The following story, which recently appeared in Texas Hospitals magazine, spotlights Ascension Seton and University Medical Center of El Paso for leadership in delivering healthy babies while cutting NICU costs. If you’re looking for expert guidance on preparing for birth and taking care of babies, go to the Ascension Seton Baby Talk website.
By Carolyn Jones
AUSTIN, Texas – (Dec. 28, 2012) – Every week, hundreds of babies are born too soon in Texas. They spend the first weeks of their lives in neonatal intensive care units, lying in an incubator instead of their parents’ arms.
Some babies will be the most high-risk, medically complex and expensive patients a hospital will treat. Tragically, not all of them will make it home; prematurity is the leading cause of neonatal death.
Those who do survive may face longer-term problems such as cerebral palsy, intellectual disabilities, visual and hearing impairments and learning difficulties. The Institute of Medicine estimates the rate of pre-term births in the United States costs society at least $26 billion a year.
The emotional cost for families dwarfs that. Hospitals also bear the burden because these tiny patients drive up huge health care expenses before they take their first trip home. While only 6 percent of Texas Medicaid-funded newborns stay in a NICU, those infants consume 66 percent of a hospital’s newborn care expenditure.
This creates a steep cost curve for obstetrical units to manage, a curve that only gets steeper as the cost of infant care grows at more than double the rate of maternal hospital care.
This situation needn’t be inevitable, however. Texas hospitals have made great advances in achieving high-quality, safe and cost-effective perinatal care – care that will help reduce preterm births, improve outcomes for newborns and get those babies home to their cribs as soon as possible.
Eliminating Elective Early Deliveries
Despite strong evidence that critical fetal growth occurs in the last few weeks of pregnancy, elective early deliveries are on the rise. Yet countering local physician practice and resisting patients wanting to schedule the end of their pregnancies is like trying to turn a ship in a tailwind.
It can be done, however. Less than two years ago, University Medical Center of El Paso found that 27 percent of its babies had been born via an elective induction or cesarean section before 39 weeks gestation. Hospital leaders were aware of research showing the implications of preterm birth: increased rates of NICU admissions, respiratory distress syndrome and feeding problems, among other complications. More concretely, they could see these risks becoming reality in their own labor and delivery unit.
In January 2011, UMC joined a national collaboration sponsored by the March of Dimes to address the problem of medically unnecessary deliveries before 39 weeks gestational age. Each hospital in the 26-strong collaboration tested a toolkit designed to help bring down elective preterm deliveries. This evidence-based toolkit, titled Elimination of Non-medically Indicated (Elective) Deliveries before 39 Weeks Gestational Age, lays out the case for reducing elective early deliveries and spells out the ways in which hospitals can make concrete change. Each month, the March of Dimes hosted a conference call with all 26 participants to discuss their progress.
“I was surprised by the stark similarities in our experiences,” said Annie Perez, Ph.D., UMC director of women’s health and prenatal services. “We all had similar concerns and shared the same obstacles in implementing the program.”
The toolkit team collected baseline data, hosted a physician grand round, standardized the way in which pregnancies were dated, and then changed hospital policies. Six months after the start of the pilot, hospital leaders implemented a hard stop on elective inductions.
“That made a big difference in compliance among the last few holdout physicians,” Perez said.
In October 2011, the Texas Medicaid program stopped reimbursing hospitals for both the physician delivery fee and the hospital newborn care costs of non-medically indicated deliveries prior to 39 weeks gestation. UMC’s implementation of the toolkit gave the hospital the momentum it needed to comply with the new Medicaid guidelines.
Today, the hospital boasts a 0 percent rate for non-medically indicated inductions and C-sections before the 39th week of gestation. Given that UMC also delivers one-third of all babies born in El Paso, a success rate like this promises to have a sweeping and long-lasting effect on the community.
Sustaining Safety Success
Inspired by the Institute of Medicine’s transformational approach to patient safety, Ascension Seton resolved to eliminate preventable perinatal deaths. The Central Texas-based system began by examining the causes of birth trauma that, though relatively rare (Ascension Seton’s rate at the time was 0.3 percent), can have devastating outcomes.
When looking at the data, Ascension Seton’s perinatal safety team found that many of the babies suffering trauma had been induced before 39 weeks. The team created report cards for each physician showing the clinical variation in induction rates and how much of the resultant birth trauma could be attributed to premature delivery.
Within months, hospital leaders saw a dramatic reduction in iatrogenic prematurity rates, a 35 percent reduction in NICU admissions and a 93 percent drop in the number of babies suffering birth trauma. The severity of birth trauma dropped, too, with a neonate’s average length of stay in the NICU dropping from 16 days to three days.
Emboldened by their success, team members broadened their scope. They standardized protocols for the appropriate use of vacuum and forceps during delivery. They made order sets and documentation forms uniform across the system. Delegations visited high-performing sites to observe them in action. Health teams learned how to deal with complex but rare incidents in simulated environments.
Finally, all sites adopted a uniform process for succinct communication in an emergency. Today, nine years after embarking on the project, Ascension Seton has won national and international awards for its results – and sustained its success.
“Our project is as close to anything I’ve seen to being hard-wired into our DNA,” said Dr. Frank Mazza, associate chief medical officer of the Ascension Seton and the executive in charge of patient safety.
He added that, although Ascension Seton’s perinatal safety culture has changed, the system can’t afford to be complacent. The administration still must recruit charismatic leaders, invest in an infrastructure that supports highly reliable teams and enable rich information collection to give staff insight into what they do.
“There is nothing better than good outcomes data to motivate health professionals to do the right thing,” said Mazza. Using the threat of peer review to nudge doctors away from business as usual also has been effective, he noted.
He was more ambivalent about the value of hard and fast rules, like Texas Medicaid’s recent stop on reimbursing medically unnecessary early inductions.
“It’s a mixed blessing because the 39-week rule now is in effect across Texas, but physicians are very drawn to data about best practices anyway,” Mazza said.
Benchmarking physicians against each other, Mazza thought, was a better way to tap into their intrinsic desire to be the best. Using clinicians’ thirst for autonomy as a lever for change and maintaining everyone’s sense of ownership were key to Ascension Seton’s success.
“Our obstetric teams continually strive to do better for moms and their babies,” Mazza said, “because they know that the perinatal safety project belongs to them.”