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HomeMy WebLinkAboutMINUTES - 12162008 - D.4 TO: BOARD OF SUPERVISORS ? s L . Contra _ FROM: William Walker, M.D., Director Costa o _ y,,,mug !s Health Services Department �aSr•__• County DATE: December 4, 2008 a CO°�' SUBJECT: Perinatal Department Utilization in Contra Costa County SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUS IFICATI N RECOMMENDATION: CONSIDER accepting a report from the Health Services Director on the challenges facing Contra Costa Regional Medical Center Perinatal Department and the strategies being used to enhance quality of care and improve patient flow. FISCAL IMPACT: No impact from this report. BACKGROUND: The average number of monthly births continues to skyrocket at CCRMC. The average monthly births in the fiscal year ending 2002 was 137.6; this past fiscal year had an 214 monthly average birth rate. These numbers represent CCRMC births being 16% of all Contra Costa County resident births. Today we're going to discuss the challenges being faced by the patients utilizing the CCRMC perinatal department and we'll focus especially on what strategies our perinatal units are using to meet the increasing patient load and provide quality care. CONTINUED ON ATTACHMENT: X YES SIG ATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OOJJJF BOARD COMMITTEE JAPPROVE OTHER SIGNATU ACTION OF BOARD ON I �( ' / 7 APPROVE AS RECOMMENDED_ L OTHER AC>P1ff-hJ 9tAh4 AlrAC40!—D VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN. ABSENT: ABSTAIN: n ATTESTED I�Y I I La DA/�TVVA,CLERK OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR Contact Person: William Walker CC: Health Services Department County Administrator's Office BY: ,DEPUTY ADDENDUM December 16,2008,Agenda Item DA On this day, the Board of Supervisors considered accepting a report from the Health Services Director on the challenges facing Contra Costa Regional Medical Center (CCRMC) Perinatal Department and the strategies being used to enhance quality of care and improve patient flow. William Walker, M.D., Health Services Director, introduced the item and members from the Perinatal Department provided a PowerPoint slide presentation (attached). Supervisor Gioia commented that today's presentation exemplified the great staff at CCRMC and he noted that at present, one-fourth of the births in Contra Costa are occurring at CCRMC in Martinez. He said it will be important to find ways to continue to provide quality of care with an increasing number of births. Supervisor Bonilla said she supported encouraging natural births in order to reduce the number of epidurals administered. She also said she would be interested in data on anticipated birth cycles and the maximum hospital capacity. Supervisor Gioia suggested looking at the issue of non-profit hospitals that do have some responsibility to provide services they may not currently be providing. By a unanimous vote of 5-0 with none absent, the Board of Supervisors took the following actions: REQUESTED regular consent calendar reports to the Board on data received from the Joint Medical conferences INSUPING C,''UALITf'Y PERINATAL. CARE 16 3 A ' CHALLENGING "IL`siON OUR COMMITMENT TO OUR PERINA TA PA TIENTS Lz *We are committed to providing high re/iabi/itycore to all - patients within our scope of practice. This care is well ij coordinated by a multidisciplinary ;) team that values family-centered .I' care. +We ore committed to providing a ;,.'` teaching environment for family practice residents and nursing ��..t students. PERINATAL CARE IS UNIQUE £PRACTICE"' FEDIAIRICs` '�� Ia6T PARNM ' „w'iw NUR6INfi t !� � L4WR AND �• � �� 'De3VEM . 1 � ,y COMPREHENSIVE CARE OF THE / PREGNANT WOMAN Y h*Nuri<ry �YuwarnMr., ' • !L'AIAL1�NOa.4 i HOW DO WE DELIVER AT cAa To OUR PA TIENTS.2 Our recent quality improvement projects are 'k. leading us to high reliability care. Perinatal Safety Committee Multidisciplinary Committee formed May 2005 ' Institute for Health Improvement Participation ,y +.Promote standardized processes and procedures that are evidenced based Decrease litigation by a reduction in adverse events and by promotion of standardized practice guidelines • ;* Empower every member of the team to intervene ,j.''ni •when care maybe unsafe Increased resident supervision s C SAFER MEDICA TION ADMINISTRA TION *Nationally,50%of cases with perinatal harm involved the use of pitocin. *By increasing the safety of our use of a, pitocin we are decreasing the chances of harm Standardization of all aspects of pitocin administration ;+ *Tracking our progress on this with data collection. ' -.. `{ Conga Costa Regional Medcal CerAelB Hearth Centers p� Augnema6on Bwdle Compliance a wm `v Pm Ye4blbne,W wNmp�anAMa n�f Yi a a '1 I ........... ...