K t k P i t lK t k P i t lKentucky Perinatal Kentucky Perinatal SystemsSystemsSystemsSystems

Perinatal Regionalization Perinatal Regionalization MeetingMeetinggg

October 28, 2009October 28, 2009

KY Indicators of Perinatal HealthKY Indicators of Perinatal HealthInfant mortality in Kentucky has been Infant mortality in Kentucky has been decreasing and is currently equal to thedecreasing and is currently equal to thedecreasing and is currently equal to the decreasing and is currently equal to the national average for states (ranked 26national average for states (ranked 26thth).).

Kentucky ranks in the bottom half Kentucky ranks in the bottom half f US t t f l thf US t t f l thof US states for nearly every other of US states for nearly every other

measurable indicator of perinatal measurable indicator of perinatal h lthh lth

Indicator

unithealth.health.–– The following slide is a summary The following slide is a summary

for 12 indicators of perinatal healthfor 12 indicators of perinatal healthraw

# rank

unit

for 12 indicators of perinatal health.for 12 indicators of perinatal health.(2005 data)(2005 data)

HP2010Goal

First TrimesterPrenatal Care

AdequatePrenatal Care

SmokingChildbearing Age

SmokingWhile Pregnant

PretermBirth

Low BirthWeight

75 2 30th

% % % % % %

73.4 45th

75.2 30th

32.3 49th 26.7 49th

15.0 45th9 39th

90 90 NA 1 7 6 5

Very LowBirth Weight

CesareanDelivery

InfantMortality

Black:WhiteInfant Mortality Perinatal

M t lit

VLBW InfantsBorn at

90 90 NA 1 7.6 5

Birth Weight Delivery MortalityRatio Mortality Level 2 or 3

2 3 20th% % %

per 1000

per 1000

1.6 38th

33 9 46th

6.8 26th2.3 20th

8.8 39th33.9 46th

48.9 48th

0.9 15 primary63 repeat

4.5 1 4.5 90

Slide from Dr. Eric Reynolds

Origins of the KY Origins of the KY SSPerinatal SystemPerinatal System

Historically, KY had a Perinatal Advisory Committee for oversight of the Historically, KY had a Perinatal Advisory Committee for oversight of the initial regionalization efforts (1976initial regionalization efforts (1976 8)8)initial regionalization efforts (1976initial regionalization efforts (1976--8)8)

–– KY Guidelines for Perinatal Care with 3 levels of care were developed and KY Guidelines for Perinatal Care with 3 levels of care were developed and regularly updated; regularly updated;

–– University hospitals were designated as Level III centers and funded to care for University hospitals were designated as Level III centers and funded to care for uninsured neonates. Level II sites were selected for each Area Development uninsured neonates. Level II sites were selected for each Area Development ppDistrict around the state District around the state

–– Sites were funded for startSites were funded for start--up costs to buy equipment. Site visits done from up costs to buy equipment. Site visits done from State MCH office to assure compliance with guidelines.State MCH office to assure compliance with guidelines.

Transports were done by air national guard. University Level III centers Transports were done by air national guard. University Level III centers developed neonantal transport services; Maternal transport services were developed neonantal transport services; Maternal transport services were recommended but never materialized.recommended but never materialized.

1990’s in Ky saw improvements in1990’s in Ky saw improvements in–– Teen pregnancy ratesTeen pregnancy rates–– Early and adequate prenatal careEarly and adequate prenatal care–– Coverage for pregnant women and infantsCoverage for pregnant women and infants–– Infant mortality much improved Infant mortality much improved

Systems of Perinatal Care in KYSystems of Perinatal Care in KYSystems of Perinatal Care in KYSystems of Perinatal Care in KYWhen funding went away over time, the MCH program no longer did When funding went away over time, the MCH program no longer did site visits, dropped the KY Guidelines for Perinatal Care and did not site visits, dropped the KY Guidelines for Perinatal Care and did not

ti th P i t l Ad i C ittti th P i t l Ad i C ittcontinue the Perinatal Advisory Committee continue the Perinatal Advisory Committee

Language added into Language added into CON Application StandardsCON Application Standards: : “An application for special care neonatal beds will be “An application for special care neonatal beds will be

consistent with this plan consistent with this plan if:if:The application documents consistency with the mostThe application documents consistency with the mostThe application documents consistency with the most The application documents consistency with the most recent published edition of the AAP and ACOG recent published edition of the AAP and ACOG Guidelines for Perinatal CareGuidelines for Perinatal Care.”.”

