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Coordinated Perinatal Systems of Care
Recommendations to the Indiana Perinatal Quality Improvement Collaborative (IPQIC)
Governing Council
Endorsed by the Governing Council on May 21, 2014
2014
2
TableofContents
LiteratureReview..................................................................................................................................................................................3
Definition...................................................................................................................................................................................................4
RolesandResponsibilities.................................................................................................................................................................5
1.PerinatalConferences:...............................................................................................................................................................5
2.TrainingforAffiliateHospitals:..............................................................................................................................................5
3.QualityAssurance.......................................................................................................................................................................6
4.SupportServicesthatwillbeprovidedbytheCenterstoaffiliatehospitals:....................................................7
5.CoordinationofMaternal‐FetalandNeonatalBackTransportstoAffiliateHospitals................................7
6.Transitiontopost‐partumandinterconceptioncare..................................................................................................8
7.NICUTransitiontoHome&Follow‐upProgram............................................................................................................8
8.Develop&ImplementAgreements(MOU).......................................................................................................................8
AppendixA:PerinatalCentersQualityMeasures.................................................................................................................12
AppendixB:TransportQualityMeasures................................................................................................................................19
AppendixC:TransportAlgorithms.............................................................................................................................................23
AppendixD:SharedPatientResponsibilities.........................................................................................................................26
AppendixE:AnnotatedBibliography.........................................................................................................................................29
3
COORDINATEDPERINATALSYSTEMSOFCARE
TheIndianaPerinatalQualityImprovementCollaborative(IPQIC)SystemDevelopmentCommitteeis
recommendingthattheGoverningCouncilendorsetherecommendationthatCoordinatedPerinatal
SystemsofCarebeestablishedthatwillpromotehighqualityservicedeliverysystemsandrisk
appropriatehealthcarebefore,duringandafterpregnancyforallwomenofchildbearingage.Thereis
significantevidencethatastatewidecoordinatedperinatalsystemofcarewillimproveinfantmortality
andmorbidityandreducethecostofcareforhighrisknewborns.TheCoordinatedSystemswillalso
promoteandensurethatallhospitals,regardlessoflevel,haveanimportantroletoplayinassuringthat
allbabiesborninIndianahavethebeststartinlife.
LiteratureReview
In1976,alandmarkdocument,TowardImprovingtheOutcomeofPregnancy,Recommendationsforthe
RegionalDevelopmentofMaternalandPerinatalHealthServices(TIOPI),wasreleasedbyanadhoc
CommitteeonPerinatalHealth.1Constructedfromagrowingbodyofevidencesuggestingthatratesof
perinatalmortalitycanbegreatlyreducedifpatientsareidentifiedearlyandgivenappropriatecare,2the
MarchofDimes,alongwithmemberrepresentationthatincludedtheAmericanAcademyofFamily
Physicians,AmericanAcademyofPediatrics,AmericanCollege(nowCongress)ofObstetriciansand
Gynecologists,andtheAmericanMedicalAssociation,proposedasystemofregionalizedcarebasedon
designatedlevelsofcareateachfacilitywhichincludedaninter‐hospitaltransportsystem,andthat
wouldhaveformaloversightbyaneutralentity.3Theimpactofthisdocumentonperinatalhealthcare
deliveryintheUnitedStateswasbroadandimmediateasthisidealsystemofcarebegantobe
implementedinvaryingdegreesbystatesoverthenextseveraldecades.Furtherresearchlookedatthe
economicimpactandtheoverallcosteffectivenessofimplementinggeographicalsystemsofperinatal
care.4
Severalstudyreviewssupportregionalizationasaconduitforimprovingperinatalmortalityand
morbidity.5‐11Thedatasuggestthatstateswithformalizedregionalprogramshavelowerinfant
mortalityrates,betteroutcomesandresourceutilization,andlowercostexpendituresthanstates
withoutsuchregionalization.12Improvingperinatalmortalityandmorbidityratesistheultimategoal,
yetshort‐termmeasuresofqualityassurancecanalsoinclude:accessequality,appropriatecapacityand
4
staffing,areductionininappropriatetransfers,andnetworksthathaverobustlocalcommunicationand
collaboration.13
Strengtheningperinatalsystemsofcareinstatesthathaveunfinishedbusinessofhighinfantmortalityis
effective,especiallyamongthemostpreterminfants.7“Althoughtheyrepresentlessthan2%ofUS
births,55%ofinfantdeathsoccuramongverylowbirthweightinfants.”5AmajorintentoftheMarchof
DimesTIOPIwastoidentifyandtransferhigh‐riskpregnanciesinutero,asneonataltransferismuch
riskier.14HealthyPeople2020goalsrecognizeincreasingtheproportionofverylowbirthweightinfants
borninLevelIIIhospitalsasanationalprioritymeasure,targetedto83.7%.15Indiana2011(latestdata
available)percentagesarelowerthannationalprioritygoalsaswellasoverallUSpercentagesatjust
69%.16
Theimpactofappropriatecareisnotlimitedtothesmallestandyoungestprematureinfants.Areviewof
17studiesrelatedtoperinataloutcomesandregionalizedperinatalsystemsfoundthat,inadditiontoa
declineinneonatalmortalityoverall,verylowbirthweightinfantsweremorelikelytobebornin
appropriateLevelIIIfacilitieswithaformalsystemofperinatalregionalization,whichimprovedthe
outcomeforinfantsadmittedtoLevelIfacilities.4Andfinally,inadditiontoimprovingoutcomesforhigh
riskpregnanciesandbirths,regionalizationstratifiescarebylevelinordertomatchperinatalpatientsby
riskandensurescost‐effectiveutilizationofavailableresources.17
BenjaminDisraeli,notedstatesman,oncesaid,“Thehealthofthepeopleisreallythefoundationupon
whichalltheirhappinessandalltheirpowersasastatedepend.”Theformaldevelopmentof
regionalizedperinatalcarewillnotbeaneasytask.Inallinstancesofimplementation,theperseverance
ofvisionaryindividuals,hospitals,supportorganizations,andgovernmentalentitiesworkingtogether
withthepurposeofimprovingperinatalhealthmustbetheoverarchingdrivertoachievesuccess.18
Definition
ThePerinatalCentermustmeettheACOGandAAPguidelinesforaLevelIIIObstetric(OB)Unitanda
LevelIIIorIVNeonatalUnit.ItsaffiliatehospitalswillmeettheguidelinesforLevelIorIIOBandfor
LevelI,IIandIIINeonatal.TheLevelIorIIOBandLevelI,IIandIIIneonatalunitsmaybeaffiliatedwith
morethanonPerinatalCenter.InadditionallPerinatalCenterswillberequiredtoparticipateinthe
VermontOxfordNetwork(VON)andtheIndianaVermontOxfordNetwork(IVON).
