Colorado Perinatal Care Council

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Colorado Perinatal Care Council

• Levels of Neonatal Care American Academy of
  Pediatrics Policy Statement
• What It Means for Colorado
• Barbara Hughes, CNM, MS, MBA, FACNM
• CPCC Chair 2004-2005

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What is the CPCC?

• ... A volunteer, non-profit, advisory group whose
  members represent a variety of professions,
  hospitals and organizations with an expertise or
  interest in perinatal care.
• Its major focus is the coordination and
  improvement of perinatal care services in
  Colorado.

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CPCC What has our role been?

• 19761983 CPCC had a State mandate to the
  certificate-of-need process
• 1991 CPCC changed to a self-assessment process
  for evaluation of an institutions level of care
• Honor system - self-assessment
• No monitoring of compliance or of outcomes
• A resource for organizations and institutions
• www.coloradoperinatalcarecouncil.com

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The VLBW Problem in Colorado

• VLBW lt 1500 grams
• 647 in 1992
• 901 in 2002
• 1.3 of all births in CO
• 37 increased chance of dying if born in Level II
  nursery instead of Level III

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How Does Colorado Rate?

• Maternal Child Health Bureau of the Health
  Research Services Administration recommends 90
  of VLBW babies are born in Level III
• 74.6 in Colorado
• 56 are born within 10 miles of a Level III

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CPCC What is our role now?

• Integrate the new AAP Guidelines for Levels of
  Neonatal Care into the current self-assessment
  process
• Integration process should include input from our
  customers
• Level 1, 2, 3 institutions,
• CDPHE

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American Academy of Pediatrics

• Levels of Neonatal Care Policy Statement
• Committee on Fetus Newborn
• Pediatrics 20041141341-1347
• See Handout

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Advantages of Uniform Definitions of Levels of
Care

• Assessment of outcomes, resource utilization and
  costs
• Informative to the public as they seek an active
  role in selecting a delivery service
• Minimize need for health coverage purchasing
  bodies to develop their own standards
• Facilitate the development and implementation of
  consistent standards of service provided for each
  level of care

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Proposed Uniform DefinitionsLevel I (basic)

• Level I Well-newborn nursery
• Provide resuscitation at each delivery
• Evaluate healthy newborns
• Provide postnatal care to newborns and mothers
• Stabilize and provide care for infants gt 35 weeks
  who remain physiologically stable
• Stabilize newborns that are ill and those lt 35
  weeks until transfer to a facility that can
  provide appropriate level of neonatal care

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Proposed Uniform DefinitionsLevel II (specialty)

• Level II Neonatal Care - 2 categories
• Level IIA Neonatal Care
• Resuscitate and stabilize preterm or ill infants
  prior to transfer to a facility that can provide
  appropriate level of neonatal care
• Provide care for infants gt32 weeks gt1500 gms
• Provide care for infants convalescing after
  intensive care
• Level IIB Neonatal Care
• Level IIA capabilities
• Additional capability to provide mechanical
  ventilation for brief periods (lt24 hours) or
  continuous positive airway pressure

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Proposed Uniform DefinitionsLevel III
(subspecialty)

• Level III NICU Care 3 categories
• Level IIIA
• Comprehensive care for infants gt28 weeks
  
  gt1000 gms
• Conventional mechanical ventilation
• Minor surgical procedures central lines,
  hernia
• Level IIIB
• Comprehensive care for infants lt28 weeks lt1000
  gms
• Advanced respiratory care - High-frequency iNO
  for as long as required
• Prompt and on-site access to a full range of
  pediatric medical subspecialists
• Advanced imaging with interpretation on an urgent
  basis
• Pediatric surgical specialists and
  anesthesiologists near-by or onsite to do major
  surgery for example, PDA ligation, repair of abd
  wall defects, NEC with perforation, TEF, spina
  bifida
• Level IIIC
• Capabilities of Level IIIB and has ability to
  provide ECMO and repair of complex congenital
  cardiac malformations that require by-pass

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Town Hall Meetings

• January 13th Colorado Dept of Health
• January 28th Boulder
• January 28th Fort Collins
• January 31st Grand Junction
• Febuary 15th Colorado Springs
• Representatives included
• Pueblo, North Suburban, Porter Central, Boulder
  Foothills, Yampa Valley, Avista, Childrens,
  Swedish, Vail Valley, Pres St Lukes, Poudre
  Valley, St Marys Grand Junction, University,
  Greeley, Delta, Sky Ridge, Colorado Spr Memorial,
  Montrose, Medical Center of Aurora, Platte
  Valley, St Mary Corwin, Penrose

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Summary of Town Hall Meetings

• Stakeholders
• Family, parents, babies
• Institutions including risk management
• Communities
• State of Colorado
• Colorado Department of Health
• Providers
• Ob, MFM, Family Practice, Pediatricians,
  Neonatology, Advanced Practice, Nursing, Home
  Health, Respiratory Therapy, Social Work, Mental
  Health, Long-term Care, Developmental Care
  Therapists
• Legal
• Payers
• Colorado Patient Safety Coalition
• COPIC