No provision for accountability after the CON is awarded; No provision for accountability after the CON is awarded; –– Levels of NICU’s not included in hospital licensure regulations; Levels of NICU’s not included in hospital licensure regulations; –– JCAHO no longer addresses Special Care UnitsJCAHO no longer addresses Special Care Units

History of (DeHistory of (De--)Regionalization in Kentucky)Regionalization in Kentucky

DeDe--regionalizationregionalization of servicesof servicesMore perinatal providersMore perinatal providers–– More perinatal providersMore perinatal providers

Urban hospitals all developed NICU’s to compete for Urban hospitals all developed NICU’s to compete for deliveries in their catchment areadeliveries in their catchment areaNeonatologists hired in rural Level II’sNeonatologists hired in rural Level II’sNeonatologists hired in rural Level II sNeonatologists hired in rural Level II s

–– Desire by patients to stay close to homeDesire by patients to stay close to homeDepends on how the choice is presented to themDepends on how the choice is presented to them

–– Reimbursement vs. ExpendituresReimbursement vs. ExpendituresNeonatologists reimbursed more for babies <1500 gmNeonatologists reimbursed more for babies <1500 gmBabies < 1500gm occupy beds for longer, keeping ADC up Babies < 1500gm occupy beds for longer, keeping ADC up and providing prolonged per diem for hospitalsand providing prolonged per diem for hospitals

Rural hospitals and lessRural hospitals and less--equipped urban equipped urban hospitals have been delivering care to smallerhospitals have been delivering care to smallerhospitals have been delivering care to smaller hospitals have been delivering care to smaller and sicker infants.and sicker infants.

Regionalized Perinatal Care in KYRegionalized Perinatal Care in KYRegionalized Perinatal Care in KYRegionalized Perinatal Care in KYState Health Plan revised yearly; in Jan 2006, made State Health Plan revised yearly; in Jan 2006, made CON l t i ti t i tCON l t i ti t i tCON process less restrictive to improve access to CON process less restrictive to improve access to neonatal careneonatal care

CON requirements for Level II NICU:CON requirements for Level II NICU:–– Level II NICU’s should preferably be 8 bedsLevel II NICU’s should preferably be 8 beds–– Formula:Formula:# births in ADD# births in ADD x 4 = cap for # Level II NICU bedsx 4 = cap for # Level II NICU beds

1000 in ADD1000 in ADD–– Utilization of existing Level II beds in the ADD must exceed 70%Utilization of existing Level II beds in the ADD must exceed 70%

Applicant must document they would provide care consistentApplicant must document they would provide care consistent–– Applicant must document they would provide care consistent Applicant must document they would provide care consistent with most recent edition of “Guidelines for Perinatal Care” with most recent edition of “Guidelines for Perinatal Care” (AAP/ACOG)(AAP/ACOG)

–– Currently 217 Level II NICU beds licensed in KY (26 hospitals)Currently 217 Level II NICU beds licensed in KY (26 hospitals)

Regionalized Perinatal Care In KYRegionalized Perinatal Care In KYRegionalized Perinatal Care In KYRegionalized Perinatal Care In KY

CON requirements for Level III NICU Beds:CON requirements for Level III NICU Beds:CON requirements for Level III NICU Beds:CON requirements for Level III NICU Beds:–– Formula:Formula:# births in ADD# births in ADD x 1 = cap for # NICU Level III x 1 = cap for # NICU Level III pp

1000 beds in ADD1000 beds in ADD–– Utilization of existing Level III beds must exceed 75%Utilization of existing Level III beds must exceed 75%–– Applicant must document they would provide care Applicant must document they would provide care

consistent with most recent edition of “Guidelines for consistent with most recent edition of “Guidelines for Perinatal Care” (AAP/ACOG)Perinatal Care” (AAP/ACOG)Perinatal Care (AAP/ACOG)Perinatal Care (AAP/ACOG)