5
RolesandResponsibilities
ThePerinatalCentershavethefollowingresponsibilitieswiththeiraffiliatehospitals'deliveryunits:
1.PerinatalConferences:
EachPerinatalSystemisresponsibleforparticipatinginaStatewidePerinatalConference,
sponsoredbytheIndianaStateDepartmentofHealth,thatbringstogetherallperinatalsystems
tosharetimelyregionalmortalityandmorbiditystatistics,identifybestpracticesand/or
challengeswithtimeforsolutiondiscussion,evaluateregionalFIMRand/orMaternalMortality
data,evaluategeneraltransportdata,andincorporateISDHupdates.
EachPerinatalSystemanditsaffiliatesmustholdanannualmeetingthatwouldincludetimely
localsystemmortalityandmorbiditystatistics,alsoidentifybestpracticesand/orchallenges
withtimeforsolutiondiscussion,evaluatesystemFIMRand/orMaternalMortalitydata,
evaluategeneraltransportdata,andincorporateISDHupdates.Perinatalsystemsthatshare
commongeographyareencouragedtojointlyconducttheirmeetings.
2.TrainingforAffiliateHospitals:
ThePerinatalCenterwillprovidetrainingfortheiraffiliatehospitalsrelatedtobothobstetricand
neonataltopics:
Obstetric
Topicsmayincludebutarenotlimitedto:
o Basicfetalheartratemonitoring(mandatory)/advancedfetalheartmonitoring;
o HighriskOB(e.g.,identificationofhighriskpatients,indicationsfortransfer,
developmentofprotocolswithneonatology);
o Conferences/Trainingsdevelopedtoaddresslocallearningneeds;
o Nursingexchangeprogram(e.g.,shadowing,orientation,nursingin‐services);
o Perinatalhospiceandbereavementtraining;
o Trainingfortransportteampersonnel;
o Teamtraining(communicationandpatientsafetyissues);and
o Conferences/Trainingsdevelopedtoaddresslocallearningneeds.
Neonatal
Topicsmayincludebutarenotlimitedto:
6
o STABLE(Postresuscitation/pre‐transportStabilizationcareofsickinfants)S.T.A.B.L.E.
standsforthe6assessmentparameterscoveredintheprogram:Sugar,Temperature,
Airway,Bloodpressure,Labwork,andEmotionalsupportforthefamily;
o NRP(NeonatalResuscitationProgram);
o Nursing/Respiratorytherapy(RT)exchangeprogram(e.g.,shadowing,orientation,
nursingin‐services);
o Perinatalhospiceandbereavement;
o Trainingoftransportteampersonnel;
o Teamtraining(communicationandpatientsafetyissues);and
o Conferences/Trainingsdevelopedtoaddresslocallearningneeds.
3.QualityAssurance
ThePerinatalCenterwillberesponsiblefortheimplementationofthefollowingobstetricandneonatal
qualityassurancemetricsinaffiliatehospitalsasappropriatetoeachhospital'slevelofcare.Thesedata
willbereportedtothestateandwillbeusedtoidentifybestpracticesthatsupportoptimalperinatal
outcomes.ThedefinitionofeachmetriciscontainedinAppendixA.
ObstetricMeasures:
o MaternalDeath;
o SentinelEvents;
o Maternaltransports;
o RupturedUterus;
o 5minuteApgar<4;
o ElectiveDeliverywithoutmedicalindicationat<390/7weeksgestation;
o Deliveryat>416/7weeksgestation;and
o FetalDemiseat>200/7weeks;
o Deathsinthedeliveryroom;
o AntenatalSteroidAdministration;and
o Anyadditionaleventidentifiedbyhospitalstaff.
NeonatalMeasures:
o Allneonataltransports;
o SentinelEvents;
o InfantMortality>12hours;
7
o InfantMortality<12hours
o AnyrespiratorysupportforVLBWbabiesat36weeks;
o Lateonsetsepsis/bacteremia;
o Hypothermiaonadmission;
o Mother'smilkatdischarge;and
o Anyadditionaleventidentifiedbyhospitalstaff.
4.SupportServicesthatwillbeprovidedbytheCenterstoaffiliatehospitals:
Obstetric:
o MaternalFetalMedicineconsults24/7(phone/telemedicine);
o MaternalFetalTransports24/7;
o MaternalFetalMedicineoutpatientservices;and
o Reliableandcomprehensivecommunicationsystemforinitiatingtransportthatcanbe
readilyaccessed(i.e.,onequickphonecalltoonenumbertoinitiatetransport).
Neonatal:
o Neonatalconsults24/7(phone/telemedicine);
o NeonatalTransports24/7;
o Reliableandcomprehensivecommunicationsystemforinitiatingtransportthatcanbe
readilyaccessed(i.e.,onequickcalltoonenumbertoinitiatetransport);and
o ImplementationofDevelopmentalFollowupProgram.
