Patient Safety Movement Foundation Presents Optimizing Obstetric Safety

Patient Safety Movement Foundation Presents Optimizing Obstetric Safety: Reducing Unnecessary C-Sections Webinar December 13, 2017 Ariana Longley, MPH, Vice President, PSMF Expert Presenter: David C. Lagrew, Jr. , MD, Executive Medical Director, Southern California Providence St. Joseph Health System

Agenda • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS) • 35 Minutes: Patient Safety Movement Foundation’s Expert Presentation led by – David C. Lagrew, Jr. , MD • 15 Minutes: Q & A

0 X 2020

Fostering New Efforts and Building On Existing Patient Safety Programs Through Commitments to ZERO

Who Can Take Action? • Hospitals & Healthcare Organizations – Make a Commitment • Committed Partners – Sign the Commitment to Action letter • Healthcare Technology Companies – Sign the Open Data Pledge • Patient & Family Advocates – Share their Patient Story, Utilize Resources

Actionable Patient Safety Solutions (APSS) 4. Failure to Rescue: Monitoring for Opioid Induced Respiratory Depression 2. Healthcare-associated Infections (HAIs) 3. Medication Errors 5. Anemia and Transfusions 6. Hand-off Communications 7. Neonatal Safety 8. Airway Safety 9. Early Detection & Treatment of Sepsis 10. Optimal Resuscitation 11. Optimizing Obstetric Safety 12. Venous Thromboembolism 13. Mental Health: Access to Acute Psychiatric Beds 14. Falls and Fall Prevention 15. Nasogastric Feeding and Drainage Tube Placement & Verification 16. Person and Family Engagement 1. Culture of Safety • Download at patientsafetymovement. org/apss

David C. Lagrew, Jr. , MD Executive Medical Director, Southern California Providence St. Joseph Health System

Reducing Cesarean Section: A long term strategy to reduce maternal mortality Presented by David C. Lagrew Jr MD Executive Medical Director, Southern California Providence St. Joseph Health System

WHAT IS MATERNAL MORTALITY? AREN’T WE DOING REALLY WELL?

Maternal Mortality Study Group (CDC/ACOG 1986) • Pregnancy-associated death- All deaths during or within 1 year of pregnancy • Pregnancy-related death (subset of above)- all deaths during or within the 1 year of pregnancy due to: – Complication of pregnancy – Aggravation of unrelated condition by the physiology of pregnancy – Chain of events initiated by pregnancy • Using all available data

Maternal Mortality Ratio (maternal deaths per 100, 000 delivers)

Maternal Mortality Worldwide

WE WERE DOING WELL, UNTIL YOU LOOK CLOSER….

Reducing Maternal Mortality

Is US Maternal Mortality Rising? • The estimated maternal mortality rate (per 100, 000 live births) for 48 states and Washington D. C. (excluding California and Texas, analyzed separately) increased by 26. 6%, from 18. 8 in 2000 to 23. 8 in 2014. California showed a declining trend, while Texas had a sudden increase in 2011– 2012. Analysis of the measurement change suggests that U. S. rates in the early 2000 s were higher than previously reported. • Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington D. C. increased from 2000– 2014, while the international trend was in the opposite direction Mac. Dorman et al Obstet Gynecol. 2016 September ; 128(3): 447– 455.

Yearly rate of decline in Maternal Mortality Ratio 1990– 2008

And some state rates are going above 30

Rates above 30 per 100, 000

We are nearing a rate per 100, 000 that ranks up with some really bad diseases!

Tip of the Iceberg • Using the New York Data for every maternal death there are 362 SMM events • New York severe maternal morbidity measure, New York hospital deliveries 2008 – 2013

SMM in the United States 1993 -2004

WHAT IS CAUSING THE RISE, WHAT IS DIFFERENT?

Cause of Death Cardiomyopathy % of All Deaths % Preventable 21% 22% Hemorrhage 14 93 PIH 10 60 CVA 9 0 Chronic condition 9 89 AFE 7 0 Infection 7 43 Pulmonary embolism 6 17 Berg CJ et al. Obstet Gynecol 2005.

Maternal Risk Factors Increased The “Big 3” we are seeing… • Maternal Age • Maternal Weight • Current C-Section and Prior C-Section

The Double Edge: Low CSR correlated with lowering maternal mortalityuntil 19% JAMA. 2015; 314(21): 2263 -2270

CESAREAN SECTION IS REALLY SAFE IN A MODERN SETTING, ISN’T IT? ….

Correlated?

CA-PAMR Found significant correlation in maternal deaths

Relatively Common Complications (per 100 deliveries) Cesarean Section Vaginal Endometritis Vag/Perineal laceration Bleeding/Anemia Prolonged urinary dysfxn Wound infection Mild fecal incontinence UTI Ileus Transient tachypnea

Relatively Uncommon Complications (per 1, 000 -10, 000 deliveries) Cesarean Section Vaginal Wound deheiscence Uterine rupture/inversion Hysterectomy Necrotizing fascitis Ureteral damage Vaginal hematoma Bowel damage Incontinence DVT/Thromboembolism Retained placenta Fetal laceration Shoulder dystocia/trauma/ICH PPHN Sepsis/asphyxia