–– Currently 117 Level III NICU beds licensed (5 Currently 117 Level III NICU beds licensed (5 hospitals)hospitals)

Percent of VLBW* Infants [<1500gm] Delivered at Hospitals for high risk deliveries and neonates; Kentucky, 1993, & 2000-2008**

9077 3

90100

54.6 54.968

77.3

59.9 62.473.8

51.761.7 54.860

7080

ent

20304050

Perc

e

01020

1993 2000 2001 2002 2003 2004 2005 2006 2007 2008 HP1993 2000 2001 2002 2003 2004 2005 2006 2007 2008 HP2010Goal

*Very Low Birth weight is defined as any live birth weighing <1500 grams (3# 5 oz) at birth**2007 & 2008 d t i li i d b ld h HK 2010 Goal: 90%**2007 & 2008 data is preliminary and numbers could change^Note: Beginning in 2006, babies born only at a Level III hospital were included in the numeratorData Source: Kentucky Vital Statistics Files, Live Birth Certificate files, 1993, & 2000-2008

HK 2010 Goal: 90%

Definition for NPM #17Definition for NPM #17Definition for NPM #17Definition for NPM #17Numerator: Numerator: (before 2006) # of very low birth weight infants delivered (before 2006) # of very low birth weight infants delivered at facilities for high risk deliveries and neonatesat facilities for high risk deliveries and neonates

(after 2006) # infants with birth weight <1500 grams born (after 2006) # infants with birth weight <1500 grams born at subspecialty facilities (Level III Facility)at subspecialty facilities (Level III Facility)

[Does this mean Level III facility or a facility having a [Does this mean Level III facility or a facility having a Level III NICU??]Level III NICU??]

Denominator: Total # of very low birth weight babies Denominator: Total # of very low birth weight babies born in state to Kentucky residentsborn in state to Kentucky residents

National Designations for National Designations for f Cf CPerinatal Levels of CarePerinatal Levels of Care

“Distinction should be made between the “Distinction should be made between the perinatal care services level that perinatal care services level that characterizes an characterizes an institution or hospitalinstitution or hospital and and the level of care provided within individual the level of care provided within individual patientpatient--care unitscare units of a hospital.” of a hospital.” GPCGPC--6, p106, p10

National Perinatal Levels of CareNational Perinatal Levels of CareNational Perinatal Levels of CareNational Perinatal Levels of Care

“The former [“The former [level that characterizes an level that characterizes an [[institution or hospitalinstitution or hospital] applies to the total ] applies to the total organization of perinatal health services and the organization of perinatal health services and the responsibilities associated with participation in aresponsibilities associated with participation in aresponsibilities associated with participation in a responsibilities associated with participation in a coordinated regional system of care. The coordinated regional system of care. The determination of the appropriate level of care to determination of the appropriate level of care to pp ppp pbe provided by a given hospital should be be provided by a given hospital should be guided by guided by prevailing local health care prevailing local health care regulationsregulations [e g CON] national professional[e g CON] national professionalregulationsregulations [e.g, CON], national professional [e.g, CON], national professional organization guidelines, and identified regional organization guidelines, and identified regional perinatal health service needs.” perinatal health service needs.” GPCGPC--6, p106, p10

National Perinatal Levels of CareNational Perinatal Levels of CareNational Perinatal Levels of CareNational Perinatal Levels of Care

“ The latter [“ The latter [level of care provided withinlevel of care provided within The latter [ The latter [level of care provided within level of care provided within individual patient care unitsindividual patient care units] is based on ] is based on the individual needs of the perinatalthe individual needs of the perinatalthe individual needs of the perinatal the individual needs of the perinatal patient, postpartum woman, and neonate. patient, postpartum woman, and neonate. In the case of neonatal services level ofIn the case of neonatal services level ofIn the case of neonatal services, level of In the case of neonatal services, level of care should be assigned according to the care should be assigned according to the classification system developed by theclassification system developed by theclassification system developed by the classification system developed by the AAP and published in 2004.AAP and published in 2004.