5.CoordinationofMaternal‐FetalandNeonatalBackTransportstoAffiliateHospitals
ThePerinatalCenterandaffiliatehospitalphysicianswilldiscusspatient(s)tobetransferredinorderto
assurethatpatientisstablefortransferandthereceivinghospitaliscapableofcontinuingcare.Theplan
ofcaremustbedeterminedjointly.PerinatalCenterspecialists(Maternal‐FetalMedicineand
Neonatology)willbeavailableforquestions,consultationandsupportregardingsharedpatients.
Ifasharedpatientisdischargeddirectlyfromperinatalcenter,specialistswilldiscussthepatientwith
theirprimaryphysician(s)todiscussplanofcare,andensurecontinuityofcare
MaternalFetal:Afterdiscussionwiththereferringobstetricprovider,therewillbeawrittenplan
ofcareforfollowuplocallyfortheremainderofthepregnancy.Thiscanbeinthedischarge
summarysenttothelocalprovider.AsampleformisincludedinAppendixB.Theplanofcarewill
8
reflectlocallevelsofcarethatcanbeprovidedbythereferringhospitalandprovider(i.e.
Gestationalagebasedcare,etc).
Neonatal:Regionalperinatalcenterswillmakeeveryefforttotransferpatientsbacktoaffiliate
(referring)hospitals(level4to3and2,level3to2)whenappropriateandbymutualagreement
asspecifiedintheMOU.PerinatalCenterswillberesponsibleforROPfollowupifneeded.
Perinatalcenterswillworkwithaffiliatehospitalattimeofdischargeandprovidedevelopmental
followupasneededandassistwithanysubspecialistfollowup
6.Transitiontopost‐partumandinterconceptioncare
Atthetimeofmaternaldischarge,thedischargingOB/MFMwillcommunicatewiththereferringOB/FP
abouttheoutcomeofthepregnancy.Thiscommunicationwouldincludethediagnosis,briefdescription
ofinpatientmanagementandoutcome.TheOB/MFMwillmakerecommendationsforpost‐deliverycare,
inter‐pregnancycareandmanagementstrategiesforthenextpregnancy.Thisinformationwillbeshared
withthepatient.Thisinformationmaybedocumentedona“form”thatthepatientandreferringMDcan
viewandkeep.
7.NICUTransitiontoHome&Follow‐upProgram
EachPerinatalSystemwillberesponsibleforthefollowingactivities:
RetinopathyofPrematurity(ROP)Screening;
ImplementationofaDevelopmentalClinicforhighrisknewborns;and
Assistanceinaccessingpediatricsubspecialtycareasneeded.
8.Develop&ImplementAgreements(MOU)
ThePerinatalCenteranditsaffiliateswillneedtodevelopandimplementindividualagreementsthat
specifytherelationshipandreciprocalresponsibilitiesthateachwillhave.Thisisespeciallyimportant
whenhospitalsaffiliatewithmorethanonePerinatalCenter.Frequencyofvisitsandspecificeducational
supportwillbedeterminedbytheneedsofeachaffiliatehospital,anddescribedintheagreement;
DatasharingagreementsmustbepartofMOU;and
PerinatalCenterswillprovidetrainingandsupport,butultimateresponsibilityforpatientcare
andoutcomeswillremainwithindividualhospitals
9
TheMOUwillneedtoaddressissuesfromboththeperspectiveofthePerinatalCenterandtheAffiliateHospitals.
ThefollowingarecomponentsthatmustbediscussedintheMOU:
1) RegionalPerinatalCenters:
a) Coordinationofregionalmeetings;
b) Training(asspecifiedinMOU)foraffiliatehospitals;
c) Annualvisittoaffiliatehospitalstoevaluateoutcomesandassistwithqualityassurance;
d) Supportservices(asspecifiedinMOU)toaffiliatehospitalsincludingtransports;and
e) Supportforthetransitionofpatientsfromspecialists(MFM/neonatologists)toprimary
physicians.
2) AffiliateHospitals:
a) Compliancewithstatestandardsrequirements;
b) Collectionofqualityassurancedata;
c) Attendanceandparticipationinregionalmeetings;
d) Collaborationwithperinatalcentersandprovisionofdataduringannualvisittoevaluate
outcomes;and
e) Collaborationwithperinatalcenterrelatedtotransitionhomeandbacktransportsofshared
patients.
10
References
1. CommitteeonPerinatalHealth.(1976).Towardimprovingtheoutcomesofpregnancy,
recommendationsfortheregionaldevelopmentofmaternalandperinatalhealthservices.White
Plains,NY:MarchofDimesNationalFoundation.
2. TheAmericanCollegeofObstetricsandGynecology.(1975).Towardimprovingtheoutcomeof
pregnancy:Recommendationsfortheregionaldevelopmentofperinatalhealthservices.Journalofthe
AmericanCollegeofObstetricsandGynecologists,45(5),375‐384.
3. MarchofDimes.(2011).TowardimprovingtheoutcomeofpregnancyIII.WhitePlains,NY:Marchof
DimesFoundation.
4. Neogi,S.,Malhotra,S.,Zodpey,S.,Mohan,P.(2012).Doesfacility‐basednewborncareimprove
neonataloutcomes?Areviewoftheevidence.IndianPediatrics,49,651‐658.
5. Lasswell,S.,Barfield,W.,Rochat,R.,Blackmon,L.(2010).Perinatalregionalizationforverylow‐birth‐
weightandverypreterminfants,ameta‐analysis.TheJournaloftheAmericanMedicalAssociation,
304(9),992‐1000.
6. Strobino,D.,Grason,H.,Koontz,A.,Silver,G.(2000).Reexaminingtheorganizationofperinatalservice
systems:Apreliminaryreport.Women’sandChildren’sPolicyCenter,Baltimore,MD.
7. Lorch,S.,Baiocchi,M.,Ahlberg,C.,Small,D.(2012).Thedifferentialimpactofdeliveryhospitalon
outcomesofprematureinfants.Pediatrics,130,270‐278.
