COLORADO PERINATAL CARE COUNCIL
A. MEETING
B. DATE
C. LOCATION
Colorado Perinatal Care Council, Meeting#: 211
September 27, 2013
Vail Valley Medical Center
Vail, Colorado
D. PARTICIPANTS:
MEMBERS, GUESTS AND EXECUTIVE COMMITTEE MEMBERS PRESENT:
Deb Bopp, Memorial Hospital, Colorado Springs
Carri Montgomery, Platte Valley Medical Center, Brighton, CO
Chantielle Blackwell, Presbyterian/St. Luke’s Medical Center, Denver, CO
Alfonso Pantoja, MD, Exempla Saint Joseph Hospital, Denver CO (CPCC Executive Committee)
Susan Engle, Yampa Valley Medical Center, Steamboat Springs, CO
Peter Hulac, MD, Children’s Hospital Colorado, Denver, CO (CPCC Chairman)
Sheila Sherman, Vail Valley Medical Center, Vail, CO
Amy Lavigne, Vail Valley Medical Center, Vail, CO
Linda Bretey, Vail Valley Medical Center, Vail, CO
Megan Lee, Presbyterian St. Luke’s/RMHC, Denver, CO
Brianna Goodfellow, Presbyterian St. Luke’s/RMHC, Denver, CO
Mike Pettersen, MD, Presbyterian St. Luke’s/RMHC, Denver, CO
Jeff Brown, MD, Vail Valley Medical Center, Vail, CO
Rochelle Bernstein, MDVail Valley Medical Center, Vail, CO
Jan Kennaugh, MD, P/SL/RMHC and Vail Valley Medical Center
Annabelle Tashma, Student
Tracie Detwiler, Vail Valley Medical Center, Vail, CO
Kathy Roper, Vail Valley Medical Center, Vail, CO
Barbara Hughes, CNM Invest in Kids
Tracy Heaberlin, NNP, Children’s Hospital Colorado (CPCC Executive Committee)
Lynne Easterly, Nurse Family Partnership
Jennie Wahrer, Nurse Family Partnership
Carol Vickery, Nurse Family Partnership
E. HANDOUTS (Available Upon Request)
1. Conference Calendar
2. CPCC Meeting Dates & Locations - 2013
3. Meeting Minutes
4. Community Program Handouts
F. SUMMARY OF THE MEETING
1. Procedural Items
a. The Council thanked Amy Lavigne, Sheila Sherman and Dr. Jeff Brown of Vail Valley
Medical Center for hosting the meeting and providing the meeting room, snacks and
refreshments.
b. Introduction of Council members and guests.
c. The Minutes from the July 26, 2013 meeting were reviewed and approved
d. The Treasurer’s Report was not available. Sandra Gardner is out sick and was not able to
attend the meeting. The Treasurer Report will be updated at the next meeting.
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: Peter Hulac, MD, Chairman reported that the CPCC
Executive Committee is currently working on the upcoming agenda for the November
meeting as well as agenda topics for next year. The November meeting will be at Children’s
Hospital Colorado on November 22nd. The Executive Committee is currently finalizing the
self-assessment guideline process including, how CPCC will interpret the new guidelines,
what systems and processes other states are utilizing and the format for submission. We will
begin the new self-assessment guideline submission process in November/December for the
years 2014 – 2015. Steve Holt will begin his term as CPCC Chairman in January. CPCC
Exec Committee is looking for a new Chairman Elect for 2014-2015. If you know of anyone
who is interested, email Heather. Voting will be held in November/December. The
Executive Committee is also reviewing legislative issues in Colorado and new collaborative
opportunities for our state. CPCC continues to work on a stronger partnership with Colorado
Department of Public Health & Environment. The Executive Committee continues to reach
out to smaller community hospitals and is working on a on establishing a system to reach out
to Level I and II hospitals to increase meeting participation through webinars and conference
calls. The Executive Committee continues to update the CPCC bylaws and guidelines.
g. Website Update: CPCC has a new website address. Please visit www.cpcc.co. Please
contact Heather Hagenson if you have any ideas or resources that can be added to the
website.
h. Conference Calendar: 2 additional conferences upcoming conferences were noted:
a. Premature and High-risk Infants – Transitioning Home from the NICU. This
conference will be on Friday, November 1, 2013.
b. A Maternal Wellness Summit on Perinatal Mood Disorders. This conference will be
on December 6, 2013.
