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Aim  Kickoff!

Making  North  Carolina  the  Best  
Place  to  Give  Birth  and  Be  Born!
Martin  J  McCaffrey,  MD,  CAPT  USN  (Ret)
For  the  Perinatal  Quality  Collaborative  of  North  Carolina  
Who  Needs  QI  and  
Collaboration?
NIH  Consensus  Statement  Antenatal  Steroids  
1994
Antenatal  Steroid  Use  in  CA  2005-­‐2007

Lee  HC  et  al.  Antenatal  steroid  administration  for  premature  neonates  in  California  From  2005-­2007.  Obstet
Gynecol.  2011  Mar;;117(3):603-­9.
Making  North  Carolina  the  Best  Place  to  Give  
Birth  and  Be  Born
• Defining  Value
• Partnership  with  patients  and  families
• Spread  best  practice
• Resource  optimization
Hospitals  (65)  Participating  in  

PQCNC  Initiatives  
Cape  Fear  Valley
• Albemarle  Women's  Center  

• Granville  Medical  Birthing  Center  
• Carolinas  Medical  Center  
• Halifax  Regional  Medical  Center  
• CMC-­‐Pineville
• Maria  Parham  Medical  Center  Maternity  Services  
• Columbus
• Nash  Health  Care  Special  Care  Nursery  
• Cleveland
• Nash  Health  Care  Women's  Center  
• Duke
• Wilson  Medical  Center  

• Granville • Carteret  General  Hospital  Brady  Birthing  Center  and  Nursery  

• New  Hanover • Outer  Banks  Hospital  

• Novant Forsyth • Bladen  County  Hospital  Birth  Center

• Novant Huntersville • Johnston  Health  Women's  Pavilion

• Wake  Med  Cary
• Novant Presbyterian
• Southeastern  Regional  Women's  Healthcare  
• Rex
• Vidant Edgecombe    
• UNC
• Alamance  Regional  Medical  Center
• Vidant (ECU)  Greenville
• Brenner  Children's  Hospital  
• Womack
• Davis  Regional    
• WakeMed
• Morehead  Memorial  Hospital  

• Caromont • Randolph  Hospital  

• Catawba  Valley • CMC  – Lincoln

• Central  Carolina • Grace  Hospital

• CMC-­‐NorthEast • High  Point  Regional  Culp  Women's  Center

• Iredell  Memorial  Hospital
• FirstHealth -­‐ Moore
• Novant-­‐Matthews
• Grace
• Rowan  Regional  Medical  Center
• McDowell
• Stanly  Regional  Medical  Center
• Mission
• Lenoir  Memorial  Hospital
• Onslow
• Watauga  Medical  Center
• Transylvania
• Wilkes  Regional  Medical  Center
PQCNC  Initiatives
• CABSI
• 39  Weeks
• SIVB
• National  CLABSI
• Exclusive  Human  Milk  Well
• Exclusive  Human  Milk  NCCC
• Patient  and  Family  Engagement  (PFE)  
• Neonatal  Abstinence  Syndrome
• CCHD  Screening  Reporting  System
• Accuracy  in  the  Birth  Certificate
• Conservative  Management  of  Preeclampsia  (CMOP)
• ASNS
• AIM  OB  Hemorrhage
Supporting   Public  
MD  MOC Advocates

Quality  
Clinical   Measures
Leaders

Making  North  
Carolina  the  Best   Payment  
Evidence
Place  to  Give  Birth   Incentives
and  Be  Born

Public   Public  
Policy Reporting  
Pay  for  
Quality  
Collaborative  
Performance
Improvement
Who  are  our  PQCNC  Partners?
Co-­‐Leads  for  National  Network  
Perinatal  Quality  Collaboratives
CDC  PQC  Project AHA/HRET
NCGA  and  CFTF BCBSNC