8. Bode,M.,O’Shea,M.,Metzguer,K.,Stiles,A.(2001).Perinatalregionalizationandneonatalmortalityin
NorthCarolina,1968‐1994.AmericanJournalofObstetricsandGynecology,184(6),1302‐1307.
9. WrightJ.,Herzog,J.,ShahM.,BonannoC.,LewinS.,ClearyK.,SimpsonL.,GaddipatiS.,SunX.,D’Alton
M.,Devine,P.(2010).Regionalizationofcareforobstetrichemorrhageanditseffectonmaternal
mortality.Obstetrics&Gynecology,116(6),1194‐1200
10. BronsteinJ.,CapiloutoE.,CarloW.,Haywood,J.,Goldenberg,R.(1995).Accesstoneonatalintensive
careforlow‐birthweightinfants:theroleofmaternalcharacteristics.AmericanJournalofPublic
Health,85(3),357‐361.
11. Haberland,C.,Phibbs,C.,Baker,L.(2006).Effectofopeningmidlevelneonatalintensivecareunitson
thelocationoflowbirthweightbirthsinCalifornia.Pediatrics,118,e1667‐e1679.
12. Staebler,S.(2011).Regionalizedsystemsofperinatalcare:healthpolicyconsiderations.Advancesin
NeonatalCare,11(1),37‐42.
11
13. Marlow,N.,Gill,B.(2006).Establishingneonatalnetworks:
14. Hein,H.RegionalizedperinatalcareinNorthAmerica.(2004).SeminarsinNeonatology9,111‐116.
15. UnitedStatesDepartmentofHealthandHumanServices.(2013).HealthyPeople20/20:Maternal,
Infant,andChildHealth.Retrievedfrom:
http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26
16. IndianaStateDepartmentofHealth.(2013).LevelsofCareOutcomes[PowerPointSlides].
17. CommitteeonFetusandtheNewborn.(2012).Levelsofneonatalcare.Pediatrics,130,587‐597.
18. Yu,V.,Dunn,P.(2004).Developmentofregionalizedperinatalcare.SeminarsinNeonatology,9,89‐97.
12
AppendixA:PerinatalCentersQualityMeasures
PerinatalCentersQualityMeasures
Page1of6
NeonatalMeasuresReportbyEachLevelofCare
Metric Definition Numerator Denominator LevelI1
LevelII
LevelIII
LevelIV
N1.Allneonatalinterfacilitytransports
QualityMeasuresidentifiedinthe IndianaPerinatalTransportStandards
E E E E
N2.Sentinelevents
“Asentineleventisanunexpectedoccurrenceinvolvingdeathorseriousphysicalorpsychologicalinjury,ortheriskthereof.Seriousinjuryspecificallyincludeslossoflimborfunction.Thephrase"ortheriskthereof"includesanyprocessvariationforwhicharecurrencewouldcarryasignificantchanceofaseriousadverseoutcome.”Reference:http://www.jointcommission.org/sentinel_event.aspx
#ofSentinelEvents
E E E E
N3.Mortality>12hours
Infantswhodidnotdieinthedeliveryroomandwhosurvivedmorethan12hoursafterbirth.Ifyourpatientistransferredtoahigherlevelnursery,anddiesthere,themortalityisassignedtoyourhospital
Reference:VermontOxfordNetwork
#ofdeaths Alladmissions E E E E
N4
Mortality<12hours
Babiesthatdieinthefirst12hoursafterdeliveryandwhodidnotdieinthedeliveryroom
#ofdeaths Allbirths> 22weeks
E E E E
1LevelIisthewellnewbornnursery.IfahospitalhasaLevelIandanotherLevelNICU,datamustbereportedseparately.
PerinatalCentersQualityMeasures
Page2of6
NeonatalMeasuresReportbyEachLevelofCare
Metric Definition Numerator Denominator LevelI1
LevelII
LevelIII
LevelIV
N5.Anyrespiratorysupportat36weeks
VLBWinfantseithercontinuouslyorintermittentlyreceivingsupplementaloxygenat36weeksgestationalageordischargedtohomebefore36weeksonoxygen.
Reference:BabyMonitor/VermontOxford
#VLBWinfantswhomeetVermontOxfordcriteriafor“ChronicLungDisease”and/or“OxygenatDischarge”
AllVLBWsurvivorstoage36weeksGAordischarge
NA E E E
N6.LateOnsetSepsis/Bacteremia
Apositivebloodculture,obtainedinthepresenceofcompatibleclinicalsignsofsepticemia,occurringafter72hours,andtreatedwithantibioticsfor≥5days.Includesculturepositiveepisodesinwhichtheinfantdiesbeforeanintendedtherapyoffiveormoredaysiscompleted.
VermontOxford
AllinfantsdiagnosedwithlateonsetsepsisasperVONcriteria
Alladmissions NA E E E
N7.Hypothermiaonadmission
Axillarytemperaturelessthan36degreescentigradewithin60minutesafterbirth.
Reference:Bhatt,White,etal.,JPerinatal2007;27:S45‐47,
Reference:BabyMonitor
AllinfantswithTemperature<36.0°C
Alladmissionswithtemperaturemeasurementinthefirsthour
E E E E
PerinatalCentersQualityMeasures
Page3of6
NeonatalMeasuresReportbyEachLevelofCare
Metric Definition Numerator Denominator LevelI1
LevelII
LevelIII
LevelIV
N8(a).Babiesweighing<1500gmsatbirthdischargedonownmother’smilk
Babiesweighing<1500gramsatbirthdischargedonanyamountofownmother’smilk
#ofbabiesweighing<1500gramsatbirthdischargedonanymother’smilk
#ofbabiesweighing<1500gramsatbirthdischargedtohome
NA
E
E
E
N8(b)AllotherbabieswithownMother'smilkatdischarge
Babiesweighing>1500gramsatbirthwhowereexclusivelybreastfedorwhowerefedformulainadditiontoownmother’smilkatdischarge.