The following summaries are from the presentations from the September 27, 2013 meeting:
I.
Perinatal Services Update at Vail Valley Medical Center
Presented by: Jeff Brown, MD, (Medical Director, VVMC/Pediatrix Pediatric Hospitalists Program)
Sheila Sherman, RN, CNS, BC-ADM, DNP-c (Director Patient Care Services)
Amy Lavigne, BSN, RNC-OB (Perinatal Clinical Educator)
The presentation began by providing an overview of the history of Vail as well as some interesting facts
regarding Eagle County. Dr. Brown then provided the history of Vail Valley Medical Center (VVMC).
Dr. Brown then discussed the services as well as the statistics for the Women’s and Children’s Center at
Vail Valley Medical Center, including:
• Prenatal/delivery care in valley:
5 Ob’s at CMM
Prenatal care at ECC
PSL MFM Clinics 2X/month
•
Pediatric Hospitalist Service (2008) – Pediatrix MG:
3 Full time general pediatricians
3 Full time Neonatal Nurse Practitioners
•
Level II Nursery:
>32 weeks GA; >1500 gms
RDS/surfactant
Vent X 24 hours
Dr. Brown pointed out that VVMC YTD C/S rate is 16.5%, which is well below the national average; He also
highlighted the various quality initiatives and services offered to patients, including: 2013 –Can Do 5! B.E.S.T.
Award, Perinatal Quality Measurement, Strong unit-based shared governance, Lactation Program / Breast Feeding
Promotion, Pediatric Literacy Program, VVMC Injury Prevention Specialist, VVMC Simulation Program,
Family-centered C/S Initiative, Pulse Ox Screening for CCHD Study, and Collaboration with Community-based
Doula Program. He also shared their Telemedicine/Tele-echocardiography program and the successes they have
experienced with implementing these services.
II.
Elevation and Newborn Oxygen Saturation: How low is too low? And why we need to know.
Presented by Tracy Heaberlin, NNP-BC, MSN, MBA and Tracie Detweiler, MSN, NNP-BC
The presentation began with an overview of the current issues:
 Acceptable Oxygen Saturations in the NICU have varied over the years between patient
population, disease process, and regional providers.
 Greater understanding of Oxygen toxicity led to lower acceptable limits
 Concern for increasing morbidity with lower sats moved limits back up
 Implementing CCHDS Screening at Altitude is driving well newborn studies
Tracy Heaberlin coordinated a phone survey with various Colorado hospitals. Twenty two hospitals at
various elevations responded to the phone survey and respondents were Newborn, NICU Nurses and
Neonatal Nurse Practitioners. In addition, both rural and metro hospitals responded with elevations
between 4593 feet to 9075 feet. Questions that were asked during the phone survey included: What is
your Low Room Air Sat percentage, Low Car Seat Sat percentage, Do you perform Room Air
“Challenges” for babies discharged home on O2, Do you utilize visiting nurses and do you utilize home
pulse oximetry. Tracy reviewed the data she collected regarding various saturation limits by elevation
ranges for RA, Car Seat and RA Challenge percentages. She then shared that 12 of the hospitals
surveyed performed room air challenged prior to discharge. The hospital surveyed who are not routinely
performing room air challenges are due to the following reasons: those providing well new born care,
some higher level of care facilities shared that screening is diagnosis dependent, and some higher level
of care do not perform. She then reviewed post diagnosis support with visiting nurses and discovered
that there is inconsistent use among hospitals and that not all areas have services available. Tracy also
discussed the use of home pulse oximetry and learned that criteria for use include age at time of
discharge, diagnosis dependent, failure of room Air challenge, and availability of DME.
Tracy Heaberlin and Tracie Detwiler then reviewed the literature regarding mean oxygen saturation in
well neonates at altitudes between 4498 and 8150 feet. It was found the mean normal oxygen saturation
levels for well neonates born at higher altitudes are lower than those born at 4498 feet. Neonates born at
or above 6800 feet may exhibit ‘normal’ oxygen saturation levels between 91-96% rather than >96%
which are usually expected. They continued to review the data and literature that is currently published.
