PQCNC SIVB2 LS2 Data / Action Plan

7/31/2019 PQCNC SIVB2 LS2 Data / Action Plan

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Perinatal Quality:Making NC the Best Place tobe Born!

SIVB II Learning Session 2October 9, 2012


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What is PQCNC?

Perinatal Quality Collaborative of North Carolina

A community of organizations,agencies and individuals

committed to making NorthCarolina the best place to be

born .


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PQCNC Mission

Promote high value perinatal careSpread best practice and reduce variationPartner with families and patientsOptimize resources


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PQCNC Table

Family MembersPerinatal providers

Doctors (OB, MFM, Neos, Peds,FP)

Nurses (Peds, NICU, & OB) Midwives

Hospital AdministratorsPayers (Medicaid, BCBSNC)State Legislators

DPHState Hospital AssociationOthers (Malpractice insurers)


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PQCNC Initiatives

39 Weeks

CABSI

Exclusive Human Milk (EHM) NICU

EHM Well Baby

Support for Intended Vaginal Birth (SIVB)

NCABSI


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39 Week Project Supporting Intended Vaginal Birth (SIVB)

Maternal Quality Initiatives


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Decrease of

43%

39 Weeks Project


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Carolinas Medical CenterPineville Presbyterian HospitalMainGaston Memorial Presbyterian HospitalMatthews

Granville Health System Forsyth Medical CenterCape Fear Valley Medical Center Mission Hospital

Carolinas Medical Center Nash General HospitalOnslow Memorial Hospital New Hanover Regional Medical CenterCarolinas Medical Center NorthEast Pitt County Memorial Hospital

Carteret General Hospital Presbyterian Hospital Huntersville

Catawba Valley Medical Center Rex HealthCentral Carolina Hospital Stanly Regional Medical CenterColumbus Regional Healthcare System University of North Carolina HospitalsFirstHealth Moore Regional Hospital Forsyth Medical Center

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.


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SIVB in North Carolina


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Data on forty patients were collected from each hospital

Inclusion Criteria:Nulliparous

Singleton PregnancyVertex

37 weeks or more

Live fetus

Exclusion Criteria:

Placenta previaVaso previa

Previous MyomectomyCord 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


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CESAREAN RISK FACTORS

Diabetes (any type) IUGR Maternal age greater than/equal to 35

Hypertensive disease Macrosomia (EFW greater than 4000g) Obesity

5.45%

2.52%

4.02%

11.48%

0.86%

11.33%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Diabetes IUGR AMA HTN Macrosomia Obese

RiskFactor

Prevalence

28.8% of all patients had at least one risk factor


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25.11%23.99%24.12%23.67%

22.16%21.98%22.80%21.02%20.37%19.05%

21.26%23.54%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

OVERALL PRIMARY C/S RATE OVER TIMEALL FACILITIES

OverallC/S

GOAL=18.83%

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


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25.11%

23.99% 24.12% 23.67%22.16% 21.98%

22.80%

21.02%20.37%

19.11%

21.29%

23.95%

20.25%

18.23%19.32%

18.66% 19.06% 19.19% 18.47% 18.27%16.95% 16.59%

18.83%

20.74%

38.01%

36.34%

34.62% 34.07%

30.20% 29.74%

35.06%

28.00%

30.41%

26.42%27.62%

32.60%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

INITIATIVE-WIDE CESAREAN RATESOVERALLC/SRATE

C/SRATE-NOC/SRISKFACTORS

C/SRATE-1+C/SRISKFACTORS

Linear(OVERALLC/SRATE)


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23.9%

21.7%

18.5%

23.0%

25.4%

17.4%

26.8%

31.2%

24.9%23.5%

20.8%

24.7%

27.6%

16.9%

14.7%

23.1%23.9%

23.1%

16.5%

25.0%

21.6%

23.4%

18.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

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

AVERAGE C/S RATE BY FACILITY:Baseline - December

Averagefacility

c/srate


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48.77%48.57%47.77%

51.23%49.78%

50.80%52.26%51.30%

53.40%

50.00%49.88%

52.78%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

%o

fpaPents

inlabor

% OF PATIENTS IN LABOR AT ADMISSION

%ofptsin

laborat

CESAREAN RATE FOR PTSNOT IN LABOR AT

ADMISSION:31.70%

CESAREAN RATE FOR PTSIN LABOR AT ADMISSION:

14.61%


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BOTTOM LINE!

Cesarean rate for patients in labor atadmission

0-3 cm 18.38%

4+ cm 10.86%

Cesarean rate for induction patients

0-3 cm 31.34%

4+ cm 28.42%

Labor is Important

*PhaseIinvolves23hospitalsandhascollecteddataonmorethan10,000deliveries


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SIVB-2 Data

A focus on Labor!

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


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GOAL=18.83%


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15%$

33%$

24%$

0%$

5%$

10%$

15%$

20%$

25%$

30%$

35%$

In$Labor$

NOT$in$Labor$

Total$

Nulliparous*C,sec/on*Rate*,*Total*

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


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This is less prominent than SIVB I results


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Drilling down on the data!

Obesity

Diabetes

Hypertension


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Mothers may have more than one risk factor


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BMI

30 OR last maternal weight

200 lbs


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BMI 30 OR last maternal weight 200 lbs


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Includes gestational diabetes well orpoorly controlled; preexisting Type II or Type 1 diabetes


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


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Many mothers carry more than one risk factor

Obesity is a poor indication for induction of labor

Very conservativeestimate


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BOTTOM LINE!

Cesarean rate for patients in labor atadmission

0-3 cm 18.38%

4+ cm 10.86%

Cesarean rate for induction patients

0-3 cm 31.34%

4+ cm 28.42%

Labor is Important

*PhaseIinvolves23hospitalsandhascollecteddataonmorethan10,000deliveries


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What do we do next?


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1. Do you have a physician or team of physicianchampions?

2. Do you have adequate time, space, and/orexpertise to diagnosis labor?

3. Are your patients educated with respect to theimportance of labor?

4. Do you have multiple mechanisms to support apatients labor?5. Does your institution track vaginal delivery rate

and report it back to the providers specifically innulliparous patients?

6. Do you have an induction protocol forNulliparous patients?7. Do you Track and review elective nulliparous

inductions less than 41 wk?


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Faces of PQCNC


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Thankyou!

Quesons?

James deVente MD/PhDAssociate Professor, Dept. OB/Gyn

Medical Director of Labor and DeliveryEast Carolina University

Brody School of MedicinePager: 252-413-4153 (please page me)

PQCNC SIVB2 LS2 Data / Action Plan

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