#ofbabiesweighing>1500gramswhowerefedonlyownmother'smilkand#ofbabieswhowerefedownmother'smilkandformula.
#ofbabieswhowereeligibleforbreastfeeding.Babieswhowerestillborn,born,pre‐termortwinsarenotincluded.
E E E E
N9.Anyadditionaleventidentifiedbyhospitalstaff
E E E E
PerinatalCentersQualityMeasures
Page4of6
ObstetricMeasuresMetric Definition Numerator Denominator LevelI LevelII LevelIIIOB1.Maternaldeath
Forreportingpurposes,apregnancy‐relateddeathisdefinedasthedeathofawomanwhilepregnantorwithin1yearofpregnancytermination—regardlessofthedurationorsiteofthepregnancy—fromanycauserelatedtooraggravatedbythepregnancyoritsmanagement,butnotfromaccidentalorincidentalcauses.Reference:http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
#ofpatientswhomeetthecriteria
Allpatientswhodeliver
E E E
OB2.Sentinelevent
Asentineleventisanunexpectedoccurrenceinvolvingdeathorseriousphysicalorpsychologicalinjury,ortheriskthereof.Seriousinjuryspecificallyincludeslossoflimborfunction.Thephrase,‘ortheriskthereof"includesanyprocessvariationforwhicharecurrencewouldcarryasignificantchanceofaseriousadverseoutcome.Reference:http://www.jointcommission.org/sentinel_event.aspx
#ofSentinelEvents
E E E
OB3.Maternalinterfacilitytransports
QualityMeasuresidentifiedintheIndianaPerinatalTransportStandards
E E E
OB4.Ruptureduterus
Uterinerupturetypicallyisclassifiedaseithercomplete(alllayersoftheuterinewallseparated)orincomplete(uterinemuscleseparatedbutvisceral
#ofwomenwhomeetthecriteria
Alldeliveries E E E
PerinatalCentersQualityMeasures
Page5of6
ObstetricMeasuresMetric Definition Numerator Denominator LevelI LevelII LevelIII
peritoneumisintact).Incompleteruptureisalsocommonlyreferredtoasuterinedehiscence.Reference:WilliamsObstetrics
OB5.5minuteAPGAR<4
BabieswithanApgar<4at5minutes
Alldeliveries E E E
OB6.Electivedeliverywithoutmedicalindication<390/7weeksgestation
Electivedeliverieswithoutmedicalindicationsthatareperformedbefore390/7weeks.WebLinktoISDH/IPQICGuidelinestoReduceEarlyElectiveDeliveries,January2014
Alldeliverieswithoutmedicalindicationlessthan390/7weeks
Alldeliveriesunder390/7weeks
E E E
OB7.Deliveryat>416/7weeks
#ofdeliveriesthatmeetthecriteriaof>416/7weeks
Alldeliveries E E E
OB8.Fetaldemiseat>200/7weeks
Fetaldeath”meansdeathpriortothecompleteexpulsionorextractionfromitsmotherofaproductofhumanconception,irrespectiveofthedurationofpregnancy,andwhichisnotinducedterminationofpregnancy.Thedeathisindicatedbythefactthataftersuchexpulsionorextraction,thefetusdoesnotbreatheorshowanyotherevidenceoflife,suchasbeatingoftheheart,pulsationoftheumbilicalcord,ordefinitemovementofvoluntarymuscles.Heartbeatsaretobedistinguishedfromtransientcardiaccontractions;respirationsare
Numberoffetaldeaths
Alldeliveries E E E
PerinatalCentersQualityMeasures
Page6of6
ObstetricMeasuresMetric Definition Numerator Denominator LevelI LevelII LevelIII
tobedistinguishedfromfleetingrespiratoryeffortsorgasps.”Reference:http://www.cdc.gov/nchs/data/misc/itop97.pdfACOGPracticeBulletin#102(March2009)
OB9.Deathsinthedeliveryroom
Deathsthatoccurafterbirthandbeforeadmissiontothenursery.
Alldeathsthatmeetthedefinition
Alldeliveries E E E
OB10.AntenatalSteroidAdministration
Antenatalcorticosteroidsadministrationtopregnantwomenbetween24weeksofgestationand34weeksofgestationwhoareatriskofpretermdeliverywithin7daysReference:ACOGPracticeBulletin#127,June2012
Womenwhodeliveredbetween24weeksofgestationand34weeksofgestation,whoreceivedatleastonedoseofantenatalcorticosteroid,atleast12hourspriortothedelivery
Allpretermdeliveriesbetween24weeksofgestationand34weeksofgestation
E E E
OB11.Anyadditionaleventidentifiedbyhospitalstaff
E E E
19
AppendixB:TransportQualityMeasures
20
StandardII:Maternal‐FetalQualityAssurance2.1Inadditiontocomplyingwithallreportsandrecordsrulesin836IAC1‐1‐5,thecertifiedprovideroftheMaternalFetalTransportProgramshalltrackthefollowingbenchmarks:
a. Delivery≤30minutesfromarrivalatreceivinghospital;b. Diversionoftransportduetomaternalandorfetalstatuschangeinroute;c. Incidenceoflossofcommunicationwithmedicalcontrolforanythinglonger
than5minutes;d. Changeintransportasset(groundtoairorviceversa);e. Deliveryinroute;f. Incidenceofsentinelevents;g. Transportcrewmemberinjuryduringtransport;h. Anyreasonfortransportdelay:
i. Accident—MotorVehicleAmbulance,flight;ii. Delayinunscheduledtransportdispatchtimeis>15minutes;iii. Delayinunscheduledtransportenroutetimeis>15minutes;iv. Mechanicalfailureofambulanceoraircraftthatleadstoatransport
delay;v. Equipmentfailure;vi. Weatherorroadrelated(constructions,accidents)issues;vii. Crewmember;
h. Maternalfetalinjuryduringtransport;andi. Maternalandorfetalstatusdeemedunstablefortransportatsendingfacility.