Tracie then reviewed the CCHD Screening History and Algorithm and discussed the hospitals that were
surveyed and whether they are currently providing CCHD screening. She also discussed parent interest
regarding CCHD screening and legislative issues surrounding this initiative. A copy of this
presentation can be requested from Heather Hagenson at heather@coloradoperinatalcarecouncil.com
III.
Critical Congenital Heart Disease Screening at Altitude: What we have learned; What we can
Discern
Presented by: Mike Pettersen, MD, Pediatric Cardiologist, Rocky Mountain Hospital Children
Dr. Pettersen began his presentation by offering several case studies regarding pulse oximetry screening
for Critical Congenital Heart Disease (CCHD) in the Newborn Nursery. Dr. Petterson then provided
background on congenital heart disease (CHD) and that CCHD accounts for approximately 25% of all
CHD.
He then reviewed the following:
a. Intervention required in first year of life
b. Up to 25% not diagnosed until after discharge from newborn nursery (UK)
c. Delayed or missed diagnosis in 7/100,000 live births (US)
He then discussed the impact of delayed or missed diagnosis and reviewed some of the current literature
that has been published. He reviewed the various types of CCHD, and discussed the use of pulse
oximetry to detect newborn screening. He then shared that on 9/21/11, Kathleen Sebelius, Secretary of
Health and Human Services, supports adding pulse oximetry screening for critical congenital heart
disease to the Recommended Uniform Screening Panel (RUSP) based on AHA/AAP scientific
statement. In January 2012, AAP issued a Policy Statement re: Recommendations for Pulse Oximetry
Screening for Critical Congenital Heart Disease. The conclusion form AHA/AAP was that, “Routine
pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital
discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have
on-site pediatric cardiovascular services incurs very low cost and risk of harm.” Dr. Pettersen then
provided an overview of the consensus screening algorithm:
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Screen after 24 hours of life or as close to discharge as possible
Screen the right hand and either foot
<90% is a failed screen
≥ 95% in right hand or foot with ≤ 3% difference – patient passes
<95% or >3% difference, then rescreen in 1 hour, and again in another hour if necessary before
considering it positive
 Rule out other conditions before cardiology evaluation
 Endorsed by AAP, ACC, and the AHA
Dr. Pettersen then discussed the CDC recommendations which include,

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Recommend universal implementation
Pulse oximetry should not replace a complete history and physical examination
Infants with a failed screen should undergo an echocardiogram
Pulse oximetry does not rule out all CCHD
Some populations require further research (e.g. patients at high altitude)
He discussed various activity regarding CCHD screening by state, and reviewed the literature as it
related to high altitude and what the normal ranges should be in addition to the effects of altitude on the
current algorithm. He recommended an altitude adjustment to the current algorithm and then then
recommended various evaluation steps for a positive screen. He discussed the use of telemedicine and
modern technology as it relates to CCHD screening. Dr. Pettersen then closed his presentation by
reviewing conclusions:
 Missed CCHD while rare, results in significant morbidity, mortality and increased utilization of health
care resources
 Pulse ox screening if widely implemented has the potential to significantly increase the rate of early
recognition of CCHD
 Additional research is needed to determine the effect of altitude on the screening algorithm
 Telemedicine will play an increasing role in the timely evaluation of these patients
IV.
Inpatient Panel Discussion
Moderator: Peter Hulac, MD, CPCC Chairman
Participants: Mike Petterson, MD, Pediatric Cardiologist; Jeff Brown, Pediatric Hospitalist; Tracie
Detweiler, MSN, NNP-BC, Alfonso Pantoja, MD, Neonatologist
Dr. Hulac facilitated a discussion of the presentations, and questions were invited and answered. The
panel also discussed the challenges that Colorado hospitals face at altitude, and stressed the fact that
further research is needed before statewide, and altitude specific standards, can be put in place. .
Several hospitals in the state are currently (or will) collect data for publication. There was also
discussion about current legislative issues within the country surrounding CCHD, and that Colorado
needed to wait to implement any legislation until the altitude research is more complete.
V.
