A Strong Core Produces Positive Outcomes February 21,2014 Lori Eckenrode RNC BSN Mary Hersey RNC BSN

Transcription

1 A Strong Core Produces Positive Outcomes February 21,2014 Lori Eckenrode RNC BSN Mary Hersey RNC BSN

2 A New Core Measure 2

3 Health care delivery is shifting to value-based care and core measures will be tied to reimbursement IOM calling for health care delivery to become STEEEP-safe, timely, effective, efficient, equitable, and patient-centered QI is the methodology used for Core Measures implementation 3

4 What are Core Measures? TJC developed Core Measures to serve as national standardized performance measurement system, providing assessments of care delivered by a health system in a focused area Core Measures are developed as a step-wise process with input from multiple stakeholders (including, CMS, IHI, NQF) Based on the evidence graded according to the USPSTF levels of evidence 4

5 PC Core Measure Set Perinatal Care Measure Set Mothers Newborns PC-01 PC-02 PC-03 PC-04 PC-05 Elective Delivery <39 weeks Caesarean Section Antenatal Steroids Blood Stream Infections Exclusive Breast Feeding 5

6 PC-01: Elective Delivery <39 weeks Patients with elective vaginal deliveries or elective cesarean sections at >/= 37 and < 39 weeks of gestation completed Required CMS reporting as of January 1,

7 OB/GYN Measure Quick Reference Perinatal Care (PC) Core Measures: PC-01 Patient Population for Mothers: All Inpatients 8 65 years old Less than or equal to 120 days Be sure to document: Core Measure Definition Documentation Rules Justification for Elective Delivery PC 01 No elective deliveries prior to 39 weeks gestation without justification The delivery or operating room records are the preferred sources of this information followed by (in this order): 1. H&P 2. Prenatal forms 3. Admission progress notes 4. Discharge summary Gestational age is defined as the number of weeks that have elapsed between the first day of the last normal menstrual period (not presumed time of conception) and the date of delivery. Gestational age should be rounded off to the nearest completed week, not the following week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days is at a gestational age of 35 weeks not 36 weeks). See reverse for complete list of justifications and CPT codes.

8 42 HUMAN IMMUNO VIRUS DIS PLACENTA PREVIA DELIVER PLACENTA PREV HEM DELIV PREM SEPAR PLACEN DELIV COAG DEF HEMORR DELIVER ANTEPARTUM HEM NEC DELIV ANTEPARTUM HEM NOS DELIV ESSEN HYPERTEN DELIVERED ESSEN HYPERTEN DEL W P/P RENAL HYPERTEN PG DELIV RENAL HYPERTEN DEL P/P OLD HYPERTEN NEC DELIVER OLD HYPERTEN DELIV W P/P TRANS HYPERTEN DELIVERED TRANS HYPERTEN DEL W P/P MILD/NOS PREECLAMP DELIV MILD PREECLAMP DEL W P/P SEVERE PREECLAMP DELIVER SEV PREECLAMP DEL W P/P ECLAMPSIA DELIVERED ECLAMPSIA DELIV W P/P TOX W OLD HYPERTEN DELIV TOX W OLD HYP DEL W P/P HYPERTENS NOS DELIVERED HYPERTENS NOS DEL W P/P POST TERM PREG DEL RENAL DIS NOS DELIVERED RENAL DIS NOS DEL W P/P LIVER/BIL TRCT DISR DEL DIABETES DELIVERED CONGEN CV DIS DELIVERED CONGEN CV DIS DEL W P/P CV DIS NEC PREG DELIVER CV DIS NEC DELIVER W P/P ABN GLUCOSE TOLER DELIV ABN GLUCOSE DELIV W P/P COAGULATION DEF DELIV COAGULATN DEF DEL W P/P TWIN PREGNANCY DELIVERED TRIPLET PREGNANCY DELIV QUADRUPLET PREG DELIVER TWINS W FETAL LOSS DEL TRIPLETS W FET LOSS DEL QUADS W FETAL LOSS DEL MULT GES W FET LOSS DEL MULT GEST FET REDUCT DEL MULTI GESTAT NEC DELIVER MULT GESTATION NOS DELIV UNSTABLE LIE DELIVERED MULT GEST MALPRES DELIV FETAL CNS MALFORM DELIV FETAL CHROMOSO ABN DELIV FET DAMG D/T VIRUS DELIV FET DAMG D/T DIS DELIVER FET DAMAG D/T DRUG DELIV RADIAT FETAL DAMAG DELIV FETAL ABNORM NEC UNSPEC FETAL MATERNAL HEM DELIV RH ISOIMMUNIZAT DELIVER ABO ISOIMMUNIZAT DELIVER FETAL DISTRESS DELIVERED INTRAUTER DEATH DELIVER POOR FETAL GROWTH DELIV POLYHYDRAMNIOS DELIVERED OLIGOHYDRAMNIOS DELIVER PREM RUPT MEMBRAN DELIV PROLONG RUPT MEMB DELIV AMNIOTIC INFECTION DELIV ABN FTL HRT RATE/RHY DEL VASA PREVIA DELIVERED V08 ASYMP HIV INFECTN STATUS V23.5 PREG W POOR REPRODUCT HX V27.1 DELIVER SINGLE STILLBORN

9 PC-02: Caesarean Section Nulliparous women with a term singleton baby in a vertex position delivered by cesarean section 9