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Summary of Town Hall Meetings

• Process of assessment of Level of care
• Avoid regulatory requirement
• There is a void in AAP statement that doesnt
  address obstetrical component, nursing, other
  physicians on staff, or hospital services
• Our application still needs to address these
  areas best basis is 5th edition
• Self-assessment relies on an honor system and
  self policing
• How well does it work?
• Re-evaluation every two years
• Include Level 1, 2, and 3
• The lower gestation or weight is not a mandate
  and needs to be clarified for the application
  process and by the institution
• How useful is gestational age given dating
  inaccuracies and how should this put back on the
  institution?
• The working instrument for self-assessment needs
  to be looked at from an evidenced-based viewpoint
  whenever possible

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Summary of Town Hall Meetings

• Gray areas
• How should the guidelines deal with those units
  that are growing and appropriately advancing
  their level of care?
• e.g., IIIA and high-frequency ventilation,
  inhaled nitric oxide
• e.g., IIB and times when gt24h mechanical
  ventilation
• When and how to deal with areas when there may be
  variations in meeting the guidelines that still
  preserves current level of services by an
  institution and protects quality of care of
  patients
• When and how to deal with shortages of
  subspecialists that otherwise limits an
  institutions ability to deliver an existing level
  of care
• The difference between Level 2 and Level 3 as for
  outcomes is probably tied to accessibility to MFM
  and perinatal management
• Probably same for neonatal morbidities
  interventions include steroids, tocolytics,
  aggressive treatment of chorioamnionitis

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Summary of Town Hall Meetings

• Department of Health will continue to monitor
  Level of care outcomes against Healthy People
  2010 goals
• We should gather a limited data set for all
  Levels of care that includes transferred moms and
  delivered/transferred babies
• Match actual care to Level of care
• State resource could be 7 Vermont Oxford
  Institutions
• University, Swedish, Rose, PSL, St Joseph, Grand
  Junction, Poudre Valley
• What is the value in these institutions getting
  together?
• How to utilize site visits if at all?

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Summary of Town Hall Meetings

• Others that need to be aware of the end result
  CPCC interpreting the AAP policy statement on
  levels of neonatal care for Colorado
• Colorado Ob-Gyn Society
• Colorado Academy of Family Practice
• COPIC
• Colorado Hospital Association
• Colorado American Academy of Pediatrics
• NANN, ANA/CAN, AWHONN
• Colorado Patient Safety Coalition!

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Changes to Guidelines

• Work group met February 22nd
• Mark Brown, Joe Toney, Kathleen Bohanon, Susan
  Clarke, Carol Wallman, Jan Paisley, Karen Sawyer,
  Susan Williams, Camille Shea-McAleavey, Mary Lou
  Hendricks, Jan Goldberg, and Barbara Hughes
• Preserved
• Breakdown into Obstetric and Neonatal components
• Physician staff, nursing staff, services, and
  protocols/policies
• Required, highly recommended, and
  recommended qualifiers for providers and
  services
• Used a consensus approach
• Have not addressed
• Outcomes
• Cover letter
• Level 1

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Changes to Level II

• gt32 0/7 weeks both IIA and IIB
• Short term mechanical ventilation
• lt24 hours
• Documentation of protocols / policies /
  procedures / guidelines in place if gt24 h
• (During short term ventilation), in-house
  qualified practitioner (e.g. Neo, ped, APN) with
  capability of diagnosing and treating a full
  range of complications of mechanical ventilation
• CPAP
• Protocols in place
• Did not require in-house practitioner

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Changes to Level III

• Gestation and birth weight
• IIIA gt28 0/7 weeks gt1000 gms
• IIIB lt 28 0/7 weeks lt1000 gms
• MFM required for all
• Primary distinction between IIIA and IIIBC
• High frequency and nitric oxide
• Provided opportunity for high frequency protocols
  for IIIA and in-house attendance
• Provided opportunity for nitric oxide protocol
  for IIIA and short term application
• Gestation age 28 weeks and birth weight 1000
  grams
• Reduced gray area and provided overlap
• Extent of complex surgeries greater for IIIBC
• Full range of pediatric specialties
• Mindful of geography and supply issues
• Range of imaging
• Mindful of geography and supply issues

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Next Steps

• Get feedback from CPCC members
• Present Guideline changes to stakeholders
• Establish minimum dataset
• Approve changes at July meeting
• Begin self-assessment process by September 1st

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For More Information...

• www.coloradoperinatalcarecouncil.com
• Barbara Hughes bhughescnm_at_aol.com
• Mark Brown mbrown80465_at_msn.com
• Jan Goldberg jan.goldberg_at_state.co.us