COLORADO PERINATAL CARE COUNCIL A. MEETING B. DATE C. LOCATION Colorado Perinatal Care Council, Meeting#: 216 July 25, 2014 Colorado Department of Public Health & Environment Denver, Colorado D. PARTICIPANTS: MEMBERS, GUESTS AND EXECUTIVE COMMITTEE MEMBERS PRESENT: Liz Whitley, CDPHE, CPCC Executive Committee Member Cheryl Yesko, ELMC Betsy Block, Consumer Teresa Sanderlin, Littleton Adventist Diane Flannery, ELMC Abe Grinberg, MD, Retired Neonatologist Mary Laird, MD, CHCO Memorial, Pediatrix Medical Group Carol Wallman, CHCO, Poudre Valley Hospital System Barb Wahl, Tri County Health Department Shelly Posey, CNM Pat Bohling-Smith, CPCC Executive Committee Member Sue Ricketts, CDPHE Briana Goodfellow, Center for Maternal Fetal Health / RMHC Cindy Gaines, St. Mary’s Hospital Grand Junction Angela Polson, Sky Ridge Medical Center Kit Harden, CHCO/CSW Kina Howard, Penrose St. Francis Amy Speers, Tri County Health Department Kathryn Ward, SFMC Bonita Shviraga, CNM, Aurora Nurse-Midwives Tiffany Glick, Children’s Hospital Colorado Cyndy Krening, Saint Joseph Hospital Marianne Neifert, MD, Dr. Mom Presentations Scott Matthews, March of Dimes Janet Milliman, Colorado Access, CHP+, SMCN Stephanie Johnson St Dic, SFMC NICU Jan Lapetino, Colorado Midwives Association Laraine Guyette, CNM, Colorado ACNM Pat Maass, Saint Joseph Hospital Nina Huffer, North Suburban Medical Center Patrick Smith, Valley Wide, La Junta Sara McCoy, RN-C, Saint Joseph Hospital Lee Morgan, MD, COPIC Jackie Garrad, MD, San Luis Valley Health Sharon Langendoerfer, MD, Denver Health Kirtley Ceballos, VCH NICU Mandy Bakulski, CHPHE Anne Behring, UCH Central Andrea Mitrorka, UCH Central Eileen Meisner, Good Samaritan Medical Center Lisbeth Gabrielski, CHC Susan Clarke, CHCO Glenda Beyers, Presbyterian/St. Luke’s Amy Dempsey, Lutheran Medical Center Aaron Miller, Colorado DEC Laura Borgelt, University of Colorado Chris Freeman, Centura Neko Upson, CNM Saint Joseph Hospital Nurse-Midwives Joanna Reeder, CHCO Kim Wood, Lutheran Annabelle Tashma, Student Erin Ross, Rose Medical Center Erica Eymore, MD, Children’s Hospital Colorado Rachel Wright, MD, Denver Health and Hospital, CPCC Executive Committee Member Suze Ketchem, Good Samaritan Medical Center Stacy Kreil, MSN, Littleton Adventist Marcia Teague, Lutheran Medical Center Deb Bopp, Memorial, Colorado Springs, CPCC Executive Committee Member Rainy Tieman, Montrose Memorial Ellen Duran, North Suburban Medical Center April McPike, Penrose/St. Francis Christie Salvi, Platte Valley Medical Center Tracy Heaberlin, Poudre Valley Medical Center, CPCC Executive Committee Member Glenda Beyers, Presbyterian/St. Luke’s Steve Holt, MD, CPCC Chairman Sally Garcia, St. Anthony North Jamie Martin, Sky Ridge Medical Center Kathy Anderson, University of Colorado Hospital Sherrie Williams, Univeristy of Colorado Hospital Lesa Nesbit, March of Dimes Mary McMahon, CPCC Executive Committee Member Kirk Bol, CDPHE Krista Beckwith, CDPHE E. HANDOUTS (Available Upon Request) 1. Agenda 2. Conference Calendar 3. CPCC Meeting Dates & Locations - 2014 4. Self-Assessment Survey Summary 5. Meeting Minutes 6. Community Program Handouts F. SUMMARY OF THE MEETING 1. Procedural Items a. The Council thanked CDPHE, Dr. Tista Ghosh and Joni Reynolds for hosting the meeting. b. Introduction of Council members and guests. c. The Minutes from the May 16, 2014 meeting were reviewed and approved d. The Treasurer’s Report was provided by Sandra Gardner, CPCC Treasurer. e. Additional conferences were noted at the meeting: For a list of upcoming conferences, please refer to the Council’s website at: www.coloradoperinatalcarecouncil.com. f. Executive Committee Report: CPCC Executive Committee is looking at our current structure and continuing to define the visions and goals of CPCC for the future. We would like to focus on more state collaborative efforts and establish more key partnerships. CPCC Executive Committee is working on the upcoming agenda for the September meeting. Topics will include: Outreach Update to Level I hospitals, Follow up Marijuana Discussion and a Conference Update. If you have any agenda topics you would like Exec Committee to consider for future meetings, please email Heather. CPCC Exec Committee is still looking for a new Chairman Elect. Dr. Liz Whitley (CDPHE) and Dr. Rachel Wright (Neonatologist, Denver Health) have now joined the Executive Committee. Welcome Deb Bobb as our newest Executive Committee Member. We are still recruiting for a Chairman elect for 2015. CPCC Executive Committee has begun to reach out to our Colorado Level I hospitals as part of our state collaborative efforts. CPCC has defined the first wave of hospitals to reach out to. The meetings will be scheduled for southeast Colorado between Sept. 29-Oct. 1: o Saint Thomas More – Canon City o San Luis Valley MC – Alamosa o Arkansas Valley MC – La Junta o Prowers Medical Center – Lamar o Evans Army Hospital – Ft Carson We have received a grant through CDPHE to visit their sites. The purpose of the CPCC visit is to introduce the work of the council, become acquainted with their regional providers, and to share data specific to their regions with comparative data from regions throughout the state. Representatives from the council, which include Maternal-Fetal Medicine, Obstetrics, Nurse-Midwifery, Neonatology and a Maternal Health Specialist from the CDPHE, would like to visit their facility. CDPHE Maternal Mortality Review Committee Members who are interested in joining CPCC on these site visits are Kent Heyborne, MD, Amy Nacht, MSN, CNM, Jessica Anderson, MSN, CNM, WHNPBC, and Torri Metz, MD. It will be a 2-3 hour site visit that will cover MMR info, OB and neonatal topics, discussions around what their needs are, and our outreach and collaborative efforts. CPCC has also requested an additional grant from March of Dimes to provide formal outreach initiatives. For example, when Level I hospitals come to a CPCC meeting, CPCC will reimburse their expenses from the grant money. We are also exploring opportunities with CHA regarding quality outcomes in areas of common interest and possible grant opportunities. g. Conference Calendar: Please send Heather any 2014 conferences from your organization or in your community The following summaries are from the presentations from the May 16, 2014 meeting: I. Colorado Department of Public Health & Environment Update Presented by: Tista Ghosh, MD, MPH, Deputy Chief Medical Officer and Director, Disease Control & Environmental Epidemiology Division (DCEED) Dr. Ghosh began her presentation discussing the history of medical marijuana in Colorado. In November 2000, Amendment 20 was passed and a registry was established in July 2001. The Ogden Memorandum was published in October 2009 and the commercial production and distribution began in 2010 under HB 10-1284 and SB 10-109. Dr. Ghosh reviewed the medical marijuana registry and shared some data regarding the active patients on the Colorado Medical Marijuana Registry from 2009-2014. She shared that 67% of them are male and the average age is 41. She shared that a medical marijuana research program was authorized in 2014 and grants to fund research regarding the efficacy of marijuana as part of the medical treatment were initiated. She then reviewed the history of retail marijuana in Colorado since Amendment 64 was passed. C.R.S. Sec. 25-1.5-111 specifically designated a role for CDPHE. It outlined specific duties which include "Monitor changes in drug use patterns, broken down by county and race and ethnicity, and the emerging science and medical information relevant to the health effects associated with marijuana use.” It also stated that "The Department shall appoint a panel of health care professionals with expertise in cannabanoid physiology to monitor the relevant information. The panel shall: • Provide a report by 1/31/15 and every 2 years thereafter* • Establish criteria for 1) studies to be reviewed, and 2) reviewing studies and other data*, and • Make recommendations, as appropriate, for policies intended to protect consumers of marijuana or marijuana products and the general public*. (*no required duties until funding is secured) Dr. Ghosh then discussed legal marijuana and public health issues and provided an overview of the Governance of Recreational Marijuana-Related Activities at CDPHE. She shared some specific concerns for legal marijuana, including marijuana contamination literature reports, high potency marijuana, increase in unintentional poisonings, prevention among youth and pregnancy/breastfeeding. Dr. Ghosh shared several educational resources that can be found on their website at