AHSOur Journey to Lowering Maternal Morbidity

April 29, 2019Diana N. Contreras MD MPH

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AHS Journey

AHS OB Journey

Principles• Data driven/Transparency• Evidence based practices• Systemwide /Team based

AHS JourneyData: Metrics for Obstetrics

Joint Commission Leapfrog Delivery data

• Method of Delivery• C/S Information• Quality Measures

o Adverse Outcome Score

AHS JourneyData: Metrics for Obstetrics

AHS Journey: Evidence Based

Dashboard changed 2018• SMFM recommendations of Quality • Added Maternal Morbidity Score

o Transfusion of 4 units of blood or more and/or admission to the ICU

– What is the baseline?– What is was the national benchmark?– What was the rate in California?

AHS Journey: Evidence Based

NTSV rates added to dashboard in 2018• Grand Rounds and Business meetings

o Rates shared with physicians• Eliminated elective inductions prior to 41

weeks June 2018

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AHS Journey: Data

NJHA AIM• All 4 Hospitals joined• Requested to be part of steering

committee for PQC• SMM AHS hospitals 2016 results on

NJHA websites– SHOCKED!!!!– Some hospitals Just OK

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AHS Journey

USA article July 2018• Hospitals know how to protect mothers.

They just aren’t doing it

• Women giving birth are needlessly dying or suffering life-altering injuries because U.S hospitals aren’t following known safety measures….

AHS Journey

USA article July 2018

• Conclusion of hospital investigations: “stunning lack of attention to safety recommendations and widespread failure to protect new mothers”

AHS Journey

System CEO inquired:• What is the system and individual

hospitals’ Mortality rate ?

• Are we following the safety recommendations mentioned in the article?

AHS Journey

Answer:• Robust dashboard: Joint

Commission, Leapfrog etc.

• Not followed on the dashboard

• Could not provide metrics for the safety recommendations

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AHS JourneyData/Evidence/Team

Meeting with Senior Leadership in September/October 2018

• NJHA SMM-Results unacceptable

• Call to Actiono Establish AHS System-wide OB

Collaborativeo New Data Dashboard with AIM Outcomes

AHS Journey: OB CollaborativeData/Evidence/Team

Evidence Based Practices• Toolkits/Bundles• Protocols• Documentation• AIM Structure and Process

Systemwide Team• No Silos• All sites represented

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AHS OB CollaborativeTeam Based/Systemwide Developed Charter

• Senior Leadership• Site Leaders • Others

Systemwide• All 4 hospitals represented• Voluntary and full time staff

o Including midwives

AHS OB CollaborativeTeam Based/System wide

Workgroups: AIM Structure and Process• Hemorrhage• Hypertension• NTSV

Situational Awareness Metrics

• Outcomes

AHS OB CollaborativeTeam Based/Systemwide

Pharmacy Workgroup• Emergency medications across system

–4 Hospitals L&D–4 Hospitals ED–2 EDs–Prehospital

AHS OB CollaborativeTeam Based/Systemwide

ED Leadership • Systemwide Maternal Hypertension

Code

o Goal: Treat antepartum and post partum preeclampsia patients within one hour

–4 Hospitals, 2 EDs and Prehospital

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AHS OB Collaborative: Data Driven

What are the baselines and what is the target?• SMM rate target?• Hemorrhage rate target?• Hypertension rate target?

What is the benchmark in New Jersey What is the benchmark in other states?

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“Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,” said the Cat.

“I don’t much care where—” said Alice.

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“Then it doesn’t matter which way you go,” said the Cat.

“—so long as I get somewhere,” Alice added as an explanation.

“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.” —Chapter 6, Pig and Pepper

AHS OB Collaborative: Data Driven

Tried to recreate SMM from NJHA • Realization SMM problematic

o Transfusion 80% of cases

–Coding/Reporting Issues

• No standardization of definition of hemorrhage

–Quantity/Coding Issues23

A key outcome measure used by these initiatives is the Severe Maternal Morbidity Measure developed by the CDC. A central data element in this measure and a key driver of maternal morbidity is blood transfusions. It is critical for hospitals to continue to code for transfusions in maternity patients.

2016

SMM: Transfusions

While coding blood transfusion procedures has been optional for hospitals, …we have been hearing that hospitals are “electing” not to code blood transfusions due to the complexity of the new codes and the lack of specificity in provider documentation (such as “through which vessel was the transfusion given...).

2016

SMM: Transfusions

Please provide guidance to your providers and coders regarding the importance of thorough documentation of blood transfusions for maternal patients or consider collecting transfusion data by an alternative method (e.g. revenue codes).