2007 Perinatal Task Force:2007 Perinatal Task Force:2007 Perinatal Task Force:2007 Perinatal Task Force:(1) Design a (1) Design a voluntary reporting systemvoluntary reporting system for Level II and for Level II and

Level III nurseries, including the Level III nurseries, including the identification of quality identification of quality , g, g q yq yindicators and data to be collectedindicators and data to be collected

(2) Analyze (2) Analyze best practicesbest practices from other statesfrom other states(3) Identify strategies to(3) Identify strategies to ensure compliance with nationalensure compliance with national(3) Identify strategies to (3) Identify strategies to ensure compliance with nationalensure compliance with national

practice guidelines for perinatal carepractice guidelines for perinatal care in regard to in regard to appropriate facilities, equipment, 4) Make appropriate facilities, equipment, 4) Make recommendationsrecommendations to the Department for Public Health to the Department for Public Health ppregarding regarding the improvement of qualitythe improvement of quality perinatal care in perinatal care in Kentucky, andKentucky, and

(4) Make (4) Make recommendationsrecommendations to the Department for Public to the Department for Public ( )( ) ppHealth regarding Health regarding the improvement of qualitythe improvement of quality perinatal perinatal care in Kentucky, andcare in Kentucky, and

(5) Analyze the policies of Level II Nurseries (5) Analyze the policies of Level II Nurseries related torelated totransport to an appropriate tertiary care perinatal transport to an appropriate tertiary care perinatal programprogram. .

2007 Perinatal Task Force:2007 Perinatal Task Force:2007 Perinatal Task Force:2007 Perinatal Task Force:University Perinatal ProgramsUniversity Perinatal ProgramsKentucky Medical AssocKentucky Medical AssocKentucky Perinatal AssocKentucky Perinatal AssocAWHONNAWHONNAWHONNAWHONNKY Board of NursingKY Board of NursingKY Hospital AssociationKY Hospital AssociationKy Dept for Public HealthKy Dept for Public HealthKy Dept for Public HealthKy Dept for Public HealthRepresentation from rural and urban Level II’sRepresentation from rural and urban Level II’sRepresentation from nonRepresentation from non--university Level III’suniversity Level III’sRepresentative from LegislatureRepresentative from LegislatureOffice of Health Policy (CON)Office of Health Policy (CON)Student from College of Public HealthStudent from College of Public HealthStudent from College of Public HealthStudent from College of Public Health

Evidence Based Practices Evidence Based Practices f Q Cf Q Cfor Quality Neonatal Carefor Quality Neonatal Care

Leapfrog EBHR Safety Standards for NICU (1992)Leapfrog EBHR Safety Standards for NICU (1992)p g y ( )p g y ( )–– VLBW Infants (<1500gm, <32 weeks) are more likely to survive at VLBW Infants (<1500gm, <32 weeks) are more likely to survive at

hospitals with large NICU’shospitals with large NICU’s, defined as ADC >=15, defined as ADC >=15Phibbs et al, NEJM May 24, 2007Phibbs et al, NEJM May 24, 2007, y ,, y ,–– For VLBW infants (10yrs data) Mortality decreased as patient For VLBW infants (10yrs data) Mortality decreased as patient

volume increased within each level of care, and with higher levels volume increased within each level of care, and with higher levels of care within each volume group. of care within each volume group. Mortality was lowest when Mortality was lowest when VLBW d li i d i L l III f iliti ith NICU’ th tVLBW d li i d i L l III f iliti ith NICU’ th tVLBW deliveries occurred in Level III facilities with NICU’s that VLBW deliveries occurred in Level III facilities with NICU’s that treat more than 100 VLBW annuallytreat more than 100 VLBW annually..

–– Associations between mortality and NICU level and volume were Associations between mortality and NICU level and volume were greatest for the smallest infants <1000ggreatest for the smallest infants <1000ggreatest for the smallest infants, <1000g.greatest for the smallest infants, <1000g.

