Tar­get­ing early de­liv­er­ies

Ini­tia­tive helped re­duce ad­mis­sions of pre­ma­ture ba­bies to NICU by 25%

Modern Healthcare - - OPINIONS|COMMENTARY -

Healthy ba­bies are worth the wait,” ac­cord­ing to the March of Dimes, and I whole­heart­edly agree. Re­search shows that ba­bies born as the re­sult of early-term, non-med­i­cally nec­es­sary de­liv­er­ies have higher neona­tal in­ten­sive-care unit ad­mis­sions and in­creased com­pli­ca­tions. Ba­bies’ or­gans continue to de­velop dur­ing the last few weeks of ges­ta­tion, so those born pre­ma­turely have an in­creased chance of com­pli­ca­tions and of­ten re­ceive costly spe­cial­ized care in the neona­tal in­ten­sive­care unit. Yet the prac­tice of non-med­i­cally nec­es­sary de­liv­er­ies be­fore 39 weeks con­tin­ues. Ac­cord­ing to one es­ti­mate, such de­liv­er­ies may con­sti­tute 10% to 15% of all births. An ar­ti­cle from the Novem­ber 2010 Amer­i­can Jour­nal of Ob­stet­rics and Gy­ne­col­ogy es­ti­mates 500,000 NICU days at a cost of $1 bil­lion an­nu­ally would be saved if this prac­tice were dis­con­tin­ued.

Med­i­cal pro­fes­sional so­ci­eties, gov­ern­ment lead­ers and na­tional ad­vo­cacy groups have en­cour­aged physi­cians and hos­pi­tals to dis­con­tinue early-term, non-med­i­cally nec­es­sary de­liv­er­ies. Hos­pi­tals have an im­por­tant role to play, and sev­eral have im­ple­mented hard-stop poli­cies to elim­i­nate them. These poli­cies in­clude adopt­ing a sched­ul­ing pro­ce­dure that re­quires physi­cians to pro­vide a med­i­cal in­di­ca­tion be­fore per­form­ing an early-term de­liv­ery or seek­ing ap­proval from the depart­ment chair or an­other au­tho­rized per­son.

Woman’s Hospi­tal’s launched its ini­tia­tive in 2007 through a col­lab­o­ra­tive with the In­sti­tute for Health­care Im­prove­ment. As a re­sult of the poli­cies we have im­ple­mented, ad­mis­sion of pre­ma­ture ba­bies into our NICU has de­clined by more than 25%. In 2011, Louisiana’s Depart­ment of Health and Hos­pi­tals joined the ef­fort as the first state agency to tar­get elec­tive births be­fore 39 weeks, and Woman’s helped ob­tain signed pledges from hos­pi­tals in the state that per­formed more than 1,000 de­liv­er­ies an­nu­ally. In 2012, DHH mod­i­fied the birth cer­tifi­cate to re­quire the rea­son for de­liv­ery be­fore 39 weeks ges­ta­tion. DHH also pro­vided fi­nan­cial as­sis­tance to par­tic­i­pat­ing hos­pi­tals to off­set the cost of IHI mem­ber­ship so that hos­pi­tals are equipped with the tools they need to be suc­cess­ful. Be­cause 70% of the ba­bies in Louisiana are cov­ered by Med­i­caid, it was a smart in­vest­ment.

We be­gan our jour­ney by form­ing a multi-

The ben­e­fits of pro­tect­ing the health

of new­borns far out­weigh the costs.

dis­ci­plinary coun­cil of nurse man­agers, qual­ity spe­cial­ists, ad­min­is­tra­tors, physi­cians and the med­i­cal di­rec­tor. Team mem­bers, in­clud­ing nurse cham­pi­ons and community physi­cians, at­tended na­tional meet­ings and IHI con­fer­ences ev­ery six months to re­view ev­i­dence­based prac­tices and dis­cuss progress with other or­ga­ni­za­tions in the same pur­suit.

