The Golden Hour: Delivery Room Management
This project addressed the transition from fetal to neonatal life of newborns with a gestational age less than 30 6/7 weeks or birth weight less than 1500 grams. This QI initiative focused on the effects of Delivery Room management practices - including teamwork, thermoregulation, oxygen administration and delayed cord clamping.
Obstetric Hemorrhage Initiative (OHI)
In order to address Florida's pregnancy-related mortality, the FPQC's maternal health advisors developed a Florida quality improvement Obstetric Hemorrhage Initiative (OHI) to address one of the largest and most preventable causes of maternal mortality in Florida.
Reducing Non-Medically Indicated Deliveries (NMID) <39 Weeks (2010-2011 Project)
March of Dimes Big 5 Project: Reducing Non-Medically Indicated Deliveries (NMID) <39 WeeksMore than 30 years ago, the American Congress of Obstetricians and Gynecologists (ACOG) created guidelines advising obstetricians against elective deliveries without medical indications before 39 weeks gestation in order to improve the health outcomes of babies. According to ACOG, the last few weeks of a healthy pregnancy are necessary for the full development of some vital organs, such as the brain and lungs. Despite these guidelines, NMID <39 weeks gestational age steadily had been increasing in the United States by 2010 – with variability in the rates of such deliveries ranging from 5 - 40+%. At that time, the March of Dimes (MOD) decided to create a national collaborative comprised of the five most populous states – Florida, California, Texas, New York and Illinois – and to focus the Big 5 Collaborative’s first quality improvement (QI) initiative on eliminating NMID <39 weeks.
With a seed grant from the MOD to represent Florida, the FPQC focused its efforts on recruiting hospitals and educating practitioners. The FPQC and the MOD partnered to aid the efforts of six Florida hospitals in the Big 5 Hospital QI Project, a year-long pilot test of the “California Maternal Quality Care Collaborative Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age” toolkit. The goal of the project was to change hospital policies and procedures to avoid scheduling these types of inductions or cesareans. To monitor project outcomes, data were collected on live births that were singleton, Florida residents and “term” pregnancies (370/7 – 386/7) with no medical conditions prior to or during pregnancies.
Each hospital was responsible for gathering together a QI team with a physician champion, nurse leader, scheduler and staff member. Without existing protocols in place, the hospitals’ QI teams were trained by the FPQC with the MOD on how to implement the California toolkit. Training included:
Establishing consistent policies and procedures for scheduling guidelines
- Creating a uniform scheduling form
- Applying a “Hard Stop” policy process
- Collecting and inputting data accurately into the MOD national web data portal
Between January and December 2011: The hospitals input their de-identified data from the scheduling forms into the data portal. Improvement was monitored by each hospital through monthly and quarterly reports as well as monthly phone calls with the MOD and the FPQC to check individual progress, compare status against others, share new ideas for enhancements and discuss challenges and opportunities.
The project was extremely effective, and the results were published by the MOD at the national level. To access the abstract for "A Multistate Quality Improvement Program to Decrease Elective Deliveries Before 39 Weeks Gestation," please click here.
The success of the project attracted the interest of the Florida Hospital Association (FHA) and others. With continued funding from the MOD and new funding from the FHA, the FPQC has started a current project expanding the initiative on eliminating early elective deliveries (EED) through the Health Engagement Network (HEN) to more Florida hospitals.
Early Elective Deliveries (EED)
With the success of its partnership in the March of Dimes (MOD) 2011 Big 5 Project to reduce non-medically indicated deliveries <39 weeks gestation, the FPQC has expanded this initiative to more Florida hospitals by continuing to work with the MOD and ACOG District XII.
Neonatal Catheter Associated Blood Stream Infection (NCABSI)The FPQC is one of the original 9 state Collaboratives in the NCABSI initiative which began in December 2011 with the goal of reducing central line associated infections through the application of defined insertion and maintenance toolkits. This project was the FPQC’s first newborn QI initiative.
Sixteen Florida Level III NICUs signed on to implement the existing protocol utilized across the nine-state project for Phase I, which was completed in December 2012. During Phase I, the Florida NICUs provided a quarter of the data and had a substantial impact on the national progress of the project – with Florida outperforming the national average in certain key measures.
Phase II began in January 2013 (red line in figure) with the goal of maintaining the gains achieved in Phase I. The NCABSI project expanded nationally to include 13 states and over 150 NICUs. The 16 Florida NICUs involved have been the largest single data contributor, with over 7800 of the 40,000 lines and over 86,000 of the 376,000 line days.
Florida has reduced central line infection by over 58.8% by August 2013. Detailed results between December 2011 and August 2013 indicated that 150 infections were avoided in Florida - saving 18 lives, reducing length of stay by more than 1,199 days and saving over $7.9 million.
The effort included individual site visits by the state Lead Investigator, conference calls involving participating centers and a series of webinars on utilizing the American Hospital Association's Comprehensive Unit-Based Safety Program (CUSP) to achieve and sustain culture change. The spirit of cooperation and collaboration which grew out of this project will give Florida a strong foundation for future projects.
If you have any questions about this initiative, please contact Dr. Douglas E. Hardy at firstname.lastname@example.org .
For detailed information on the NCABSI initiative presented at the FPQC’s 2013 Annual Neonatal-Focused Meeting (September 2013), please click here.
November 2013 Update