–– Model estimated that 21% of VLBW deaths were potentially Model estimated that 21% of VLBW deaths were potentially preventable if those infants had been cared for in a high level, high preventable if those infants had been cared for in a high level, high volume NICUvolume NICU

National Guidelines National Guidelines ––Guidelines for Perinatal CareGuidelines for Perinatal CareGuidelines for Perinatal CareGuidelines for Perinatal Care

Vol 6, Nov 2007Vol 6, Nov 2007

“Careful documentation of birth“Careful documentation of birth--weight specific mortality weight specific mortality rates by hospital of birth has shown that the rates by hospital of birth has shown that the survival of survival of premature, very low birth weight infants is highest when premature, very low birth weight infants is highest when births occur in hospitals with larger neonatal intensive births occur in hospitals with larger neonatal intensive care unitscare units. This finding has been reported in the United . This finding has been reported in the United States and other countries. States and other countries. Given the weight of the Given the weight of the ggevidenceevidence, it must be emphasized that inpatient perinatal , it must be emphasized that inpatient perinatal health care services should be organized within health care services should be organized within individual regions or service areas in such a manner that individual regions or service areas in such a manner that ggthere is a there is a concentration of care for the highest risk concentration of care for the highest risk pregnant women and their fetuses and neonates in the pregnant women and their fetuses and neonates in the highest level perinatal centershighest level perinatal centers.” P10 .” P10 g pg p

multiple reference articles listed, p 17multiple reference articles listed, p 17--1818

National Perinatal Levels of CareNational Perinatal Levels of CareNational Perinatal Levels of CareNational Perinatal Levels of Care

Levels of Perinatal Care by Hospital/ FacilityLevels of Perinatal Care by Hospital/ FacilityLevels of Perinatal Care by Hospital/ FacilityLevels of Perinatal Care by Hospital/ Facility

Level ILevel I Basic CareBasic Care

Level IILevel II Specialty CareSpecialty Care

L l IIIL l III S bS b i lt Ci lt CLevel IIILevel III SubSub--specialty Carespecialty Care

Regional CenterRegional Center Level III + regional Level III + regional responsibilitiesresponsibilities

Detailed in GPC 6 Table 1 3Detailed in GPC-6, Table 1-3

National Perinatal Levels of CareNational Perinatal Levels of Caref Gf GModel for KY GuidelinesModel for KY Guidelines

Levels of Care by Neonatal Care Unit:Levels of Care by Neonatal Care Unit:Levels of Care by Neonatal Care Unit:Levels of Care by Neonatal Care Unit:–– Level I Level I –– Basic CareBasic Care

Level IILevel II Specialty careSpecialty care–– Level II Level II –– Specialty careSpecialty careLevel II A Level II A Level II BLevel II BLevel II B Level II B

–– Level III Level III –– Subspecialty CareSubspecialty CareLevel III ALevel III ALevel III ALevel III ALevel III BLevel III BLevel III C p 13Level III C p 13--1414

National Guidelines for National Guidelines for f Cf CPerinatal Levels of Care Perinatal Levels of Care

ALL LEVELSALL LEVELSALL LEVELS:ALL LEVELS:Identify high risk perinatal patients and Identify high risk perinatal patients and determine which should be transferreddetermine which should be transferreddetermine which should be transferreddetermine which should be transferredCapability for emergency CCapability for emergency C--section within 30 section within 30 minutesminutes

ffResuscitation and stabilization of neonatesResuscitation and stabilization of neonatesConsultation and transfer arrangementsConsultation and transfer arrangementsData collection and storageData collection and storageData collection and storageData collection and storageQuality Improvement programs, including efforts Quality Improvement programs, including efforts to maximize patient safetyto maximize patient safetyAdequate support services P 11Adequate support services P 11

National Guidelines for Perinatal Levels of CareNational Guidelines for Perinatal Levels of CareLEVEL I LEVEL I –– BASIC CAREBASIC CARE

P id OB CNM P d FPP id OB CNM P d FPProviders: OB, CNM, Ped, FPProviders: OB, CNM, Ped, FP