Nurse Family Partnership Program
Presented by: Presented by: Lynne Easterly, RN, BSN; Jennie Wahrer, RN, BSN; Carol Vickery
Carol Vickery began the presentation by providing an overview of the Nurse Family Partnership (NFP)
Program. NFP is an evidence based, community health nursing program that transforms lives of
vulnerable first-time mothers living in poverty for over 30 years. The program goals include improving
pregnancy outcome, improving child health and development and improve parents’ economic selfsufficiency. The key program components are First-time, at-risk mothers, Registered nurses, Intensive
services (intensity, duration), Focus on behavior and Program fidelity (performance management
system). Carol reviewed a human brain development char over a 30 month period. The chart
demonstrated that during the first 30 months of a child’s life – the period in which Nurse-Family
Partnership works with their clients – basic functions related to vision, hearing, and language develop.
It is during this time period that trained registered nurses can have a huge impact on both mother and
child. She then reviewed the data regarding their program:
• 48% reduction in Child Abuse and Neglect
• 56% reduction in ER visits for accidents and poisonings
• 59% reduction in arrest of children age 15
• 67% reduction in behavioral and intellectual problems in children age 6
• 72% fewer conviction of mothers when children are age 15
Funding for NFP is provided by the Master Tobacco Settlement ($13.6 Million for 2,557 clients).
Medicaid accounts for roughly 10% of this. It is also funded by the MIECHV: Maternal Infant Early
Childhood Home Visitation through the Affordable Care Act ($1.6 Million for 420 clients) NFP is
offered throughout the state of Colorado in all but 7 counties. Colorado NFP Results include:
• 16,065 families served in Colorado since the program began
• 80% reduction in domestic violence during pregnancy
• 90% of babies were born full term and 90% were born at a healthy weight- at or above (5.5 lbs.)
• 92% breast feeding rate at birth
• 90% of children received all recommended immunizations by 24 months (vs. 78% CO average)
• 20% reduction in smoking during pregnancy
• 32% reduction in alcohol use during pregnancy
The RAND Corporation estimates Nurse-Family Partnership can return up to $5.70 for each $1 spent on
the program. In addition, Nurse-Family Partnership ranked among the highest programs reviewed in
terms of net benefit to society among pre-K, child welfare, youth development, mentoring, youth
substance prevention and teen pregnancy prevention programs. Jennie Wahrer introduced a mother who
then shared her experience with NFP, including the impact of the NFP Program in her life and how it
has helped her succeed. To refer 1st time pregnant women call your local NFP program & for
more information go to Nurse Family Partnership Website: nursefamilypartnership.org
Lynn Easterly then provided a presentation of specific services that NFP Nurses provide in the home
environment. She shared that they educate new moms on baby language, feeding patterns and cycles
and sleep cycles (both normal and abnormal), as well as teaching the new moms to notice infant cues.
She shared data regarding the families that the Intermountain NFP Program serves:
•
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Families living at high altitude
Five of our counties have families living above 8,000 feet Gilpin, Clear Creek, Summit, Lake
and Park.
We have worked in this areas for more that 10 years.
In supporting families one of the first things we think about is oxygen saturation when they are
sharing problems.
She reviewed some of the resources that are available and discussed the high altitude and newborn
challenges, including:
• Feeding issues
• Weight gain issues
• Sleep issues
• Irritability
• Provider support for moms at high altitude with newborns.
She shared that there are currently no American Academy of Pediatrics guidelines for newborns and
oxygen use at high altitude, and that there are varying practices. She then discussed some case studies
that they have observed during their home visits with families, and stressed the importance of educating
parents prenatally for signs and symptoms of oxygen saturation issues at altitude.
VI.
Outpatient Panel Discussion
Moderator: Peter Hulac, MD, CPCC Chairman
Participants: Mike Petterson, MD, Pediatric Cardiologist; Jeff Brown, Pediatric Hospitalist; Tracie
Detweiler, MSN, NNP-BC, Alfonso Pantoja, MD, Neonatologist,
Carol Vickery, RN, MSN, Intermountain Nurse Family Partnership
Dr. Hulac facilitated a discussion of the presentations, and questions were invited and answered. The
discussion focused on the benefits of NFP, and how their program can align with at risk mothers and
babies once they are discharged. The discussion also included the significant impact the program has
with these mothers.
VII.
The meeting was adjourned. The next Council meeting is scheduled for November 22, 2013 at
Children’s Hospital Colorado from 9am – 12pm.
Respectfully Submitted,
Heather Hagenson, CPCC