DPH  Maternal NCHA  and  NCQC
And  Infant  Health

Division  Medical  
NC  March  of  Dimes PQCNC Assistance  &  CCNC

Office  Rural  Health   NC  Partnership  for  
Community  Care Maternal  Safety  

62  Hospitals Family  Support  
Network Joint  Commission  
13  States  171  NICUs  in  PQCNC Perinatal  
Led  NCLABSI Core  Measures  Panel
Initiative  Design
• Select  initiative  topic
• Identify  Expert  Team
• Expert  Team  Develops  Aim  Statement  and  Charter
• Problem,  intervention,  defined  goal
• Expert  Team  Develops  Action  Plan  (Key  Driver  Diagram)
• Identify  key  challenges
• Identify  recommended  interventions
• Outcomes  desired
• Expert  Team  Defines  Key  Measures
• Process  and  outcome
• Create  Web  Based  Data  Reporting  System
• Hospital  Perinatal  Quality  Improvement  Teams  Formed
• Face  to  face  Learning  Sessions,  Monthly  Webinars,  Weekly  Newsletters,  QI  
Facilitation  
PQCNC  Initiatives  
2009-­‐2016
• Reduction  of  Early  Elective  Deliveries  (<39  Weeks)  (2009)
• Reduction  of  First  Birth  Cesarean  Delivery  Rate  (Support  for  Intended  Vaginal  
Birth  SIVB)  (2010-­‐2012)
• Reducing  Central  Line  Associated  Blood  Stream  Infections  in  NICUs  (CLABSI)  
(2009,  2010-­‐2011)
• Increasing  Breastfeeding  Rates  in  Well  Nurseries  (2010-­‐2012)
• Increasing  Maternal  Milk  Use  in  NICUs  (2010-­‐2012)
• Conservative  Management  of  Preeclampsia  (2014-­‐Present)
• Neonatal  Abstinence  Syndrome  (2014-­‐Present)
2017  PQCNC  Initiatives  
• Phase  1/2  (Post-­‐Pilot):  Conservative  Management  of  Preeclampsia  (CMOP)  
(includes  23  Hospitals)
• Antibiotic  Stewardship  Newborn  Sepsis  (48  hospitals,  56  teams)
• AIM  (Alliance  for  Innovation  on  Maternal  Health)
• Prevention  of  morbidity  and  mortality  associated  with  maternal  hemorrhage
• 2018  Newborn  Initiative:  Hypoglycemia
39  Weeks  Project

Decrease  of  
43%

Berrien  K  et  al.  The  perinatal  quality  collaborative  of  North  Carolina's  39  weeks  project:  a  quality  improvement  program  to  decrease  elective  deliveries  before  
39  weeks  of  gestation.  N  C  Med  J.  2014  May-­‐Jun;75(3):169-­‐76.
PQCNC  Support  for  Intended  Vaginal  Birth  
(Reduction  of  Rate  of  NTSV  CS)

50.0%
45.0%
40.0%
35.0%
Cesarean  Rate

30.0%
25.0% All  Patients
20.0%
High-­‐Risk  Patients
15.0%
Low-­‐Risk  Patients
10.0%
5.0%
0.0%
Baseline
February
March
April
May

July
August
June

September
October
November
December

Phase  I Phase  II/III

In  nine  months  we  saw  a  15%  increase  in  the  likelihood  of  first-­time  
mothers  delivering  vaginally  in  24  participating  centers
Mothers  may  have  
more  than  one  risk  
factor
INITIATIVE-­‐WIDE  CESAREAN  RATES
50.00% OVERALL  C/S  RATE

C/S  RATE  -­‐ NO  C/S  RISK  FACTORS
45.00%
38  to  26%...33%  increase  in  likelihood  of  SIVB
20  to  16%...24%     C/S  RATE  -­‐ 1+  C/S  RISK  FACTORS
40.00% 38.01%
36.34% Linear    (OVERALL  C/S  RATE)
34.62% 35.06%
34.07%
35.00% 32.60%
30.20% 29.74% 30.41%
30.00% 28.00% 27.62%
26.42%
25.11%
23.99% 24.12% 23.67% 23.95%
25.00% 22.16% 22.80%
21.98%
21.02% 21.29%
20.37%
19.11%
20.00%
20.25% 20.74%
19.32% 18.66% 19.06% 19.19% 18.83%
18.23% 18.47% 18.27%
15.00% 16.95% 16.59%

10.00%

5.00%

0.00%
Conservative  Management  of  Preeclampsia  
(CMOP)  2013-­‐Present
• New  ACOG  and  CCNC  guidelines  related  to  classification  and  management  of  
HTNsive disorders
• CMQCC  toolkit  for  hypertensive  disorders  of  pregnancy
• Key  metric  of  time  to  treatment
• Advocacy  groups  for  mothers  with  preeclampsia
• Interest  from  payers  
• 23-­‐32  centers  actively  participating,  42%  of  NC  births
• Likely  consideration  by  JC  of  measures  related  to  maternal  hypertension
• Aims
• 1)  Eliminate  deliveries  37  weeks  for  GHTN  and  Preeclampsia  Without  Severe  Features    
• 2)  Increase  Time  to  Treatment  or  BP  Control  <  1  hour  to  90%  
• 3)  Increase  antenatal  steroid  rates  to  90%
• 4)  Increase  rates  of  maternal  postpartum  education  
Antibiotic  Use  in  the  NICU
”When different
physicians are
recommending
different things
for essentially
the same
patients, it is
impossible to
claim that they
are all doing the
right thing."
(Eddy DM)

Schulman  J  et  al.  Neonatal  intensive  care  unit  antibiotic  use.  Pediatrics.  2015  May;135(5):826-­‐33.  
AIM
By  January  2018,  PQITs  in  NC  hospitals  will    utilize  defined  best  practices  for  evaluating  risk  
for  sepsis  to  demonstrate  a  decrease  of  20%  in  the  number  of  patients  exposed  to  any  
antibiotic  and  a  decrease  of  20%  in  duration  of  antibiotic  administration  past  the  first  48  
hours  of  life  with  a  negative  blood  or  CSF  cultures.