10 OB/GYN Measure Quick Reference Perinatal Care (PC) Core Measures: PC-02 Patient Population for Mothers: All Inpatients 8 65 years old Less than or equal to 120 days Core Measure Definition Gestational Age Documentation Rules Conditions That May Justify C Section PC 02 Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section The delivery or operating room records are the preferred sources of this information followed by (in this order): 1. H&P 2. Prenatal forms 3. Admission progress notes 4. Discharge summary Parity is defined as the number of deliveries, live birth the patient experienced prior to current hospitalization. Gestational age is defined as the number of weeks that have elapsed between the first day of the last normal menstrual period (not presumed time of conception) and the date of delivery. Prior uterine surgery Prior classical cesarean section Prior myomectomy Prior uterine surgery resulting in a perforation of the uterus History of a uterine window noted during prior uterine surgery History of uterine rupture requiring surgical repair

11 CPT Codes that can justify a Caesarean Section 11

12 PC-03: Antenatal Steroids Patients at risk of preterm delivery at >= 24 and <32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns 12

13 OB/GYN Measure Quick Reference Perinatal Care (PC) Core Measures: PC-03 Patient Population for Mothers: All Inpatients 8 65 years old Less than or equal to 120 days Core Measure PC 03 Document either step 2 or step 3 Definition Gestational Age Documentation Rules Documentation of Reason Patients at risk of preterm delivery at greater than or equal to 24 and less than 32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns Where you can document the medication. o H&P o Prenatal forms o Medication administration record (MAR) o Progress notes o HMR Physician needs to document if the patient is or was on initial antenatal steroid therapy: o 12mg bethamethasone IM o 6mg dexamethasone IM Gestational age is defined as the number of weeks that have elapsed between the first day of the last normal menstrual period (not presumed time of conception) and the date of delivery. Reasons for not initiating antenatal steroid therapy must be explicitly documented. Example: Patient had adverse reaction to the medication in the past unable to initiate antenatal steroid therapy

14 PC-04: Newborn BSI Staphylococcal and gram negative septicemias or bacteremias in high-risk newborns 14

15 OB/GYN Measure Quick Reference Perinatal Care (PC) Core Measures: PC-04 Patient Population for Newborns: All patients with birth weight of grams Core Measure Definition Documentation Rules Documentation of Reason PC 04 Staphylococcal and gram negative septicemias or bacteremias in high risk newborns This core measure is collected by ICD codes. Is there documentation within the first 48 hours after admission that the patient had a bloodstream infection present on admission or is receiving treatment for a suspected bloodstream infection or septicemia on admission.

16 PC-05: Exclusive Breast Milk Feeding Exclusive breast milk feeding during the newborn s entire hospitalization 16

17 OB/GYN Measure Quick Reference Perinatal Care (PC) Core Measures: PC-05 Core Measure PC 05 Definition Documentation Rules Documentation of Reason Documentation that the newborn was exclusively fed breast milk during the entire. Hospitalization. Exclusive breast milk feeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines. These are the only acceptable maternal medical conditions for which breast milk feeding should be avoided which includes one or more of the following medical conditions: HIV infection Human t lymphotrophic virus type I or II Substance abuse and/or alcohol abuse Active, untreated tuberculosis Taking certain medications, i.e., prescribed cancer chemotherapy, radioactive isotopes, antimetabolites, antiretroviral medications and other medications where the risk of morbidity outweighs the benefits of breast milk feeding Undergoing radiation therapy Active, untreated varicella Active herpes simplex virus with breast lesions Admission to Intensive Care Unit (ICU) post partum Adoption or foster home placement of newborn Previous breast surgery, i.e., bilateral mastectomy, bilateral breast reduction i h h h i bl d b ilk

18 Healthy People 2020 Breastfeeding Objectives Increase the proportion of infants who: Descriptor Baseline Objective Were ever breastfeed 74.0% 81.9% Were breastfed at 6 months 43.5% 60.6% Were breastfed at 1 year 22.7% 34.1% Were breastfed exclusively through 3 months Were breastfed exclusively through 6 months Increase the proportion of employers that have worksite lactation support programs Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies 33.6% 46.2% 14.1% 25.5% 25% 38% % 8.1%

19 Percent of U.S. breastfed children supplemented with infant formula Goal 14.2% 25% and rising 19

20 The most significant predictor of duration was the receipt of supplemental feedings while in the hospital (P <.0001), Howard, C. R. et al. Pediatrics 2003;111: Shorter duration of breastfeeding if used formula in the first month (2.79, CI ), Vogel, et al. Acta Pediatr 88: , Six times more likely to be exclusively breastfeeding at 8 weeks if not supplemented with formula in the hospital (OR 6.3 Exclusive BF) Breastfeeding and New Jersey Maternity Hospitals: A Comparative Report, using data from the New Jersey Pregnancy Risk Assessment Monitoring System (NJ-PRAMS) Only not receiving supplemental feedings remained significant for reaching Feeding goals (Adj OR= 2.3, 95% CI 1.8, 3.1), Perrine, et al. Pediatrics, 2012; Jul, 130:1,

21 1.Form a multidisciplinary team to write infant feeding policy using model hospital template 2.Educate Everyone doctors, nurses, staff, community, society, and women prenatally and before pregnant 3. Recommend breastfeeding to mothers; health decision rather than lifestyle choice, but be careful to Inform rather than Control 4. Implement skin-to-skin in first hour or at least until after first feeding the sooner, the longer, the better! 5. Emphasize supply and demand, early hours/days most crucial 21

22 Ten Practical Steps to Exclusive Breastfeeding continued 6. Use formula only for medical indication 7. Keep mom and baby together 8. Teach feeding cues, breast massage, and hand expression 9. Teach and normalize infant behavior, set realistic expectations, teach and model calming techniques 10. Support moms before, during and especially after the hospital perform community outreach to educate, normalize, advocate 22

23 The Bottom Line.. Giving our best so they can be the best they can be! 23