“Level I Units provide a basic level of newborn “Level I Units provide a basic level of newborn care to infants at care to infants at low risklow risk. They can stabilize and . They can stabilize and care for late preterm infantscare for late preterm infants (35(35 37 weeks) who37 weeks) whocare for late preterm infants care for late preterm infants (35(35--37 weeks) who 37 weeks) who remain physiologically stableremain physiologically stable; Stabilize infants ; Stabilize infants who arewho are less than 35 weeksless than 35 weeks gestation or whogestation or whowho are who are less than 35 weeksless than 35 weeks gestation or who gestation or who are ill are ill until they can be transferreduntil they can be transferred.” P. 10,22.” P. 10,22

National Guidelines for Perinatal Levels of CareNational Guidelines for Perinatal Levels of Care

LEVEL II LEVEL II –– SPECIALTY CARESPECIALTY CARE

B d C tifi d Ob t t i i P di t i i tiB d C tifi d Ob t t i i P di t i i tiBoard Certified Obstetricians, Pediatricians, sometimes Board Certified Obstetricians, Pediatricians, sometimes NeonatologistsNeonatologists“A level II nursery provides care for infants born at “A level II nursery provides care for infants born at more than 32 more than 32

k t ti d i hi th 1500k t ti d i hi th 1500 h hh hweeks gestation and weighing more than 1500g weeks gestation and weighing more than 1500g who have who have physiologic immaturity, who are moderately ill with problems that physiologic immaturity, who are moderately ill with problems that are are expected to resolve rapidlyexpected to resolve rapidly and are and are not anticipated to need not anticipated to need subspecialty services on an urgent basissubspecialty services on an urgent basis or who areor who aresubspecialty services on an urgent basissubspecialty services on an urgent basis, or who are , or who are convalescing.” P10, 22, Table 1convalescing.” P10, 22, Table 1--33

Level II ALevel II A Level II BLevel II BDo not have the capability to Do not have the capability to provide assisted ventilation provide assisted ventilation except on a limited basis until the except on a limited basis until the infant can be transferredinfant can be transferred

Additional capacity to provide Additional capacity to provide mechanical ventilation for brief mechanical ventilation for brief duration (up to 24 hrs) or CPAPduration (up to 24 hrs) or CPAPP13 20P13 20infant can be transferredinfant can be transferred P13,20P13,20

Level IILevel II--B v.s. Level IIIB v.s. Level III--AAL l IIIL l III AALevel IILevel II--BB

GPCGPC--6 (AAP 2004)6 (AAP 2004)>32 weeks, >1500 gm, CPAP>32 weeks, >1500 gm, CPAP

Level IIILevel III--AAGPCGPC--6 (AAP 2004)6 (AAP 2004)>28 weeks, >1000gm, but only >28 weeks, >1000gm, but only

conventional ventconventional ventConventional vent <24 hrsConventional vent <24 hrs

Issues:Issues:IIII--B’s with neonatologist doB’s with neonatologist do

conventional ventconventional vent

Issues: Issues: Having a Neonatologist does not Having a Neonatologist does not

make you a Level IIImake you a Level IIIIIII--B s with neonatologist do B s with neonatologist do conventional vent >24 hrs but still conventional vent >24 hrs but still short term; most do not need subshort term; most do not need sub--specialistsspecialists

If can only do vent <24 hrs, unit willIf can only do vent <24 hrs, unit will

make you a Level IIImake you a Level IIIFew Level III’s have all the “other Few Level III’s have all the “other

stuff”stuff”“Other stuff” not clearly defined“Other stuff” not clearly definedM t d b i lti fM t d b i lti fIf can only do vent 24 hrs, unit will If can only do vent 24 hrs, unit will

not be staffed by a neonatologist; not be staffed by a neonatologist; most likely will be physician most likely will be physician extenders with remote access to a extenders with remote access to a physician/neophysician/neo

May not need subspecialties for May not need subspecialties for limited ventilation & >1000 gmlimited ventilation & >1000 gm

Do you need a perinatologist? On Do you need a perinatologist? On site?site?

