Spitzer datawarehouse

The Pediatrix Clinical DataWarehouse and
The 100,000 Babies Campaign—Tools for
Quality Improvement in Neonatal Medicine

NICU
Peri Practice
PICU
Ped Hospitalists
Ped Cardio Practice
Anesthesia Practice
Regional Office
Headquarters
09.20.09
Southern CA
16 NICUs, 2 PICUs 2
OBX, 3 Hosp. Prgm.
Denver
10 NICUs, 1 OBX, 3 PICUs
1 Cardi & 2 Hosp. Prog.
South FL
7 NICUs, 2 PICUs
4 Cardi & 1 Hosp. Prog.
Puerto Rico
9 NICUs & 5 PICUs
Dallas-Ft. Worth
27 NICUs, 2 Cardi
3 OBX & 3 Hosp. Prog.
Houston
11 NICUs & 1 OBX
Austin
10 NICUs, 1 Cardi
1 OBX & 2 Hosp. Prog.
San Antonio
9 NICUs, 1 OBX
& 1 Cardi
El Paso
5 NICUs
& 1 CardiPhoenix
4 NICUs, 1 Cardi
& 1 OBX
Oklahoma City
8 NICUs
Seattle/Tacoma
14 NICUs, 1 Cardi
1 PICU & 3 OBX
Chattanooga
3 NICUs
Las Vegas
6 NICUs, 2 PICUs,
& 2 Hosp. Prgm.
San Jose
3 NICUs, 1 OBX, 1 PICU
& 1 Hosp. Prog.
Tampa
6 NICUs, 1 Cardi
& 1 OBX
Kansas City
3 NICUs & 1 OBX
McAllen-Harlingen
6 NICUs
Atlanta
9 NICUs, 1 PICU
4 OBX & 1 Anesth Pr.
Charlotte
4 NICUs
Columbia
3 NICUs
Dayton
4 NICUs
Wash. DC
7 NICUs
1 Cardi &
1 Anesth Pr.
Greenville
3 NICUs
Knoxville
4 NICUs
Central FL
6 NICUs & 1 Cardi
San Francisco
4 NICUs
Akron
3 NICUs
Cleveland
3 NICUs
Nashville
9 NICUs
Ped ER

3
YTD 2010
 > 275 Hospital NICUs
 ADC 4,500-4,600
 > 90,000 NICU admissions annually
 Covering approximately 22% NICU patients nationally
 EHR (BabySteps) present in approximately 90% of the NICUs
 Active participation of NICUs in our CQI projects and outcomes
metrics

4
YTD 2010
 34 States – 221 core practices
 137 Neonatology practices
 22 MFM practices
 18 Cardiology practices
 16 PICU practices
 10 Peds Hospitalists
 7 Peds Services
 5 OB Hospitalists
 6 Other specialty services

CENTER FOR RESEARCH, EDUCATION, AND QUALITY (CREQ) HELPS PEDIATRIX
“TAKE GREAT CARE OF THE PATIENT”
Discover Understand Teach
Empowered
providers
Educated
parents
Better care
Implement

 Better patient care
 You are probably not as good as you think you are
 ABP Maintenance of Certification Part IV
 Need to demonstrate active participation in CQI every
5 years
▪ Part 1 – Licensure
▪ Part 2 – Evidence of Life Long Learning
▪ Part 3 – Exam (every 10 years)
 Research outcomes—new observations

Pediatrix Continuous Quality Improvement
A Model for Improving Neonatal Intensive Care
Implement

Implement
Bedside Care BabySteps Clinical Data Warehouse
QualitySteps
Implement
CQI Projects
Improved Outcomes

The Pediatrix model for
continuous quality
improvement starts at
the bedside
Physicians and
advanced practice
nurses provide bedside
care to thousands of
babies every day

As daily care is provided, clinical data is entered
into the BabySteps clinical documentation
system to generate clinical notes
Key data is immediately available within the
system to guide clinical decision making:
• Growth charts, medication days, duration of
vascular catheters and endotracheal tubes, etc.
Most importantly, these multiple data points are automatically
extracted into the Clinical Data Warehouse, providing detailed
information on outcomes and key processes in that neonatal
intensive care unit