2016

SMM: Transfusions

Morbidity Cases 70 87 48 86 45 101

Transfusions 25 81Other 20 20

Birth Certificate 49

SMM Morbidity Rate 1.59% 1.98% 1.05% 1.87% 0.98% 1.98%

2017 20182017 20182016 2016

SMM rate with and without Transfusions by Charge

AHS OB Collaborative: Data

coding charges

SMM: Hemorrhage Codes AIM Definition:

• Denominator: All mothers during their birth admission, excluding ectopic and miscarriages, meeting one of the following criteria:o Presence of abruption, previa or antepartum

hemorrhage diagnosis codeo Presence of transfusion procedure code

without a sickle cell crisis diagnosis codeo Presence of postpartum hemorrhage

diagnosis code• Numerator: Among the denominator, all cases

with any SMM code

SMM: Hemorrhage Codes

CODES• O72.1 Postpartum hemorrhage

• Includes atony of uterus with hemorrhage

• Included in SMM codes• Quantity not specified

• O75.89 Atony, postpartum without hemorrhage

• Not included in SMM codes• Quantity not specified

SMM: Hemorrhage Codes

ACOG definition• Postpartum hemorrhage as cumulative

blood loss equal to 1000ml or more along with signs or symptoms of hypovolemia within 24 hours after delivery (including intrapartum loss), regardless of route of delivery

No standardized coding definition of postpartum hemorrhage

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AHS OB Collaborative: Definitions SMM - Transfusions determined by charges

Hemorrhage • Cumulative QBL of greater than or equal to

1000cc OR• Blood loss accompanied with signs and

symptoms of hypovolemia within 24 hours after the birth process

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Monitor what Matters32

AHS OB Collaborative : Data

AHS New Dashboard

AHS Journey: Evidence Based

Hemorrhage InitiativeParticipated in the 2014-2016 Association of Women’s Health, Obstetric and Neonatal Nurses(AWHONN) with NJHA and Merck for Mothers

Result : Lower LOS in ICU

Where are we now? QBL compliance rates?

AHS OB Collaborative: DataHemorrhage: QBL Metrics

2017 Average Completions:

o Total QBL Completion 56%

o C/S QBL Completions 78%o Vaginal QBL Completion 46%

No Significant Improvement during 2017

AHS OB Collaborative: Hemorrhage QBL Metrics

Why were our results so low? What were the causes?

• Physicians not believing in QBL o Wanted to continue with EBL

• Midwives and tub births-difficult to measure• Not enough time • Too difficult/Staffing• Silos- “Nursing driven”

o Lack of involvement of the MDs

AHS OB Collaborative: Hemorrhage QBL Metrics

Eliminated Silo• Team created-Nursing/Physician Champions

Goal at least 85% by year end

• **HIGH PRIORITY

• Leadership support o Chairo Nurse Manager

AHS OB Collaborative: Hemorrhage QBL Team

Nursing-Physician Champions• Monthly Report to Chair and Nurse

Manager• Monthly Report to Department Quality

and Safety meeting

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AHS OB Collaborative: Hemorrhage Team QBL Results

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Vaginal Cesarean Goal

2017 2018 2019

Nurse-MD Team Started

AHS OB Collaborative: DataHemorrhage Cases

Monthly Report Analysis Expanded• How many PPHs (Based on QBL of > of

1000cc or symptoms)o Totalo % Vaginal o % C/S

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

Sept Oct Nov Dec Jan Feb March

Vaginal deliveries % C/S %

AHS OB Collaborative: DataHemorrhages Cases by Delivery Type

AHS OB Collaborative: DataHemorrhage Cases

Monthly Report Expanded• Transfusion Details

o Amount and type of blood products

• Brief Event Descriptiono Checklist followedo Medications receivedo QBLo Pre and post Hemoglobin

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AHS OB Collaborative: DataHemorrhage Cases

Monthly Report Expanded• ICU admissions

o One in last 7 months• Hysterectomy

o None in last 7 months

AHS OB Collaborative: Continuous Improvement: Hemorrhage Cases

PDSA cycleso Process changes needed?

Proactive ?o What was the risk assessment score?o Active management of 3rd stage of

labor?

AHS OB CollaborativeHemorrhage Data Systemwide

Auditing Tool and Monthly Reports• Standardized the auditing tool• Systemwide Rollout• Eliminating silos• Developing Nursing-Physician Champion• Evaluate compliance and accurate QBL

AHS Collaborative: Data Hemorrhage

Reinforced need to lower C/S• More C/S more hemorrhages• More Vaginal births less hemorrhages

Champions Important• Team based approach BEST

AHS OB Collaborative

Principles• Data driven/Transparency• Evidence based practices• Systemwide /Team based

On the Journey• Just at the beginning• Never ending

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