__ _....... _- .. -----------... ....W.Om SAFER CARE IN AN EMERGENCY THROU6H PRACTICE SIMUl.WZGN T. * Improve team work A and communication t" * Practice emergency 4- procedures on mannequins 100 team members participated YY r THROU6HIMPROVED RESPONSE. TIME 08 RESPONSETC . -A C Ar'-ly r, *Research shows if tasks happen simultaneously in a coordinated fashion in an emergency there are better outcomes. With a universal paging system we can ...assemble a team in less than 5 p x ;minufes. SAFER CARE OF THE FETUS THROUGH IWROt/ED FETAL MONITORING b °""" �.;�.:�, """""° ■Interdisciplinary fetal monitoring classes - +Physician notification a m� guidelines s Monthly strip review '''.e...._. with physician and `l = nurses *Adopted National :�.. _.._ standards for X µ terminology n i r ' u r' RPU XPCNDy, INTRD' CINARy y HU p pLEy, DEBRIEIN i � k BED5TDE RoUND5 f p Y x tt r EXECUTIVE WALKING t y ROUNDS Mohthly visits from r Lisa Massarweh, T CNO and Jeff k i Smith, CEO to tl Perinatal to talk r with staff about the workings of the unit. SAFER AND HEAL TRIER > ` NEWRORNS `" 4THE BREASTFEENNG INITIATIVE arTnerrw Yh� LwZ Pubtic Nmlthi;: - miMdaaplry. CLAM[ Y isak fare x.}- Br ro ming Improvement J Initial ve Edumhm of nic. f< ` Inc"reascd 'r&�aitlly s V IMPROVED ACCESS TO PRENA TA L: CARE RECORDS - f,4' *Faxing of Prenatal Records from 'v multiple outlying clinics to labor and delivery(This is a work around) *Most ultrasound reports are now `'ty. ,__, immediately available by computer F� *All specialty visits are now dictated and on the computer : : *Behavioral Care Plan Increased Resident r*7111 Supervision and Instruction % Dcily teaching Supervision a`all a '<" sessions 3 t'triage patients Mandatory fetal Supervision of all monitoring course deliveries x' •• Decreased multi- Increased tasking by limiting Attending ;s responsibilities to participation in ' labor and delivery direct rare and �.•;,w ,., Co mmunication j $ with the patients SAFER CARE FOR OUR 6ROWIN6 POPULA TION OF DIABETIC r PATIENTS m w . d 3 '. ,�`•. *SUCCESS . . social worken '- I'CSOUI'CCS '' CONTINUED PLANS FOR IMPROVIN6 SAFETY Ja .` *Improved safety with vacuum E assisted deliveries ` #Lniproved safety in caring for. :.tO;,4'P- patients undergoing a.vaainal birth aiter:a previous cesarean section. *Improved care of inf ants born.too " n. early, fi Providing Safe, Patient and Community Centered Care with our Increasing Patient Volume w,l / t y l OUR LM/ COORDIA/ATIN6 WITH MULTIPLE COMMUNITY CLINICS •Piewtel5ervir%s in Medmez Bmntwootl Baypoint^.}. � � Plnatiuig Concortl"Rlchrnond antl Nortli,Rlcllmond Pntladi' - 1 X Le ClmKa Pal fined Parenthood }t , s In Con�Clan�Paeburg �Prenatal Programs x, � '^t 7i Total Live Births to#of Physician Staff lk. , -- ,.. 3 = ---- ---y ------_:::_ _---- a;'.L�fi-*ooh----:[_:__:- fi -- __ _-------- ---------- _ _ - . 5s..^i�.y'r tar•-+___ r � -- t x ; g 1P a I] f] g 11 r e II law iwu xcoo 1oc1'xcor zam as mm zme xor xace ?. S i. �,.. _roar»aiu. k1^ omnnna�m f r' Ai Total Live Births to#of Nursing Staff zxw 21N. -- - -- -- - -- - - --- -- - - ;. 1m :.. .Via.., ®e se xiJ p x 1891 IYBI AO IIDt ]¢R X61 NII AY 3tltl DJ] ID% *early C/Sections to#of Nursin Staff `i - m j a -, i o y 3 'w gip, 4211 t�'yg wa 1'4 "yKYjs+im SQS @Y Ql e ,n{ lane . . . 1Cm EN ]mx ]mJ NO N11 VG YEARLY NEONA TAL TRANSFERS TO #OF NURSING STAFF �r ' t b - as a � ,ea ,r moa mo. >� mm zod mm mm M1 P HEALTHY.START INTAKES TO NUMBER OF STAFF a. 15 m a 1� ___ _ a a ' 5 1101 r nm ____________ ----------------------- ____ .. in „w .n ' P '{ ]CO +f 1011 MAt 3aR w, MYM MVi M MI91 'IDH +� �Neily iGb CpHN OiM COM'O��A6M14 J y PERINATAL- IN 1998 Decreased ability 7 � to apply safe y cam No Safety rdf A,.77 Framework No Communication i Adequate tools - Staffing- - - Less Rcsident ti'AdequateSpau Supervision -,Sim ler "�He la th<ar< system 1 PERINATAL IN 2008 i' ��4i�-,.r �T —._– Increosed Volume t Lrcreased Acuity . rLy Space Canetrmnts r y Staffing Constraint, Work Araunds Inability Dadlwtuan to . �,s¢ter care w + masim eto implemeudation of Natl...I - safety...res Movement to due to tack of ,';:.. ;' fe - - meeting or project :cw. la°_ty time. Siandardlzed �grotorols - - ,7 �CommmicoHan taels - OUR CURRENT USE OF { "` OUR SPACE w. Y a d' WHAT TYPE OF <s, CHANGES z ,ARE NEEDED TO Y BRING US - „ a-;""" BACK INTO BALANCE? CHANGES ALREA©YIN PROGRESS: . *,Move anteoertum testing center to the r„ `< , outpotienI'area in Building one *Plan for CCHP advice nurse onsa,,er triage ., d -calls novv'going to labor and delivery Assign a trincie nurse and a.physician to 1` expedite the evaluation and discharge