Clinical Data Warehouse (CDW) is the largest
known database for neonatal medicine. More
than 700,000 patients and 13,000,000 patient
days currently exist in the CDW
More than 20% of the babies receiving NICU
care in the US are included in the CDW
Prior to extraction into the CDW, the clinical data undergoes an extensive
de-identification and validation process to establish compliance with
Common Rule and HIPAA regulations and ascertain data reliability
Personal identifiers are removed from the data, but the NICU location is
retained to enable each practice to view it’s own data and compare and
benchmark their results against the Pediatrix Network

How does data get from BabySteps to the CDW??
Clinical data
(medications, procedures,
diagnoses, cultures, lab
results, etc) is entered
into BabySteps
Key fields (563 data
points) are extracted and
imported into the CDW
database to generate
specific clinical reports

How does the CDW work?
Multiple clinical
reports are available,
including mortality and
many morbidities.
Numerous reports are
available on nutrition,
medication use,
ventilator days, central
catheter use and
much more
Clinical reports can be filtered in various ways,
such as by birth weight, gestational age,
inborn/outborn status, region, and NICU volume

 Clinical DataWarehouse evolution
 Most detailed database for neonatal medicine
 More than 700,000 pts. and 13,000,000 pt. days
 Forms the basis for many CQI projects at both corporate
and local levels
 Queried for information by NIH, FDA, NICHD Neonatal
Network
 Recognized by AAP and ABP for its scope
▪ Pediatrix selected as charter member ofAAP/ABP Quality
Improvement Committee
▪ CDW and QualitySteps will serve as basis for Board Maintenance
ofCertification Part IV for Pediatrix MDs (“Portfolio Sponsor”) of
ABP – first (and only) group to date granted this privilege

CDW Report Example: Breast Milk in the First Week
Breast Milk in the First Week
Gestation: All; Birth Weight: 501 - 1500g
Admit Group: Inborn; Network: High Volume PDX Sites
Report Name:
Filters:
Pediatrix Network
33rd-66th Percentile
(blue area)
Specific NICU’s
Breast Milk Rate
(green line)

QualitySteps: CQI Project Documentation Tool
Data from the CDW is
used to determine what
areas are in need of
improvement
QualitySteps provides
resources and guidance
for the development and
implementation of CQI
projects
QualitySteps serves as a CQI project management tool. Project goals, teams,
progress notes, additional data, and more are collected and stored on the
system, enabling multidisciplinary teams to collaborate efficiently on projects

 The Run Chart will have all the data points you documented
along with annotations.

 By programming an
appropriate series of
questions, QualitySteps
has the flexibility to be
used in any specialty of
medicine
 Currently developing
anesthesiology module
as seen here

Implementing CQI Projects
During project
implementation, data from
BabySteps continuously
feeds into the CDW, with a
one week time lag
This provides the essential
data feedback needed for
ongoing improvement
Implement

Improved Outcomes
The information that begins
at the bedside is
transformed into in
improvements that come
back to the bedside
The end result: improved
patient outcomes

 Activity Reports:Types of discharges (home, transfer, in-hospital, etc.); Admissions
by GA; Admissions by BW; Length of stay; Average daily census;Type of delivery
 Morbidity and Mortality Reports: Mortality; Survival, BPD at 28 days of life, BPD at
36 weeks’ gestational age, IVH, Late-onset sepsis, NEC, PDA, PVL, RDS and
surfactant use, ROP, Severe IVH, Severe ROP, Pneumothorax; Catheter-related
blood stream infection (rate/1000d)
 Management Reports: Maximal ventilator support, Median ventilator Days,
Temperature from DR to NICU,Types of lines inserted and duration of use, Median
daily weight gain during the first 28 days; Hepatitis B immunization rates; Infants
breast feeding during hospitalization; Per cent of infants breast feeding at
discharge; Breast milk in the first week of life;TPN Use Day 1; DR surfactant use;
Bilirubin reports; Discharge Needs (oxygen, monitoring, NG feeding)
 Infection reports: Percent of NICU admissions treated with antibiotics; Median
days of antibiotic therapy with negative cultures; Use of cefotaxime; Percent of
patients treated without cultures; Nosocomial/ line sepsis—infections/ 1000
catheter days
 Medication reports: All common medications in the NICU, frequency of use
 Summary Dashboard Report and NetworkTrends Reports
 PracticeTrend Report

o Dashboard report for
assessing the
outcomes of any
NICU during a
defined period of
time.
o Performance
Compared to 33-66%
for PDX Medical
Group (blue bar)