2.2Whenasentineleventoccurs,theperinataltransportteam,medicaldirector,andmedicalcontrolphysicianmusthaveadebrief.Thedebriefmustbeinitiatedwith72hoursandtherootcauseanalysiscompletedwithin5workingdays.2.3Teamsarerequiredtohaveapre‐transportbriefingregardingthepatient(s)conditionpriortoassumingcareofthepatient(s).2.4Eachperinataltransportteamshallhavewritteninternalqualityreviewprocedures/protocols.2.5EachhospitalwithanperinataltransportteamshallimplementaroutinescheduleofQualityImprovementmeetingsandarecordofminutesmaintained.2.6Transportteamsmustconductquarterlyreviewsofthefollowingelementsandmaintaindocumentationofthereviewsincompliancewith836IAC1‐1‐5(c):
a) Transportindication(s);b) Medicaland/ornursinginterventionperformedormaintained;c) Timeofintervention:
a. patientresponsetointerventions;andb. appropriatenessofinterventionperformedoromissionofneeded
21
StandardII:Maternal‐FetalQualityAssuranceintervention
d) Patientoutcomeatarrivalofdestination;e) Patient'schangeinconditionduringtransport;f) Timelinessandcoordinationofthetransportfromreceptionofrequesttoliftoff
orambulanceenroutetime;g) ReviewofPre‐transportinspectiondocumentationh) Safetypracticesdocumented;i) Operationalcriteria:
a. numberofcompletedtransports;b. numberofabortedorcanceledflights/transportsduetoweather;c. numberofabortedorcanceledflights/transportsduetomaintenance;d. numberofabortedorcanceledflights/transportsduetopatientcondition
andalternativemodesoftransportation;ande. numberofabortedorcanceledflights/transportsduetounavailable
team.j) Communicationscenterororganizationmustmonitorandtrack:
a. InstrumentFlightRules(IFR)/VisualFlightRules(VFR);b. Weatherattimeofrequestofthereferringandacceptingfacilityand
duringtransportifchangesoccur;c. Transportacceptancetoliftofftimesortheroadtimes;andd. Allabortedandcancelledtransportrequests‐times,reasonsand
dispositionofpatientsasapplicable.
StandardVI:NeonatalQualityAssurance6.1Inadditiontocomplyingwithallreportsandrecordsrulesin836IAC1‐1‐5,theCertifiedProvideroftheNeonatalTransportProgramshalltrackthefollowingbenchmarks:
a) Unplanneddislodgementoftherapeuticdevices;b) Radiographverificationoftrachealtubeplacement;c) Averagemobilizationtimeoftransportteam;d) Firstattempttrachealtubeplacementsuccess:
a. visualizations;b. attemptsatplacement;
e) Rateoftransport‐relatedpatientinjuries;f) Rateofmedicationadministrationerrors;g) RateofCPRperformedduringtransport;h) Incidenceofsentinelevents;i) Unintendedneonatalhypothermiauponarrivaltodestination;
22
StandardVI:NeonatalQualityAssurancej) Transportcrewinjuryduringtransport;andk) Standardizedpatientcarehand‐offperformed(sitespecificprotocolused).
6.2Whenasentineleventoccurs,theneonataltransportteam,medicaldirector,andmedicalcontrolphysicianmusthaveadebriefthatisinitiatedwithin72hoursandtherootcauseanalysiscompletedwithin5workingdays.6.3Teamsarerequiredtohaveapre‐transportbriefingregardingthepatient(s)conditionpriortoassumingcareofthepatient(s).6.4Eachperinataltransportteamshallhavewritteninternalqualityreviewprocedures/protocols.6.5EachhospitalwithaneonataltransportteamshallimplementaroutinescheduleofQualityImprovementmeetingsandarecordofminutesmaintained.6.6TheneonataltransportteamconductsaQuarterlyReviewofthefollowingelementsandmaintaindocumentationofthereviewsincompliancewith836IAC1‐1‐1‐5(c):
A. Reasonfortransport;B. Mechanismofillness;C. Medicalinterventionperformedormaintained;D. Timeofinterventionconsistentlydocumentedfor:
a. patientresponsetointerventions;andb. appropriatenessofinterventionperformedoromissionofneeded
intervention;E. Patientoutcomeatarrivalofdestination;F. Patient'schangeinconditionduringtransport;G. Timelinessandcoordinationofthetransportfromreceptionofrequesttoliftoffor
ambulanceenroutetime;H. Pre‐transportcheckofambulancebyEMTonTransportrecords;I. Operationalcriteriatoinclude,ataminimum,thefollowingqualityindicators:
a. numberofcompletedtransports;b. numberofabortedorcanceledflights/transportsduetoweather;c. numberofabortedorcanceledflights/transportsduetomaintenance;d. numberofabortedorcanceledflights/transportsduetopatientcondition
andalternativemodesoftransport;J. CommunicationsCenteroforganizationmustmonitorandtrack:
e. InstrumentFlightRules(IFR)/VisualFlightRules(VFR)f. weatherattimeofrequestandduringtransportifchangesoccur;andg. allabortedandcanceledtransportrequests‐times,reasonsanddisposition
ofpatientsasapplicable.