or . �. admission of triage patients l. * Transfer pediatric nursing staff-to postpartum and nursery and create a ._ , 'transition nurse position. IK �. CHANGES WE HA VE BEGUN TO t LAY THE GROUND WORK FOR: Perform elective cesarean deliveries with separate staff on a regular f f' schedule off the unit. Have this family,mother, father and baby recover together. *5tructural changes to the nursery to _ make the space more functional MOSTIDEAL CHANGES d — ''. * Use a consultant to evaluate patient census, ` mandated patient/nurse ratios and patient flow J' and advise us on safe staffing patterns. •rg * Use the consultant to evaluate patient census and flow and advise an a cost effective and safe 24 hour physician staffing structure. * Have perinatal take over the entire fifth floor of the hospital creating additional labor rooms and - - �1j �- single,postpartum rooms YA ItY MOSTIDEAL CHANGES: Increase ancillary staff to keep the nurse at the `' - bedside. - .- �'+ *Remove direct patient care responsibilities.from a' charge nurse duties ` ' + Expand and adequately staff the Healthy Start. f Program in order to provide critical linkage and follow up for.the pregnant woman. *Improve prenatal services to provide efficient, v, patient centered,culturally sensitive care across ,. . ..� _ :the continuum. OUR COMMITMENT TO OUR PERINA TA PA TIENTS We are committed to providing • 3€r high reliability care to all patients within our scope of practice. This care is well coordinated by a multidisciplinary team that values family-centered care. * We are committed to providing a teaching environment for family practice residents and nursing students. Thank you for assisting us with meeting our }art�ti;.d, challenges Health Services Emergency Department Challenges Page 2 of 2 1. We want to reiterate a point made in a recent presentation to the Board of Supervisors about the Emergency Department: as the medical providers of last resort, we are becoming the only option for both insured as well as uninsured people who are unable to get care elsewhere. This remains true of the perinatal unit as well. 2. The current physical "foot print" of the labor, delivery, recovery, nursery, and post partum units was constructed for an average delivery rate of 130 births/month. Every year, for the past seven fiscal years, the birth rate has steadily risen with the sharpest peak in the past two years. 3. CCRMC is assuming the intrapartum and post partum care of mothers from not only our Health Centers, Planned Parenthood and La Clinica, but has recently assumed care of mothers from the Brookside Health Center as well; this has resulted in an increase of approximately 45 patients per month. 4. In addition to a rising census, the acuity of the perinatal patients has increased. Our patients have more medical and obstetrical complications than several years ago. This has required more cesarean births. Patients having cesarean sections require more nursing care hours and have a longer length of stay. 5. With this increasing volume, clinical leaders have taken steps to promote efficiency and improve the safety of the care of the perinatal patients: a. Simulation training: An important training exercise that helped the clinical team identify areas for improvement in communication and functional improvements to the perinatal operating room. b. Baby Friendly Status: A program to improve the rate of mothers at CCRMC who choose to breast feed their babies. Studies have shown that improved breast feeding rates decrease the rate of childhood obesity, among other benefits. c. New OB response team: This has decreased the health care team's response time to emergency cesarean section. We can now assemble the entire health care team for delivery in less than 5 minutes. d. Pitocin Safety bundle: Improved the safety of the administration of this high alert medication. e. Improved fetal monitoring bundle: Improved clinical providers'and nurses' ability to recognize and respond to abnormal fetal heart rate tracings. Improved the communication between providers and nurses with regards to fetal heart rate monitoring. f. Improved communications: instituted interdisciplinary rounds, huddles, bedside rounds and debriefings in order to improve communication between all members of the health care team. Communication errors are a root cause of approximately 90% of medical errors. By improving our communication we decrease our medical errors. g. Continued Safety: The perinatal unit has a continuous plan for improving our safety. Our future goals include improved safety with the use of vacuum assisted deliveries, vaginal birth after cesarean section, and care of babies born too early.