Better Health for Mothers and Babies November 13, 2018 Agenda - PowerPoint PPT Presentation

Better Health for Mothers and Babies November 13, 2018

Agenda  Welcome  Background  Review AHA Initiative  Quality Improvement Approaches from a health system  Using data to drive improvement  Maternal Mortality Review Boards  Questions

Better Health for Mothers and Babies

Maternal Deaths largely occur outside week of birth Caveat: Data is not complete but suggests trend

Caveat: Data is not complete but suggests trend

Partnering with AIM https://safehealthcareforeverywoman.org/aim-program/

Improving Maternal Health  Establish or Reaffirm Commitment  DATA  Regularly review internal data with interdisciplinary team and look for improvement opportunities.  Access across continuum of care  Health Disparities  Prioritize and implement targeted strategies known to combat risk factors  Accountability  Review care protocols and discharge transitions  Advance evidence based practices  Listen to Mothers :  Engage Mothers and work with like-minded community based organizations to improve public education to lower risk

Initiative: Better Health for Mothers and Babies (BHMB) New website: https://www.aha.org/better-health-for-mothers-and-babies  Provide a forum for hospitals to engage in sharing leading practices through webinars like this one, case studies, and podcasts, etc.  Convene national summit of Center for Health stakeholders to share leading practices Public Policy Innovation and identify collaborative actions Better Health for  Share quality improvement tools and mothers facilitate QI training to address and Babies improvement and disparities  Partner with community based Field Engagement organizations  Urging Final Passage of S. 1112, Maternal Health Accountability Act

STRENGTH IN NUMBERS

Preventable Causes of Maternal Death: Focus on Severe Maternal Morbidity

Maternal Mortality Review Committees (MMRCs) 2015: Maternal Mortality Review Information Application (MMRIA or “MARIA”) • Supports MMRCs and provides resources to promote a standard approach to case review • Key decisions for each death reviewed: • Was the death pregnancy-related? • Underlying cause of death? • What factors contributed to the death? • Recommendations and actions to address contributing factors? • Anticipated impact of actions if implemented? • Was the death preventable? Centers for Disease Control and Prevention. Report from Maternal Mortality Review Committees: a view into their critical role. https://www.cdcfoundation.org/sites/default/files/files/MMRIAReport.pdf Accessed December 20, 2017 and MMRIA. Review to Action. http://reviewtoaction.org/implement/mmria. Accessed February 20, 2018.

Preventability • Report of 9 MMRCs in 2018 estimated that 63.2% of pregnancy-related deaths were preventable • 70% of deaths from hemorrhage 63.2% were preventable • 63.2% of deaths from cardiac disease were preventable • Report of 4 MMRCs in 2017 determined that 59% of pregnancy- related deaths were preventable Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.

Preventability Review of North Carolina Hemorrhage 93% maternal deaths: 21% of Chronic medical conditions maternal deaths could 89% have been prevented had Preeclampsia 60% care conformed to Infection 42% nationally recognized Cardiovascular conditions 40% standards Cardiomyopathy 22% Preventability varies by Pulmonary embolism 17% cause of death Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol , 2005; 106(6): 1228-34.

Standardized Decision Form for MMRCs: Preventability • What was the chance to alter outcome (good chance, some chance, no chance, unable to determine)? • Contributing factors and description • Patient/family • Provider • Facility • System • Community • Recommendations / specific feasible actions that if implemented should have or might have altered the course of events Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.

Focus on Reducing Severe Maternal Morbidity: Review by Birthing Facility Continuum of Morbidity and Mortality 0.5 -3% of 18.0 per 100,000 pregnancies live births in 2014 Pregnancy Potentially life- Survival despite complication or pre- threatening experiencing an existing medical condition with unanticipated event condition predisposition to likely to result in end-organ injury death SMM to maternal deaths: 100:1 Adapted from: Witcher PM, Lindsay MK. Maternal morbidity and mortality. In: Troiano NH, Witcher PM, Baird SM (eds). High Risk and Critical Care Obstetrics, 2019; Wolters Kluwer: Philadelphia and Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-mortality-surveillance-system.htm. Accessed on 10/30/2018

Severe Maternal Morbidity Review • Purpose: identification of improvements in processes and systems • SMM Committee • Presentation of abstracted review • Identification of opportunities to improve outcomes • Focus on systems and processes • Refer cases to peer review as indicated • Aggregate, trend and disseminate data • Sanction by facility to provide peer review protection in accordance with state’s legislation and statutes • Root cause analysis for sentinel events Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: Rationale and process . Obstet Gynecol , 2014; 124(2 Pt 1): 361-6.

Severe Maternal Morbidity Review Reviewable Events Multidisciplinary Review Committee • • • A peripartum event (pregnancy to first 24 OB providers Consider patient • hours postpartum) that requires 4 or more Anesthesia providers advocate • • units RBCs Obstetric nurses Scribe • • • A peripartum event that necessitates ICU Quality Consider admission improvement team partnership with • • Unexpected and severe event that occurs Administration regional perinatal during pregnancy, peripartum, or postpartum center (small center) Timing of Review Review Methodology • • • Timing of review will be determined by the Peer review Trained abstractor • severity of the event and number of events (i.e. protection (gather Presentation of larger birth facility may consider regularly confidentiality primary review • scheduled meetings) statements from Utilize standardized members) format • • Past and current Conclude medical records recommendations Specific resources available at: https://safehealthcareforeverywoman.org/patient-safety-tools/

Debriefing • Care providers involved in the SMM event • Supplements standardized SMM review by multidisciplinary committee Type of event: _______________________ Date: ________________ Location of event: ____________________ Members of team present: _________ Systems and processes Opportunities for improvement • • Systems issues (such Human factors (such that went well as availability of as communication, equipment, supplies, teamwork, situational or medications; blood awareness, decision products; transport making) issues; staffing Actions to be taken Issue Person responsible Resources: Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: Rationale and process . Obstet Gynecol , 2014; 124(2 Pt 1): 361-6. https://www.cmqcc.org/resources/1533/download

Severe Maternal Morbidity, 1993-2014 • Acute MI • Aneurysm • Acute renal failure • ARDS • Cardiac arrest / v-fib • Conversion of cardiac rhythm • DIC • Eclampsia • Heart failure / arrest during procedure • Puerperal cerebral disorders • Pulmonary edema • Sepsis • Shock • SCD • Air & thrombotic embolism • Blood transfusion • Hysterectomy SMM indicators and corresponding ICD codes during delivery hospitalization • Temporary tracheostomy • Ventilation Source: CDC. Severe maternal morbidity in the United States. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Updated on 11/27/2017. Retrieved on 2/19/2018.

SMM in 25 US Hospitals 2008 - 2011 Secondary analysis of Eunice Kennedy Shriver NICHD MFMU Network cohort of women and neonates in 25 US hospitals Grobman WA, Bailit JL, Rice MM, et al. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol , 2014; 123(4): 804-10.