23
AppendixC:TransportAlgorithms
Draft Maternal Fetal Transport AlgorithmOctober 2013
> 23 Weeks with Viable Fetus
On Magnesium Sulfate
Active Labor
Other Maternal Co-morbidities
Surgical Candidate
Potential for Maternal and/or Neonatal
complications at delivery
Currently requires continuous Maternal Fetal
Monitoring
Maternal Fetal RN lead Ground or Flight
Transport
Consider Flight for:• Maternal admission to an adult intensive care unit• High risk of delivery before the ground unit would return with patient• Maternal trauma• Ground team unavailable
Patient receiving intermittent Maternal Fetal Monitoring but not
required during transport
Post partum, fetal demise and/or <23 weeks, maternal status stable
Y
Y
Y
Y
Y
N
N
N
N
Y
N
Y
Basic Life Support (BLS) orAdvanced Life Support
(ALS) Transport
Consider private care if mother and fetus are stable and require no immediate
actionY
Post partum, fetal demise and/or <23 weeks,
unstable maternal status
Consider Maternal Fetal ground, Advanced Life
Support (ALS) or air transport depending on
acuity and distance
Y
Draft Neonatal Transport AlgorithmOctober 2013
LEVEL I NURSERY
Infant less than 35 weeks gestation
Requires supplemental oxygen and/or respiratory
support
Failed Cyanotic Congenital Heart Disease
Screen
Possible Sepsis or Chorioamnionits
Other clinical concerns not supported by the
Institution
Continue to Monitor Infant
Prepare infant for transfer to Level III or Level IV
Institution
LEVEL II NURSERY
Infant less than 32 weeks gestation or birth weight
less than 1500 grams
Failed Cyanotic Congenital Heart Disease
Screen without availability of Newborn
Echocardiography
Likely or Need for Prolonged Respiratory
Support (greater than 24 hours)
Y
Y
Y
Y
Y
Y
N
N
N
NOther clinical concerns
not supported by the Institution
Congenital anomaly requiring surgical
intervention
Continue to Monitor Infant
Y
Y
Y
Y
Y
N
N
N
N
LEVEL III NURSERY
Cyanotic Congenital Heart Disease
Severe Pulmonary Hypertension potentially requiring ECMO if iNO is
not available or failing iNO
Pediatric Surgery need not supported by
Institution
Other Medical or Surgical need not supported by
the Institution
Continue to Monitor Infant
Prepare transfer to
Level IV Institution
Y
Y
Y
Y
N
N
N
NN
N
26
AppendixD:SharedPatientResponsibilities
SUMMARYOFRECOMMENDATIONSFORANTEPARTUMCAREAFTERHOSPITALIZATION
PatientName:
GestationalAge:
SendingHospital:
DateofDischarge:
PrimaryPhysician:PhoneNumberforanyQuestions(24/7):ReceivingHospital:PrimaryPhysician:
ContactInformation:
DiagnosisatDischarge:
MedicationsatDischarge:
AntepartumSurveillanceFrequencyRecommendations:
FrequencyofPrenatalVisits:
BPP:_________________________________________
NST:_________________________________________
GrowthUltrasound:________________________
CervicalLength:____________________________
PrimaryOB:____________________________
o NextAppointment:______________
TertiaryCenter:_________________________
o NextAppointment:______________
DeliveryTiming: DeliveryRoute: Cesarean
Vaginal
OperativeVaginal
DeliverySite: LocalHospital
Tertiary(orhigherlevel)center)
AdditionalRecommendations:
SUMMARYOFRECOMMENDATIONSFORNICUPATIENTSATDISCHARGE
PatientName:
Gestationalageatbirth:Gestationalageatdischarge:
Hospital:
DateofDischarge:
DischargePhysician:PhoneNumberforanyQuestions:
Email:
PrimaryPhysician:
ContactInformation:
BW_________%____LT_______HC______%__________DCWT_______%____LT_______HC___________%_____Main(Active)DischargeDiagnoses:
MedicationsatDischarge:
FEEDINGINSTRUCTIONS:
IMMUNIZATIONSGIVEN(ifany):
FOLLOWUPAPPOINTMENTS:
HOMEHEALTHCAREFOLLOWUP:
(nameofagency/frequencyofvisitsordered)
ADDITIONALRECOMMENDATIONS:
29
AppendixE:AnnotatedBibliography
History of Perinatal Regionalization Annotated Bibliography
1. Bode, M. O’Shea, M., Metzguer, K., Stilies, A. (2001). Perinatal regionalization and neonatal
mortality in North Carolina, 1968-1994. American Journal of Obstetric Gynecology,
184(6), 1302-1307.
Bode et al. study the trends of neonatal mortality in a changing health delivery
environment in North Carolina from 1969-1994. Authors analyzed the number of weighing 500-
1500 g, what level of hospital they were born in, and whether there was a correlation in where
they were born and the mortality rates. Authors conclude the likelihood of very low birth weight
neonates being born outside level III hospitals decreased by an average of 24 percent from 1968-
1994 and after 1974 birth in a hospital with level III services was associated with a reduced rate
of mortality.
2. Bridgman Perkins, B. (1993). Rethinking Perinatal Policy: History of Evaluation of Minimum
Volume and Level-of-Care Standards. Journal of Public Health Policy, 14(3), 299-319.
Bridgman Perkins gives the historical origins of perinatal standards in the United States
from the 1930s through the 1970s. The author details the change in opinions beginning in the
1980s as the health care system in the United States became more competitive in nature. The
paper notes that the discrepancy between the research findings and changes in the delivery of
care continues to be problematic from a financial standpoint.
3. Committee on Fetus and the Newborn. (2012). Levels of neonatal care. Pediatrics, 130, 587-
597.
“Levels of neonatal care,” is an updated policy statement that reviews levels of care for
neonates in the United States since the 2004 policy statement by the American Academy of
History of Perinatal Regionalization Annotated Bibliography
Pediatrics (AAP). Authors present new data since the 2004 AAP statement which largely
support a well-defined regional system of perinatal care. The statement provides standards for
health outcomes data comparisons, standardized definitions for public health, and standardized
definitions for healthcare providers who provide neonatal care in the United States.
4. Clement, M. (2005). Pernatal Care in Arizona 1950-2002: A Study of the Positive Impact of
Technology, Regionalization and the Arizona Pernatal Trust. Journal of Perinatology, 25,
503-508.