www.colorado.gov/marijuana and reviewed the CDPHE monitoring activities. She discussed that the PRAMS 2014 survey asks the question if a woman used marijuana or hashish during certain time periods in her pregnancy. CDPHE is working with Denver Health to develop standard screening questions on the frequency and method of use of marijuana and will match the data to the birth defects registry. Dr. Ghosh identified the members of the Retail Marijuana Public Health Advisory Committee. She reviewed their literature and evidence review strategies and summarized the findings. The committee has determined some initial approved public health messages: • There is no known safe amount of marijuana use during pregnancy. • THC can pass from mother to the unborn child through the placenta. • The unborn child is exposed to THC used by the mother. • Maternal use of marijuana during pregnancy is linked with negative effects on exposed children. • There are negative effects of marijuana use during pregnancy regardless of when it is used during pregnancy. • THC can also be passed from the mother’s breast milk, potentially affecting the baby. Dr. Ghosh concluded her presentation with a discussion of the next steps including developing prevention messaging, continuing to collect and analyze surveillance data and reporting on data/trends as they become available. A copy of Dr. Ghosh’s presentation can be found on the CPCC website. II. Building a statewide, population-based, perinatal health improvement collaborative Presented by: Ed Donovan. MD, Retired Neonatologist, CPCC Consultant Dr. Donovan began his presentation by defining the principles that drive the vision/mission collaborative efforts. These include: • Primary focus on population health: denominator • Relentless attention on short-term results • “One cannot improve without measurement” • Transparency • Public – Private Partnership • Trusted, respectful leadership He then reviewed what it takes to build a successful, statewide, perinatal improvement collaborative and reviewed each of the following points in detail: • Population-based, rapid-response data system [CDPHE] • Well-connected, committed, clinical leadership in both obstetrics and pediatrics • Access to one or two years of baseline data [CDPHE] • Involvement of key state agencies & professional organizations [CPCC, CDPHE, MOD] • Centralized administrative infrastructure [CPCC] • Access to rigorous, improvement science expertise [?] • Integration of community and academic providers • Open to idea of transparent sharing of results Dr. Donovan concluded his presentation by discussing the next steps regarding where CPCC should start, including the creation of mission and vision statements, an organizational structure that represents key stakeholders and key responsibilities, identification and communication with key stakeholders, publicize widely and share examples. He challenged the group to choose a first project that is popular and doable so that the group can stay focused. He stressed the importance of identifying QI expert partners and developing a timeline and budget. Dr. Donovan emphasized the importance of sharing early, small successes! A copy of Dr. Donovan’s presentation can be found on the CPCC website. III. Marijuana in Pregnancy and Lactation: Weeding Out the Myths Presented by: Laura Borgelt, PharmD, FCCP, BCPS, NCMP, Professor, University of Colorado, Department of Clinical Pharmacy and Family Medicine Dr. Borgelt began her presentation by polling the audience as to whether they knew someone who is pregnant or breastfeeding and using marijuana for medical or recreational purposes. She then shared a patient case and outlined how complicated the issues can be. She then provided an overview of the pharmacology and the effects of cannabis exposure during pregnancy. Dr. Borgelt reviewed some of the relevant literature and statistics, and reviewed how marijuana should be studied. She then reviewed 3 prospective longitudinal studies regarding the fetal development and birth outcomes. The studies specifically looked at neonatal development, infant behavior, child behavior and cognitive development and young adults through functional magnetic resonance imaging. She discussed that there are 3 routes of administration: the lungs (vaporized or smoked), the gut (oral ingestion) and the