Our team shared what they learned at the IHI meet­ings with staff and led a dis­cus­sion on Woman’s most re­cent data. The en­tire team an­a­lyzed dis­crep­an­cies in the data and sug­gested changes that could per­fect the guide­lines and im­prove out­comes. All team mem­bers pro­vided in­put and came to an agree­ment on the ap­pro­pri­ate next steps for Woman’s Hospi­tal.

This type of col­lab­o­ra­tion was es­sen­tial. To al­le­vi­ate ten­sion among pa­tients and their fam­i­lies, physi­cians and the hospi­tal, ob­ste­tri­cians were en­cour­aged to ad­vise pa­tients that hospi­tal reg­u­la­tions pro­hib­ited early-term de­liv­er­ies that are not med­i­cally nec­es­sary. Ob­stet­ric pa­tients re­ceived pam­phlets dur­ing pre­na­tal vis­its iden­ti­fy­ing the po­ten­tial risks as­so­ci­ated with births, the im­por­tance of wait­ing was dis­cussed in pre­na­tal classes and we worked with the March of Dimes to in­crease aware­ness.

Pe­di­a­tri­cians also as­sisted by ex­plain­ing the risks to the baby with ex­pec­tant par­ents. The dis­com­fort and in­con­ve­nience that caused moth­ers to re­quest in­duc­tions quickly dissi- pated when they un­der­stood the con­se­quences of de­liv­er­ing early.

The im­ple­men­ta­tion of hospi­tal poli­cies to re­duce early-term, non-med­i­cally nec­es­sary de­liv­er­ies re­quires the in­vest­ment of con­sid­er­able re­sources to col­lect the data, mon­i­tor progress and ed­u­cate em­ploy­ees, the med­i­cal staff, pa­tients and their fam­i­lies. But the ben­e­fits of pro­tect­ing the health of new­borns far out­weigh the costs. And al­though rev­enue in the NICU has been re­duced con­sid­er­ably be­cause of the elim­i­na­tion of ad­mis­sions for early-term de­liv­er­ies, we never ques­tioned the de­ci­sion be­cause it is sim­ply the right thing to do.

As a field, all hos­pi­tals must ad­dress the rise in early-term, non-med­i­cally nec­es­sary de­liv­er­ies and ed­u­cate pa­tients on their po­ten­tial con­se­quences. That’s why the Amer­i­can Hospi­tal As­so­ci­a­tion’s board of trus­tees re­cently adopted a for­mal po­si­tion that sup­ports poli­cies to elim­i­nate early-term, non-med­i­cally nec­es­sary de­liv­er­ies. The AHA is sup­port­ing its po­si­tion state­ment re­gard­ing the elim­i­na­tion of early-term non-med­i­cally nec­es­sary de­liv­er­ies by shar­ing strate­gies and best prac­tices with our mem­bers on­line and in a we­bi­nar.

The CMS and its Part­ner­ship for Pa­tients ini­tia­tive also en­cour­age fa­cil­i­ties across the coun­try to pledge to elim­i­nate early elec­tive de­liv­er­ies. Amer­ica’s hos­pi­tals are com­mit­ted to pro­tect­ing the health and well-be­ing of all pa­tients, in­clud­ing new­borns. Im­prov­ing our na­tion’s health by us­ing ev­i­dence-based prac­tices will im­prove pa­tient out­comes while mak­ing the most ef­fec­tive use of re­sources.

For these rea­sons, elim­i­nat­ing elec­tive de­liv­er­ies prior to full-term ges­ta­tion should be a pri­or­ity for hos­pi­tals. We know that it will lead to bet­ter out­comes for pa­tients and com­mu­ni­ties, and we en­cour­age all hos­pi­tals to par­tic­i­pate in this crit­i­cal ef­fort so that our youngest pa­tients may reach their high­est po­ten­tial.

Teri Fon­tenot is pres­i­dent and CEO

of Woman’s Hospi­tal, Ba­ton Rouge, La., and Amer­i­can Hospi­tal As­so­ci­a­tion board chair.

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