Partnership for Patients
Safe Deliveries Roadmap
On-Boarding Webcast
July 8, 2013
Safe Deliveries Roadmap Project Coordinator
Mara Zabari, Director of Integration
Partnership for Patients
206-216-2529
maraz@wsha.org
Project Leaders
Tom Benedetti, MD
University of Washington
Dale Reisner, MD
Swedish Hospital
Safe Deliveries Roadmap
Consultants
Eric Knox, MD
Kathleen Simpson
PhD, RNC, FAAN
The BIG Picture
Today’s Webcast Objectives
• Project updates
• Review induction management bundle
clarification
• Laying the foundation
• Medicaid Quality Incentive – OB measures
• Sharing practices
• Discuss upcoming activities
Participating Hospitals
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Cascade Valley
Central Hospital
Coulee Medical Center
EvergreenHealth
Harrison Medical Center
Highline Medical Center
Island Hospital
Jefferson Healthcare
Kittitas Valley Healthcare
Lake Chelan Community Hospital
Mid Valley Hospital
Multicare Auburn
Multicare Good Samaritan Hospital
Multicare Tacoma General Hospital
Newport Hospital
Northwest Hospital
Othello Community Hospital
Overlake Hospital
PeaceHealth Southwest
PeaceHealth St. Joseph
Providence Mt. Carmel Hospital
Providence Regional Medical Center
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Providence St. Mary Medical Center
Providence St. Peter Hospital
Pullman Regional Hospital
Samaritan
Skagit Valley Hospital
St. Francis Hospital
St. Joseph Medical Center
Sunnyside Hospital
Swedish Ballard
Swedish First Hill
Swedish Edmonds
Swedish Issaquah
Three Rivers Hospital
University of Washington Medical Center
Walla Walla General Hospital
Whidbey General Hospital
Whitman Hospital
Valley General Hospital
Valley Hospital
UW/Valley Medical Center
Yakima Valley Hospital
Project Time Line Update
• June – July
• Laying the foundation
• August – November
• Education
• Tools testing and revision
• December
• Baseline data collection
• January
• Implement bundle practices
AND, THEY’RE OFF!
Other Project Updates
• Hospital questionnaire
• Contact lists
• List-serves
• Meeting notifications
• Primary contact
• Provider session topics
• Readiness assessment
Induction Management Bundle Clarification
Failed Induction
Definition: Induced, but does not enter active labor (>6cms)
• Uterine contractions
• Failure to achieve contractions every 3 min with cervical change after 24 hrs
of pitocin plus ruptured membranes (if no contraindications), or
• Contractions every 3 min x 24 hrs without entering active phase for those
with initial Bishop score less than 8 or if cervical ripening used
• Inadequate response to a needed, clinically appropriate, second cervical
ripening agent
• Membranes have been ruptured with inadequate progress (assuming feasible
and no contraindications to AROM)
• Pitocin has been given per hospital protocol if inadequate frequency +/or
intensity of contractions occur after cervical ripening alone
• If ROM, Pitocin given x 12 hrs without regular contractions resulting in cervical
change
Discuss options for further management:
Consider RBA of all options (D/C home w/plan for f/u
versus C-Section, depending on the clinical situation)
Laying the Foundation
Early Establishment of EDD
ACOG Criteria
Estimated Date of Delivery - use EDD, not EDC and report as wks + days,
not in decimals – eg 38 5/7 wks (ReVitalize, 12/2012)
The best obstetrical Estimated Date of Delivery (EDD) is determined by:
 1) Last menstrual period (LMP) if confirmed by early ultrasound or no
ultrasound performed *, or
 2) Early ultrasound if no known LMP or the ultrasound is not consistent
with LMP, or
 3) Known date of conception (eg. ART, IUI, IVF) dating
* Ultrasound-established dates should take preference over menstrual dates
when discrepancy is >7 days in 1st tri and >10 days in the 2nd tri.
US considered to confirm menstrual dates if GA agreement within
1 week by 1st trimester CRL or within 10 days by averaging multiple
2nd trimester fetal biometric measurements (up to 20 wks gestation)
ACOG Practice Bulletin 101
Laying the Foundation
Early Establishment of EDD
8% Rule
 Comparison of Ultrasound with LMP clinical dating for best EDD
 Most accurate method at any gestational age
 Method (may be used by Radiology, MFM): Convert LMP & US
EGA’s from wks to days, multiply x .08 for # days diff & use US if
greater, use LMP if less than calculated variance.