Clement describes the changes in perinatal care in Arizona from 1950-2002 and its
positive impact on neonatal outcomes. The paper measures these outcomes quantitatively by
analyzing birth and death records in 1950 and 2002 in order to report the change in mortality rate
over time. Clement acknowledges a significant reduction in neonatal mortality rates over the
past 50 years which he attributes to both and advancement in technology and health policy
developed to reduce infant mortality and disparities in the state.
5. Hein, H. (2004). Regionalized perinatal care in North America. Seminars in Neonatology, 9,
111-116.
In this paper, Hein details the status of regionalized perinatal health care in North
America using the Iowa regionalization model. He reviews the history and evolution of
regionalization in the 1960s and 1970s and the role of the March of Dimes in setting the first set
of national guidelines for regionalized perinatal systems of care. In conclusion, Hein makes
suggestions for controlling the impact of managed care on regionalization and quality perinatal
care and makes a case for maintaining a regionalized system and prioritizing utilizing outcome
data when making policy decisions.
History of Perinatal Regionalization Annotated Bibliography
6. Philip, A. (2005). The evolution of neonatology. Pediatric Research, 58(4), 799-815.
Philip gives a history of the practice of neonatology in the United States beginning with
first meeting of the perinatal section of the American Academy of Pediatrics in 1975. Philip
surveys the important innovations in technology which coincided with the subspecialty practice.
In conclusion, Philip notes that the change and improvement in neonatal care in the United States
as “remarkable” despite the fact that challenges still exist in the field of modern neonatology.
7. The American College of Obstetrics and Gynecology. (1975). Toward improving the outcome
of pregnancy: Recommendations for the regional development of perinatal health
services. Journal of the American College of Obstetrics and Gynecologists, 45(5), 375-
384.
This policy statement, which was published by the American College of Obstetricians
and Gynecologists in 1975, is the first recommendation for a regionalized system of perinatal
care. The document outlines the hospital levels of care and the basic requirements of each level
for optimal care. The document further outlines recommendations for communication,
collaboration, and referral networks that must exist in a functional system. The final
recommendation in this document acknowledges the financial burden to the higher level
designated hospitals and patient number minimums for each level.
8. March of Dimes. (2010). Toward Improving the Outcome of Pregnancy III. [PDF] Retrieved
from: http://www.marchofdimes.com/materials/toward-improving-the-outcome-of-
pregnancy-iii.pdf
Toward Improving the Outcome of Pregnancy III (TIOP III) is a toolkit which intends to
guide practitioners and policy makers in improving the quality, safety, and performance in the
History of Perinatal Regionalization Annotated Bibliography
sphere of perinatal care. TIOP III distinguishes itself from the previous TIOPs by focusing on
the application of evidence based practice and acknowledging the importance of a woman’s
health throughout her life-course and its impact on a healthy pregnancy.
9. Staebler, S. (2011). Regionalized Systems of Perinatal Care. Advances in Neonatal Care,
11(1), 37-42.
Staebler presents options for policies on regionalization of perinatal care from a “doing
nothing” (p. 39) approach to a state or federally mandated regionalized system of care. A
“deregulation” (p. 37) of neonatal services occurred in the United States as the number of
neonatologists and NICUs grew beyond geographical need and hospitals began operating under a
more competitive model. The four policy options Staebler presents are no standardization,
organizational/individual health system standardization, incremental changes at the state or
federal levels, and formal regionalization. While the author gives the pros and cons of each
option, she recommends option four, formal regionalization, as it “has the potential to decrease
unnecessary duplication of services…improve morbidity and mortality, decrease costs, and
promote better utilization of limited workforce personnel” (p. 41).
10. Shaffer, E. (2001). State Policies and Regional Neonatal Care: Progress and Challenges 25
Years After TIOP. [PDF] Retrieved from: http://www.equalhealth.info/wp-
content/uploads/Final-NICU-Report.pdf
This study, completed for the March of Dimes, is the results of a survey of state health
departments and of literature on perinatal systems and their operation in the United States. The
study includes current, by state, (as of the writing of the report) terminology for neonatal
intensive care unit (NICU) levels, policy for defining NICU levels of care, and its enforcement,
History of Perinatal Regionalization Annotated Bibliography
as well as how the systems have changed or are currently changing. Major finding of the study
include: substantial variation among states on levels of care definitions, little public knowledge
of NICU levels, and disparate opinions exist among facilities and staff on NICU levels.
11. Yu, V. Y.H., Dunn, P. M. (2004). Development of regionalized perinatal care. Seminars in
Neonatology, 9, 89-97.
Yu and Dunn present a brief history of regionalized perinatal care in Canada, the United
Kingdom, Australia, and the United States. The authors conclude that while regionalizing
perinatal care has great benefits in birth outcomes in all countries studied, there is commonality
in problems that arise when attempting to institutionalize a system of care. Additionally, authors
further conclude that while developing and maintaining regionalized perinatal care is a difficult
task, it can be achieved once the multidisciplinary teams and institutions are able to reach a
common vision for the health of the population.
12. Van Mullen, C. Conway, A., Mounts, K., Weber, D., Browning, C. (2004). Regionalization
of perinatal care in Wisconsin: A changing health care environment. Wisconsin Medical
Journal, 103(5), 35-38.
Van Mullen et al. describe changes in perinatal heath delivery structure in Wisconsin and
the results of an increase in NICUs and neonatologists since the 1970s. This paper is a product
of a series of meetings initiated by the Wisconsin Association for Perinatal Care (WAPC) in
order to discuss the changing perinatal health environment and worsening of perinatal outcomes
in the state. The authors conclude that the competitive health marketplace and lack of
coordinated services have “led to the unnecessary duplication of services within a single
community or geographic region, with the potential fragmentation and decreased coordination of
History of Perinatal Regionalization Annotated Bibliography
care resulting in potential fragmentation and decreased coordination of care resulting in
increased patient morbidity and mortality, as well as increased cost” (p. 37). The WAPC will
continue to review the status of the state’s regionalization of perinatal care including
implementing designations for standard levels of care and defining perinatal outcomes with a
focus on quality of care.