and the safety of your patients
How education can change
behavior
 Results of 2007 non-clinically indicated IOL at less than 39
weeks.
 Actions that impacted results were:
 1. Following data per physician, and notifying physicians
that data would be collected.
 2. Provided education to physicians regarding ACOG
bulletin listing appropriate clinical indicators for IOL at less
than 39 weeks.
 3. Provided education to physicians regarding increased
morbidity, mortality and increased LOS related to the near
term infant.
 4. Provided feedback to department of OB/GYN and
individual physicians regarding data collection results.
How education can change behavior
 First quarter non-clinically indicated IOL <
39 weeks was 29.6% of total IOL
 Second Quarter non-clinically indicated IOL
< 39 weeks was 24.3% of total IOL
 Third Quarter non-clinically indicated IOL <
39 weeks was 21% of total IOL
 Fourth Quarter non-clinically indicated IOL <
39 weeks was 12.6% of total IOL
NSMC
 OB Department is evaluating and considering the following
 If indication for induction is not included in the ACOG
Technical Bulletin # 10 and gestational age is less than 39
0/7 weeks OB Provider to discuss with L&D manager or
Chairperson of OB before scheduling an elective induction
 Specific consent of labor form must be completed which
includes the indication-one practice is currently using this
form
 Any deliveries determined to be elective –prior to 39 weeks
are sent to peer review
 Laboring and augmented patients are excluded
Other HealthONE Hospitals
 PSL and Aurora both have accepted this
standard and are in process of tracking
compliance and determining best ways to
impact change in practice
 Regional Perinatal Task Force meets
quarterly with additional regular conference
calls between HealthONE managers and
HCA clinical leadership-this data is being
tracked for all HealthONE and HCA
Hospitals
PEER review-An Educational and
Constructive Approach
 Many centers have chosen to look at <39
week inductions on a case by case basis
 Better to have a group of peers look at
specific cases and make recommendations
than to be “told what to do”
 Is there room for “judgment” and “special
cases” ?
 Amniocentesis? For all or in some special
cases
? OTHER INDICATIONS
 Advanced cervical dilation
 Husband leaving for Iraq at 38 weeks and 4
days
 She wants you to do her Section and you
are on vacation at 39 weeks or not on call
 Grandma just bought a plane ticket and has
to go home at 39 completed weeks.
PEER Review-An Educational
Process at Rose
 Started Auditing Charts Feb. 2008 with
discussions at department meetings and
peer review
 Memos and department Newsletters
highlighting NQF and ACOG
recommendations
 Oct, Nov, Dec, Jan audit of all “Elective
Deliveries” both inductions and C-Sections
 True “fall outs” reviewed in PEER review
and “educational letters” sent to those
providers along with a copy of recent ACOG
Educational Letter
Dear Dr. Holt,
Your patient, ____, was electively delivered at between 38 and 39 completed
weeks gestation. This letter is from the OBQI committee and serves as a
reminder that all elective deliveries at this gestational age both Cesarean
Sections and Inductions of labor are being audited by the Committee, This is
based on the recommendations of ACOG, the American Academy of Pediatrics
and the National Quality Forum advising against elective deliveries less then
39 completed weeks gestation due to adverse neonatal outcomes associated
with this practice
We have decided to provide this information to our OB Providers as an
educational tool for the next 3 months. After this time frame we will begin
assigning Peer Review Levels to all Providers who electively deliver
patients at less then 39 completed weeks gestation. The specific Level
assigned will be determined on a case by case basis. This information
will become a part of your Credentialing File in the Medical Staff Office
EDUCATIONAL LETTER
We would be glad to provide you with data in support of
this practice for you to share with your patients as you
decide timing for elective deliveries. The Green Journal
has had ACOG Practice Bulletins and articles of support of
this practice this year.
We appreciate your continued efforts to provide the best
possible quality of care for your OB patients at Rose
Medical center.
Your OBQI committee
PEER Review-An Educational
Process
 Oct.-1 letter was sent 3 charts reviewed
 Nov.- 3 letters were sent 20 charts reviewed
 December 1 letter was sent 18 charts
reviewed
 Jan. 4 letters sent and 14 charts reviewed
 During this “educational period” we
experienced < 2% elective delivery rate at
<39 weeks.
Rose Experience
 We continue to review all charts without
medical indications for delivery at less than
39 weeks in Peer Review
 2nd Q data 4/372=1.08% <39 week elective
delivery rate
 We have decided to trend these cases and
not assign a peer review level at this time
 New educational letter in preparation for
public reporting as a Perinatal Core
Measure starting April 2010
 Work group is designing a patient education
Current Peer Review letter
Dear __________
Re: Medical Record Number _______
In our routine chart audits for quality
improvement, this case “fell-out” for elective
delivery at less than 39 weeks gestation.
This letter is from the OBQI Committee and
serves as a reminder that all elective
deliveries less than 39 weeks, both
Cesarean Sections and Inductions of labor
are being reviewed, The Joint Commission
plans to include public reporting of elective
Current Peer Review letter
This letter is intended to assist you in
tracking and trending your practice against
this indicator and to provide education
regarding the latest research on this issue.
Enclosed are two recent articles, one from
AJOG and one from the New England
Journal of Medicine documenting the
significant differences in outcomes in
neonates delivered <39 weeks compared to
>39 weeks. This includes outcome
differences in those delivered at 38 weeks
and 4 days to 38 weeks and 6 days in the
Current Peer Review letter
There are no plans to restrict this practice at
Rose. We understand every patient
situations is unique. We plan to trend <39
week elective (not medical) deliveries by
provider in preparation for public reporting
Your OBQI Committee
Thank you
Steven Holt, MD, FACOG
Chair Department of OB/GYN
Rose Medical Center