Action  Plan  Recommendations
• Kaiser  sepsis  calculator
• Antibiotic  Time  Out  
• Parent  partnership • Focus  is  acute  infection
• Targets  mother-­‐baby  units  and  NICUs

www.pqcnc.org
UNC  Experience

Process Change

A  70%  reduction  in  antibiotic  exposure  to  infants  in  UNC  NBN  
From  7.5%  to  2.3%  of  newborns  receiving  antibiotics
ASNS  in  NC

122,719  births  in  NC  (2016)

85,903  infants  participating  in  
PQCNC  ASNS  – nearly  70%  of  
births  in  NC
PQCNC  ASNS  
By  the  numbers…
44
Hospitals  Participating

85,903 6,442
Infants  Currently  Being  
North  Carolina   Exposed
Newborns

1,288  (3,221)
Infants  per  year  
protected  from  
unnecessary  exposure  
to  antibiotics
ASNS  NBN

Reduction  from  2.3%  to  1.6%...30%
ASNS  NBN
ASNS  NICU

23%  to  13%...44%  reduction
ASNS  NICU

Reduction  from  33%  to  24%...28%
=  PQCNC  Projects

ETD,  CS  Rates,  Neonatal  Mortality
32.3 32.9 32.8 32.8 32.8 32.7 32.2
31.8
31.2 31.3 31.7 31.4 32 31.9
30.3 31.1
30.3 30.4 30.6 30.3
29.1 29.8 29.5 29.3 29.4
28.8
27.8
27.5 27 27
26.8
26.1 26
25.3 25 24.6
24.4 39  Weeks 24
23 22.9
• 15%  reduction  in  early  term  deliveries
SIVB SIVB CMOP
• 8%  reduction  in  overall  CS  rate
• 6%  reduction  in  neonatal  mortality PMH PMH
• 14%  reduction  in  32-­‐36  week  deliveries
HEN

11.2 11.4 11.4 11.1 10.8 11.1 10.6 10.1 9.6 9.5 9.5 9.8

6 5.6 5.7 6 6.1 5.6 5.7 5.3
5.2 4.9 4.9 4.9 5 4.9

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
CS  Rate  NC CS  Rate  US Neo  Mortality Early  Term  Deliveries 32-­‐36  Week  Deliveries
Partnering  in  Public  Health  Monitoring
• CCHD  Screening
• Accuracy  in  Birth  Certificate  Reporting
• State  Center  for  Health  Statistics  (Kathleen  Jones-­‐Vessey,  Matt  Avery  and  NC  
Birth  Certificate  Registrars)
• Vital  Records  (Tamma Hill,  Field  Services  Manager  for  Vital  Records)
PQCNC  Return  On  Investment
2009-­‐2016
• Savings
• $29,928,000  for  SIVB/39  Weeks
• $11,854,498  for  massive  reductions  in  37-­‐38  week  deliveries  and  newborn  costs
• $1,400,000  for  CMOP  avoiding  preterm  births
• $3,500,000  for  NAS  avoiding  NICU  and  hospital  days
• None  of  these  savings  include  estimated  20%  professional  fees
• Additional  $9,336,499
• $23,400,000  for  CLABSI
• Total  savings  estimated  =  $79,418,997
• Cost
• CMS  Transformation  Grant  ($650K  over  three  years)
• UNC  Innovations  Grant  ($600K  over  three  years)
• ORHCC/BCBSNC  ($1M)  one  time  support
• NCGA  Approved  DPH  Maternal  Block  Grant  ($250K  x  3  years,  $350K  x  2  years)
• NCGA  (2016)  $475K
• CDC  Grant  ($200K/year  x  2  years)
• Total  funding  (2006-­‐2014):  $4,575,000
• ROI
• 1735%  over  last  six  years
Stakeholders
Non-­‐Denominational  
On  the  Road
Data
We’re  making  changes,  are  we  changing  culture?
Think  Big
TEAMWORK

Alone  we  can  do  
so  little,  together  we  
can  do  so  much.
Helen  Keller
CMOP  Phase  2

66%  reduction

Rising  to  85%

• Hospital  cost  avoidance  $2,374,320  using  
Tricare  calculator  (infants  1500-­‐2500  grams)
• Pro  fees  not  included  (estimate  $474,866)
• Increasing  use  of  ANS  for  infants  requiring  
18%  increase delivery  at  <  34  weeks  (from  71%  to  85%)  
impact  on  reducing  RDS,  IVH,  and  NEC.
• Increasing  treatment  of  HTN  moms  within  1  
hour  from  68%  to  80%