N l di ti ti f t ffiN l di ti ti f t ffiEven doing CPAP, any vent should Even doing CPAP, any vent should require neonatologistrequire neonatologist

Unlikely these units would participate Unlikely these units would participate in data collection (VON)in data collection (VON)

No clear distinction of staffing, No clear distinction of staffing, services in A v.s. IIIservices in A v.s. III--B and IIIB and III--C C ––just buy equipment and they could just buy equipment and they could do anythingdo anything

May or may not participate in dataMay or may not participate in dataCould a pediatrician run a IICould a pediatrician run a II--B B May or may not participate in data May or may not participate in data collection (VON)collection (VON)

National Guidelines for Perinatal Levels of CareNational Guidelines for Perinatal Levels of CareLEVEL IIILEVEL III –– SUBSUB--SPECIALTY CARESPECIALTY CARELEVEL III LEVEL III –– SUBSUB--SPECIALTY CARESPECIALTY CARE

Full time MFM Specialists; Neonatologists; Pediatric SubspecialtiesFull time MFM Specialists; Neonatologists; Pediatric SubspecialtiesInIn house OB and anesthesiahouse OB and anesthesiaInIn--house OB and anesthesiahouse OB and anesthesiaNeonatal FollowNeonatal Follow--Up Program “is an essential component” of subspecialty Up Program “is an essential component” of subspecialty servicesservicesOutreach educationOutreach educationOutreach educationOutreach educationAdvanced Quality Improvement and data analysisAdvanced Quality Improvement and data analysis

Level III ALevel III A Level III BLevel III B Level III CLevel III C

-- Provides comprehensive Provides comprehensive care for infants born at care for infants born at more than 28 weeks more than 28 weeks

--additionally cares for additionally cares for infants infants <28 week and <28 week and <1000 gm<1000 gm;;

--all Level III B, and all Level III B, and can also provide can also provide ECMO and open ECMO and open

gestation and weighing gestation and weighing more than 1000gm;more than 1000gm;-- Conventional mechanical Conventional mechanical

gg ;;--advanced respiratory advanced respiratory support such as HFV;support such as HFV;

ppheart surgeryheart surgery

ventilation onlyventilation only P 13P 13--14, 2414, 24--2525

Proposed 2008 Kentucky Proposed 2008 Kentucky Guidelines for Perinatal CareGuidelines for Perinatal CareGuidelines for Perinatal CareGuidelines for Perinatal Care

5 Levels of Care5 Levels of Care–– Level I: Basic neonatal care, >35 weeksLevel I: Basic neonatal care, >35 weeksLevel I: Basic neonatal care, 35 weeksLevel I: Basic neonatal care, 35 weeks–– Level IIA: Mildly ill neonates, >34 weeks, >1800 gramsLevel IIA: Mildly ill neonates, >34 weeks, >1800 grams–– Level IIBLevel IIB: : Moderately ill neonates, >28 weeks, >1250 gms, Moderately ill neonates, >28 weeks, >1250 gms,

CPAP, mechanical ventilation (<7days), conventional only; CPAP, mechanical ventilation (<7days), conventional only; requires neonatologistrequires neonatologistLevel III: Complex diseases any gestational age or birthLevel III: Complex diseases any gestational age or birth–– Level III: Complex diseases, any gestational age or birth Level III: Complex diseases, any gestational age or birth weight, protracted mechanical ventilation, advanced weight, protracted mechanical ventilation, advanced ventilation techniques; ECMO, ped surgery in some centers; ventilation techniques; ECMO, ped surgery in some centers; requires neonatologist, perinatologist , ped subspecialtiesrequires neonatologist, perinatologist , ped subspecialties

–– RPC: Level III clinical care, educational outreach, referral RPC: Level III clinical care, educational outreach, referral and consultation specialized transport developmentaland consultation specialized transport developmentaland consultation, specialized transport, developmental and consultation, specialized transport, developmental followfollow--up, interventional servicesup, interventional services

KY VLBW Mortality Level of CareLi k d D th Bi th fil 2000 2005Linked Death-Birth files 2000-2005

(Exclusions: InfantsTransferred In or Out)KY IM by Level, Inborn

Inborns < 1500 gm Level III

Level II

Level I

Inborns <1250 gm

th W

eigh

t

Inborns < 1000 gm

Birt

0 50 100 150 200 250 300 350 400 450 500

Inborns < 750gm

Deaths per 1000

* Data is raw data, not risk adjusted; differences are statistically significant. However, Number of cases is low, especially for Level I centers, and should be considered statistically unstable.