Eg: LMP ga is 9wks (63days x .08 = +/-5 days) but US ga is 10wks (or
7days greater) – thus the US is most accurate EDD for this pg (by
ACOG would stay with LMP dating since +/- 1 wk)
 Hadlock FP, Deter RL, Harrist RB, Park SK. Estimating fetal age: Computer-assisted
analysis of multiple fetal growth parameters. Radiol. 1984;152:497-501.
 Savitz DA, Terry JW, Dole N, Thorp JM, Siega-Riz AM, Herring AH. Comparison
of pregnancy dating by last menstrual period, ultrasound scanning and their
combination. Am J Obstet Gynecol. 2002;187:1660
Laying the Foundation
Induction Consent
• Combination Patient Education and Consent Form explains:
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Why induction is being done (Medical indication or “Elective”)
Potential Risks & Benefits & Alternatives
Possible options for cervical ripening, if needed
Oxytocin use
• Providers appreciate the balance of informing women of the
increased risk of C/section, longer labor, poor fetal transition,
when induction is not medically necessary – but information is
presented in a manner to not scare them if delivery is
medically indicated.
• Discuss & Sign at time of Scheduling the Induction! Fax to L&D
• Some versions include Bishop Score, thus may aid schedulers
• Do not take the place of hospital consents for care
Questions
Medicaid Quality Incentive
Safe Deliveries: Induction Appropriateness and
Elective Deliveries Prior to 39 Weeks
(Hospitals with obstetrical programs only)
Improvement measure: percent of patients undergoing a
medical or non medical labor induction with documentation
of consent, Bishop Score, and indication
Sustaining measure: percent of patients with Elective
Deliveries 37 to less than 39 weeks gestational age
Induction Appropriateness
• Numerator:
Number of patients undergoing a medical or non-medical induction with
documentations of consent, Bishop’s score and indication
• Denominator:
Number of patients undergoing a medical or non-medical induction
Documentation sources for Bishop score and induction can be taken from the consent,
medical record, or checklist available if audited by the Healthcare Authority. Hospitals
are encouraged to make a part of the medical record if possible.
Induction Appropriateness (Cont:)
For hospitals that use on each of their induction patients a standard hospital
consent that includes all elements, no audit is needed.
For written consent the following is required under RCW 7.70.060(1):
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Identification of patient
Name of hospital in which treatment is to be performed
Name of attending physician
Nature, anticipated results, alternatives to and risk of proposed treatment, including
nontreatment
When the proposed treatment will be given
Date and time of signing the consent
Signature of patient or patient’s representative
Witness
If hospital does not use a standard consent for all induction patients, the hospital will
conduct an audit of a minimum of thirty records randomly selected to review if all elements
of consent are present. Audit must be available for the Health Care Authority to review.
http://www.wsha.org/qualityincentive.cfm
Induction Appropriateness (Cont:)
Fields to be reported:
• Number of patients undergoing a medical or non-medical
induction with documentation of consent, Bishop score
and induction indication. (numerator)
• Number of patients undergoing a medical or non-medical
induction. (denominator)
Data collection period:
• September 1, 2013 - December 31, 2013
• Reporting deadline: 45 days following the end of the
quarter
Award table:
Consent and Scheduling Form
Community Sharing
Elective Deliveries Prior to 39 Weeks
(Applies to hospitals with obstetrical programs only)
Sustaining Measure: Percent of Patients with Elective
Deliveries 37 to Less than 39 Weeks Gestational Age
• Review Process
• No Sampling
Safe Deliveries
http://www.wsha.org/0513.cfm%20
Elective Deliveries Prior to 39 Weeks (Cont:)
Fields to be reported:
• Patients with elective deliveries >= 37 and < 39 weeks of gestation
• Patients delivering newborns with >= 37 and < 39 weeks of gestation after exclusions
removed (see denominator definition above)
Data collection period:
July 1, 2013 – December 31, 2013
Reporting deadline:
90 days following the end of a quarter and final data in by March 30, 2014
Award table:
Community Sharing
Meeting Schedule
• On-boarding (webcast)
• Thursday, August 15th 7:00 – 8:00 a.m.
• Monthly (webcast)
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Tuesday, September 3rd 7:00 – 8:00 a.m.
Tuesday, October 22nd 7:00 – 8:00 a.m.
Tuesday, November 5th 7:00 – 8:00 a.m.
Thursday, December 5th 7:00 – 8:00 a.m.
• Safe Table (in-person)
• Tuesday, November 19th 9:00 – 2:30 p.m.
First Quarter 2014 meetings will be determined by October 2013
Questions?
Mara Zabari, Director of Integration
Partnership for Patients
206-216-2529
maraz@wsha.org