Perinatal Services Report to Quality Council January 19, 2010 Nela C. Ponferrada Nursing Director-Perinatal Services Fe Hortinela Nurse Manager-Infant Care Center Shilu Ramchand Clinical Educator-Infant Care Center Louise Dimattio Nurse Manager-Birth Center Ocean Berg Perinatal CNS Maya Vasquez Lactation Consultant
Performance Measures 2008-2009 1) Timing of cesarean section antibiotic prophylaxis: 9 of the 12 months >90% 2) OB patient satisfaction Feeding babies: 8 of 10 months 100% Danger signals: 8 of 11 months 100%
Performance Measures 2008-2009 6H Infant Care Center Standardize feeding management of the Late Preterm Infant. 6C Birth Center Increase the utilization of Intermittent Auscultation (IA) to monitor fetal well-being during labor.
Late Preterm Infant (LPI) A subgroup of preterm infants, born between 34 and 36 6/7 weeks gestation 71% of preterm births in 2006 Compared to full term babies, LPIs are at greater risk for: Hypoglycemia Hypothermia Feeding intolerance Excessive weight loss Jaundice Breastfeeding failure
LPI: Impostor
LPI In October 2008 Several LPIs had health setbacks associated with feeding intolerance Informal tracking highlighted the variance in feeding practices for the LPIs There was no Standard of Practice for feeding this population!!!!!
5 infants were tracked for feeding tolerance 2 were R/O for NEC 3 had feeding intolerance as evidenced by gastric residuals and vomiting
LPI AIM: Standardize feeding management of the Late Preterm Infant by August 2009 in the Infant Care Center at SFGH
LPI: Actions Creation of breastfeeding policy for the LPI algorithm feeding guidelines parent educational tools RN education Class on LPI In-service on policy, algorithm, feeding guidelines and parent educational materials LPI feeding guideline order was added to the preprinted admission order
Implementation: PLAN: Initiate standardized feeding guideline for the identified LPI DO: Roll out policy to medical provider, nursing staff, and selected LPI and family STUDY: Monitor MD and nursing compliance to feeding guideline ACT: Provide guidance to heighten knowledge of policy
LPI: Analysis October December 2009 Total Births = 312 LPI = 30 (9.6%) Charts Reviewed = 23 Feeding guidelines implemented 60% Educational material given to parents 18% Discharge feeding plan given to parents 24%
LPI: Future Continue to monitor compliance of LPI breastfeeding policy Expand policy to address other LPI morbidities such as hypoglycemia, hypothermia and hyperbilirubinemia
Other Projects Decreasing Catheter-associated Bloodstream Infection (CABSI) in Neonates Joint Commission Perinatal Core measure (2009) AIM: Decrease number of CABSIs by 50% by implementing the central line bundle by February 2010.
6C Birth Center Intermittent Auscultation: AIM: Increase the utilization of Intermittent Auscultation (IA) to monitor fetal well-being during labor for eligible women by 20% by March 2009
Methods of listening to fetal heart tones Similar to US Heart valves Opening closing EKG (R waves)
IA Use doppler device to listen to fetal heart tones VS fetal monitoring device that produces visual interpretation of heart rate Strongly supported by governing organizations As safe as continuous monitoring More freedom of movement More natural Fewer interventions Decreased cesarean rate and instrumental vaginal birth Supported by governing bodies
Actions: Policy revisions Clearer exclusion/inclusion More instructive Education Town hall meetings RN Annual update & Orientation OBGYN resident rounds CNM meetings OB group (RN leadership, CNM, OBGYN, FP) Equipment Doppler for every LDR
Analysis chart review Pre intervention (N = 55) Performed by CNMs and CNS in November 2008 Post Intervention (N= 104) Repeated by CNS and MSN student in March 2009 IA DATA sheet Patient Name B# DOB 1. IA ordered: yes no If No, please state reason: Maternal reason: Fetal reason: Cholestasis Variant fetal heart tracing Pre-eclampsia Nonreactive tracing Pre-eclampsia rule-out VBAC Labor reason: Vaginal bleeding Pitocin administration Other, please describe below No known reason ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- --- 2. IA performed throughout labor: yes no mostly If No or mostly, please describe reason: Risk status of patient has increased, please describe below: ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- --- 3. Provider type OB Family Practice midwife
Women who are eligible to receive IA Pre Post 38% 62% Continous IA eligible 35% 65% Continous IA eligible
Variance of IA 60% 80% 50% 40% 30% 20% 10% 57% 43% 56% 44% IA ordered IA not ordered 70% 60% 50% 40% 30% 20% 10% 25% 75% 55% 45% IA performed IA not performed 0% PRE POST 0% PRE POST
Analysis of IA Rates of eligible women remained static Rates ordered remained static RNs had increase in confidence and skill with this technique and therefore patients received this intervention for almost 50% longer duration during labor
2010 Perinatal Project Skin-to-Skin in OR post Cesarean Section Improves breastfeeding behaviors increase breastfeeding initiation longer duration of breastfeeding Facilitates bonding