Washington State Perinatal Collaborative
Update on Quality Improvement Initiatives
 Elective Deliveries 37-<39 wks
 Episiotomies
 Breast Milk Feeding
Thomas Benedetti, MD, MHA
University of Washington Medical Center
Department of Obstetrics and Gynecology
and
Jean O’Leary, MPH, RD
Nutrition Consultant
Washington State Department of Health
WIC Nutrition Program
November 19, 2013
Presented at Washington State Hospital Association Safe Table 11/19/2013
90% reduction in Early Elective
Deliveries between 37 to 39 weeks.
$5 million in cost savings.
Over 1,900 fewer early deliveries!
Percentage of Hospitals Under 5% by Quarter
Baseline: 16%
Q1 2011: 35.5%
Q2 2011: 44.4%
Q3 2011: 51.2%
Q4 2011: 54.9%
Q1 2012: 69.5%
Q2 2012: 66.7%
Q3 2012: 69.1%
Q4 2012: 88.5%
Q1 2013: 88.2%
Washington State
Percent of All Term Births >= 37 wks Gestation that were 37-38 wks
29%
37-38 wk birth % of all term >=37 wks
28%
27%
27.6%
26.7%
27.8%
27.8%
27.1%
26.9%
26.7%
26.7%
26%
24.9%
25%
24.5%
24%
23%
22%
2003
2004
2005
2006
2007
2008
2009
2010
Presented at Washington State Hospital Association Safe Table 11/19/2013
2011
2012
Washington State Stillbirths by Gestational Age
Rates per 1,000 Ongoing Pregnancies
Stillbirths per 1,000 Ongoing Pregnancies
2.25
2
1.75
1.5
1.25
1
0.75
0.5
0.25
0
2003
37 wks
2004
2005
38 wks
2006
39 wks
2007
2008
40 wks
2009
2010
41 wks
Presented at Washington State Hospital Association Safe Table 11/19/2013
2011
>=42 wks
2012
Washington State Trends
Percent of All Term Births >= 37 wks Gestation that were 37-38 wks
NTSV Cesarean rate
Primary Term Singleton Vertex Cesarean rate
28%
26%
24%
22%
20%
18%
16%
14%
12%
2003
2004
2005
2006
37-38wks % of all term >=37wks CY
2007
2008
2009
NTSV C-section % SFY
2010
2011
2012
2013
Primary TSV C-section % SFY
Presented at Washington State Hospital Association Safe Table 11/19/2013
Optimizing Episiotomy Rates Review
Methods and Components 2012-2013

Statewide voluntary project

Regionally promoted by WSPC, WSHA-Partnership for
Patients, PRN coordinators and physician champion

Measure: Episiotomy rate for spontaneous vaginal deliveries
(National Quality Forum-based Measure; excludes shoulder dystocia, forceps, vacuum)

Distribute baseline vs. blinded hospital peer 2011 data to
hospitals (WSHA Nov 2012: data source CHARS)

Hospitals will validate baseline data

2012-2013 Target rate < 5%

Quarterly 2012-2013 hospital rates provided by WSHA

Hospitals encouraged to track related episiotomy rate with
instrument and third and fourth degree perineal lacerations
(Note: target rate is Not 0%)
Presented at Washington State Hospital Association Safe Table 11/19/2013
2011 Washington State Episiotomy Rates vs. 3rd & 4th Degree
Laceration Rates for Spontaneous Vaginal Delivery
8%
R² = 0.3915
7%
Correlation Coefficient (r) = 0.628
Moderately Strong Association
Laceration Rate
6%
5%
4%
3%
2%
1%
0%
0%
5%
10%
15%
Episiotomy Rate
Presented at Washington State Hospital Association Safe Table 11/19/2013
20%
25%
Episiotomy Rate for Vaginal Deliveries without Forceps/Vacuum
Target Rate < 5%
All WA Hospitals (Partnership for Patients (PFP) and non-PFP)
10%
23.9% decrease
from CY 2011 baseline
9%
8%
7%
6.52%
6%
5.93%
5.90%
5.27%
4.96%
5%
4%
3%
2%
1%
0%
Baseline 2011
(48,563)
Q1-2 2012 (23,302) Q3 2012 (12,914)
Q4 2012 (11,740)
Time Period (Denominator)
Presented at Washington State Hospital Association Safe Table 11/19/2013
Q1 2013 (11,484)
Episiotomy rate without forceps or vacuum
Proportion of Hospitals with rates < 5% and > 8%
All WA hospitals (both PFP and non-PFP)
70%
61.0%
60%
48.5%
54.8%
54.0%
51.7%
50%
40%
30%
34.8%
28.3%
27.0%
20%
25.4%
25.8%
10%
0%
Baseline 2011
(48,563)
Q1-2 2012 (23,302)
Q3 2012 (12,914)
Q4 2012 (11,740)
Time Period (Denominator)
% of Hospitals < 5%
% of Hospitals > 8%
Presented at Washington State Hospital Association Safe Table 11/19/2013
Q1 2013 (11,484)
Episiotomy rate for vaginal delivery with forceps and
vacuum
All WA hospitals (both PFP and non-PFP)
40%
30%
29.5%
28.0%
28.4%
27.4%
Q1-2 2012 (1,381)
Q3 2012 (681)
Q4 2012 (980)
29.7%
20%
10%
0%
Baseline 2011
(3,167)
Presented at Washington State Hospital Association Safe Table 11/19/2013
Q1 2013 (943)
Third and Fourth Degree Laceration Rate for Vaginal Delivery
without forceps or vacuum
All WA hospitals (both PFP and non-PFP)
4%
2.4%
2.3%
2.2%
2.1%
2.1%
Baseline 2011
(48,563)
Q1-2 2012 (23,302)
Q3 2012 (12,914)
Q4 2012 (11,740)
Q1 2013 (11,484)
2%
0%
40%
Time Period (Denominator)
Third and Fourth Degree Laceration Rates for Vaginal
Delivery with forceps or vacuum
All WA hospitals (both PFP and non-PFP)
30%
20%
16.9%
16.0%
14.0%
16.5%
17.7%
Q4 2012 (980)
Q1 2013 (943)
10%
0%
Baseline 2011 (3,167) Q1-2 2012 (1,381)
Q3 2012 (681)
Time Period (Denominator)
Presented at Washington State Hospital Association Safe Table 11/19/2013