skin (topical application). Dr. Borgelt shared data that demonstrated the potency of seized marijuana in the US has shown a 121% increase from 1998 – 2010. She then provided a summary of prenatal marijuana exposure and reviewed the short term and long term effects of marijuana exposure as it relates to birth outcomes. She then further reviewed a summary of human and animal studies. Dr. Borgelt also summarized marijuana and breastfeeding studies. She reviewed that there also needs to be proper retail marijuana labels. She reviewed CDPHE’s statement regarding “Is Marijuana Safe for Pregnant or Breastfeeding Women?” The official statement is as follows: “As with alcohol and cigarettes, there likely is no “safe” amount of marijuana use during pregnancy. THC, the chemical in marijuana that makes a person “high,” can pass from mother to the unborn child through the placenta. This means the unborn child is exposed to THC used by the mother. Smoking also passes carbon monoxide to the unborn child, which disrupts the oxygen supply and can result in growth issues, possible premature birth, miscarriage or stillbirth. There is some evidence marijuana use during pregnancy can result in babies with low birth weight, certain birth defects and symptoms similar to fetal alcohol syndrome. THC can also be passed from the mother’s breast milk, potentially affecting the baby.” Additional information can be found in the following link: https://www.colorado.gov/pacific/sites/default/files/M_RM_Marijuana-Health-Effects-FAQs.pdf Dr. Borgelt then provided some general recommendations: 1. Ask about the use of marijuana and consider screening in high-risk patients 2. Educate women about impact of cannabis during pregnancy and lactation and strongly advise discontinuation or use harm-reduction approach 3. Offer drug services/counseling and/or cognitive behavioral therapy 4. Perform appropriate developmental milestones 5. Counsel about patient safety issues including keeping out of the reach of children and using proper packaging and labeling of marijuana 6. Avoid second hand/passive exposure 7. Follow hospital policies and procedures She finished her presentation by offering the following conclusions: • • • • Marijuana most likely used more frequently than reported in pregnancy and lactation No evidence of teratogenicity (birth defects) Although inconsistent, clinical studies indicate prenatal exposure to heavy marijuana use may have: Little/no effect in early infancy • • • Some specific cognitive or behavioral outcomes in childhood Altered executive function in adolescence Marijuana should be regarded as harmful to the developing fetus and breastfeeding infant A copy of Dr. Borgelt’s presentation can be found on the CPCC website. IV. Community Experts: A panel discussion regarding the issues of marijuana Moderated by: Steve Holt, MD, CPCC Chairman Hot topics were discussed and questions were invited and answered from the panel. Dr. Holt reiterated that this will be the first of many discussions that will be occurring within CPCC, and that CPCC is considering forming a Marijuana Task Force or Sub-Committee that will continue to address these ongoing issues in partnership with other hospitals and organizations. Panel Experts: Laura Borgelt, PharmD, FCCP, BCPS, NCMP Professor, University of Colorado, Department of Clinical Pharmacy and Family Medicine Tista Ghosh, MD, MPH Deputy Chief Medical Officer and Director, Disease Control & Environmental Epidemiology Division (DCEED), Colorado Department of Public Health and Environment (CDPHE) Sarah Rasche, MSW Social Work Care Manager, Center for Women & Infants, Saint Joseph Hospital Carol Wallman, NNP-BC Poudre Valley Hospital – University North Kathryn Wells, MD, FAAP Medical Director, Denver Health Clinic at the Family Crisis Center President, Colorado Chapter of the American Academy of Pediatric Jade Woodard Executive Director, Colorado Alliance for Drug Endangered Children Rachel Wright, MD Interim Director of Newborn Services, Denver Health Medical Center Instructor, Department of Pediatrics, Section of Neonatology University of Colorado School of Medicine The meeting was adjourned. The next CPCC meeting is scheduled for September 26, 2014 at Estes Park Medical Center in Estes Park, CO from 1pm – 4pm. Respectfully Submitted, Heather Hagenson, CPCC Coordinator