We are forgetting: “Compounded” Risk • Consider that we must not only compare two outcomes but all possible outcomes in probability this is called a compounded event: – A compound event is one in which there is more than one possible outcome. Determining the probability of a compound event involves finding the sum of the probabilities of the individual events and, if necessary, removing any overlapping probabilities. Probability is the likelihood that an event will occur

If 1 st delivery was cesarean compared to vaginal: Outcome Uterine Rupture PP with bleeding Abruptio Placenta Thromboembolism Cord p. H < 7. 00 Perinatal Death Hysterectomy RR 42. 18 2. 06 1. 87 2. 81 2. 49 1. 33 6. 07 Rageth et al Obstet Gynecol 1999; 93: 332 -7. Absolute Risk 1/316 vs. 1/13, 318 1/227 vs. 1/468 1/171 vs. 1/255 1/330 vs. 1/928 1222 vs. 1/552 1/246 vs. 1/328 1/359 vs. 1/2, 177

Previous Vaginal Delivery is the safest delivery! Rate/1000 RR 95%ile P Prev CS Vaginal Abruption 5. 05 2. 96 1. 70 1. 19 -2. 44 <0. 01 Placenta previa 7. 96 4. 42 1. 79 1. 35 -2. 40 <0. 001 CS NRFHR-AP 7. 73 2. 48 3. 13 2. 25 -4. 35 <0. 001 CS NRFHR-IP 22. 34 13. 95 1. 60 1. 35 -1. 90 <0. 001 Breech 37. 78 20. 50 1. 84 1. 61 -2. 11 <0. 001 Suspected Rupture 2. 69 0. 11 25. 72 8. 24 -80. 25 <0. 001 Stillbirth 3. 70 2. 65 1. 40 0. 93 -2. 10 NS 5 min Apgar <7 5. 83 4. 28 1. 36 0. 98 -1. 88 NS Thick meconium 22. 18 30. 53 0. 75 0. 64 -0. 88 <0. 001 Table 1: Maternal/Neonatal Outcomes Resus by Tube 22. 34 11. 55 1. 93 1. 67 -2. 24 <0. 001 Shoulder Dystocia 14. 85 24. 47 0. 61 0. 44 -0. 83 <0. 001 Emergency CS 2. 13 1. 49 0. 87 -2. 55 NS D and C 0. 11 0. 07 0. 67 0. 26 -1. 49 NS Hysterectomy 3. 05 0. 56 5. 43 2. 95 -9. 97 <0. 001 Galyean, Lagrew, et al. J Perinatol. 2009 Nov; 29(11): 726 -30.

Abnormal Placentation •

Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005; 192: 1458– 61.

Chance of Previa relative to prior Cesarean Sections Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985; 66: 89– 92.

If Previa then…. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985; 66: 89– 92.

Real increasing incidence of hysterectomy for placenta accreta “ 1975 -2010. The frequency of placenta accreta correlated steadily with the CS rate until 2000. Since then, the incidence has nearly doubled in women with previous CS scars, suggesting an additional causative influence on risk. ” Higgins et al Eur J Obstet Gynecol 2013

World Wide Review of Peripartum Hysterectomy Indications Risk Factors Mortality Placental pathology (38%) Uterine Atony (27%) Uterine Rupture (26%) Current pregnancy CS (OR 11. 4) Previous CS (OR 7. 5) Older Age Higher Parity Average blood loss 3. 7 L Overall mortality: 5. 2 per 100 Poorer settings: 11. 9 per 100 Richer settings: 2. 5 per 100 van den Akker T, et al. Obstet Gynecol. 2016.

CDC Report: Changes in SMM • Compared with the 1993– 2004 period, 13 SMM indicators had substantial (50% and more) rate increases in 2013– 2014. The largest increases were among the following indicators: – – – Acute renal failure at 369%. Blood transfusion at 363%. Shock (body is not getting adequate blood flow) at 233%. Adult respiratory distress syndrome at 189%. Cardiac arrest (sudden loss of heart function) or ventricular fibrillation (heart beats so quickly and irregularly that it stops pumping blood) at 158%. – Acute myocardial infarction (heart attack) at 133%. – Aneurysms of the aorta (balloon-like bulge in the body’s largest artery) at 1, 110%. https: //www. cdc. gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity. html

“Medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous” Cyril Chantler MD Chantler C. The role and education of doctors in the delivery of health care. Lancet 1999; 353: 1178 -81

BUT CAN WE DO ANYTHING ABOUT IT?

There is a Large Variation in Cesarean Rates Among California Hospitals

The Toolkit is Aligned with the ACOG/SMFM Consensus Statement and the AIM Patient Safety Bundle § Readiness § Recognition and Prevention § Response to Every Labor Challenge § Reporting

The CMQCC Toolkit § Comprehensive, evidence-based “How-to Guide” to reduce primary cesarean delivery in the NTSV population § Will be the resource foundation for the CA QI collaborative project § The principles are generalizable to all women giving birth § Released on the CMQCC website April 28, 2016 § Has a companion Implementation Guide 47

CONCLUSIONS

International problem! Betran et al PLOS ONE DOI: 10. 1371/journal. pone. 0148343 February 5, 2016

Summary • Rising maternal mortality is a worldwide issue • Cesarean section and compounded long term risk appears to be contributing • Therefore, long term reduction of maternal mortality (and morbidity) will require work to reduce unnecessary cesarean sections • Efforts are started • Research, new strategies and technology are needed

Q&A

Thank you!