Infant Mortality by Level of Care and Infant Mortality by Level of Care and Experience in KentuckyExperience in KentuckyExperience in KentuckyExperience in Kentucky

[Inborns only, non[Inborns only, non--transfer, unadjusted]transfer, unadjusted]

419.4433.1450

<1500 Gm

336.1 338.9314.5

350

400<1500 Gm

<1000 Gm

258.3 264.4

314.5

267.5

250

300

165.8 148 151.5 146.3150

200

100

150

0

50

Level I Level II Level III <10 VLBW / yr 10-25 VLBW / yr >100 VLBW / yr

Kentucky and TennesseeKentucky and TennesseeKentucky and TennesseeKentucky and TennesseeKentuckyKentucky TennesseeTennessee

Infant MortalityInfant Mortality 6.86.8 8.78.7

Neonatal Neonatal 4.14.1 5.65.6Mortality (<28 Mortality (<28 days)days)VLBW % birthsVLBW % births 1.6% 1.6% 1.4% 1.4%

Black/White IM Black/White IM 2.32.3 2.22.2ratioratioPerinatal Perinatal 8.28.2 10.310.3MortalityMortality

KY Guidelines Not AdoptedKY Guidelines Not AdoptedKY Guidelines Not AdoptedKY Guidelines Not Adopted“That’s not my hospital’s data”“That’s not my hospital’s data”Families want to stay close to home (it was the Families want to stay close to home (it was the family’s decision)family’s decision)It’s the doctor’s call whether or not to transferIt’s the doctor’s call whether or not to transferIt’s the doctor’s call whether or not to transferIt’s the doctor’s call whether or not to transferWe don’t want more regulationWe don’t want more regulationNational guidelines say we can “adapt” to localNational guidelines say we can “adapt” to localNational guidelines say we can adapt to local National guidelines say we can adapt to local circumstancescircumstancesNational guidelines change, so what I was doingNational guidelines change, so what I was doingNational guidelines change, so what I was doing National guidelines change, so what I was doing before was OK, and now I am doing the same before was OK, and now I am doing the same thing but it is not OKthing but it is not OK

NPM #17NPM #17 –– What are we Doing?What are we Doing?NPM #17 NPM #17 What are we Doing?What are we Doing?Seeds of a Perinatal Quality CollaborativeSeeds of a Perinatal Quality CollaborativeSeeds of a Perinatal Quality CollaborativeSeeds of a Perinatal Quality Collaborative–– Committee of Kentucky Perinatal AssociationCommittee of Kentucky Perinatal Association

VONVON-- KY state group report for comparison ofKY state group report for comparison ofVONVON KY state group report for comparison of KY state group report for comparison of participating hospital to like KY hospitalsparticipating hospital to like KY hospitalsReRe--aligned univeristy contracts to reflect GPCaligned univeristy contracts to reflect GPC--6 6 g yg yperinatal center classificationperinatal center classificationPossible new regulationsPossible new regulationsggFIMR FIMR –– two pilot sitestwo pilot sitesPRAMSPRAMS

NPM # 17: What would be helpful?NPM # 17: What would be helpful?NPM # 17: What would be helpful?NPM # 17: What would be helpful?

Uniform definition for this indicatorUniform definition for this indicatorGuidance on how to use this indicator with other Guidance on how to use this indicator with other measures to monitor “regionalization”measures to monitor “regionalization”More concrete national standards, especially More concrete national standards, especially description of differences in Levels and subdescription of differences in Levels and sub--levels particularly which are essential for Levellevels particularly which are essential for Levellevels, particularly which are essential for Level levels, particularly which are essential for Level III A,B,CIII A,B,CMore specific definition of “24/7 coverage by More specific definition of “24/7 coverage by o e spec c de t o o / co e age byo e spec c de t o o / co e age byneonatologist” (e.g. on site, inneonatologist” (e.g. on site, in--house, nearby, house, nearby, via telemedicine???)via telemedicine???)