Examples of Improved Outcomes: Sample Pediatrix
Network Trends
0.0
5.0
10.0
15.0
2004200520062007 200820092010
33
50
66 0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
33
50
66
35.50
36.00
36.50
37.00
33
50
66
0.0%
20.0%
40.0%
60.0%
80.0%
33
50
66
Catheter Associated Infections Chronic Lung Disease
Admission Temperatures Breast Milk Use
Data show for babies 501-1500 gms, “33, 50, 66” represent the Pediatrix Network percentiles

Report still in
validation stage,
hospital names
covered until
data can be
verified
Lowest 10 performers
Copyright , MEDNAX PSO 2010
Top 10 performers

 Denial: These data can’t be right!
 Anger: Why are they picking on me? Don’t I have enough
to do already?
 Bargaining: My patients must be sicker than everyone
else’s, my NICU is different, I don’t agree with those data
definitions, etc.
 Depression: I can’t do anything about it anyway….
 Acceptance: OK…what can I do to improve the outcomes
in my NICU?
Courtesy of Dan Ellsbury, MD, Pediatrix Medical Group

 CQI Quality Summits (3x annually)
 Three day CQI experience
▪ Led by Dan Ellsbury, MD, and Robert Ursprung, MD
▪ One session held in conjunction with NEO Conference
(Feb.)
▪ Upcoming Meeting in Dallas (Nov.)
 PDX physicians expected to attend one session
every two years
 CQI efforts underway in MFM, Pediatric
Cardiology,Anesthesiology
▪ Anesthesiology practices to partner in this process
using QualitySteps program

No other group has more than 4 approved projects on ABP web site

Comprehensive Oxygen Management
for the Prevention of ROP
Evidence-Based Principles of ROP Toolkit:
•Avoid hyperoxia
•Avoid large oxygen saturation fluctuations
•Educate all NICU staff and parents about ROP
•Provide mechanisms to assess actual implementation
“COMP-ROP”

5.8%
6.4%
3.5%
Toolkit introduced

Common use of antibiotics:
Infant with suspected sepsis
(Most common NICU admission)
Hypothesis:
Ampicillin-Gentamicin and
Ampicillin-Cefotaxime are
equivalent approaches…
or are they?
Evaluated > 128,000 infants
Clark et al., Pediatrics 2006; 117:67

23 to 26 27 to 30 31 to 34 35 to 38 39 to 42
Adjusted Odds Ratio 1.14554672 1.61184607 1.78188665 1.87900805 1.43224032
0
0.5
1
1.5
2
2.5
AdjustedOdds Ratio
Clark et al., Pediatrics 2006; 117:67
Wks. gestation
N > 128,000
Odds
Ratio

Example: Cefotaxime Use
After dissemination of data showing fungal infection and increased mortality with
cefotaxime use, network use of cefotaxime dropped markedly
Fungal infection
and cefotaxime
Increased mortality

Medication Use, Pediatrix Network
Infants <1000 grams
0
5
10
15
20
25
30
35
40
2003 2004 2005 2006 2007 2008
Cefotaxime
H2-blockers
Metoclopramide
Epo
Spironolactone
Percent of babies
receiving the med

Singh BS, Clark RH,
Powers RJ, and Spitzer AR.
J. Perinatol. 2009; 29:497

 Ibuprofen-Indomethacin Comparison
 Inhaled Nitric Oxide in Premies
 Neonatal Renal Insufficiency
 March 2010 Clinics in Perinatology on
CQI, edited by Ellsbury and Spitzer

Clark RH, et al. J. Perinatol., 2010; 30: 800-804

 Significant numbers of
premature infants have
renal problems in the
neonatal period
 Categorization of these
issues is variable from
NICU to NICU, yet it is very
important to establish clear
criteria for renal failure

Mean LOS decrease of ~2 days
16 d
14 d

 Olsen et al., Pediatrics
2010;125:e214–e224
 Significant Differences
from Lubchenko growth
charts, done in Denver
more than 40 years ago
 Problems: few survivors
<30 weeks gestation,
altitude at Denver
 To be distributed
nationally by Abbott
Nutrition

Pediatrics 2010;125:e214–e224

Dan Ellsbury MD
Director, Continuous Quality Improvement
Center for Research and Education
Pediatrix Medical Group

 Perform an innovative, comprehensive system
redesign of critical practices and procedures in
neonatal intensive care
 Over a two year period, redesign the system of
care provided to 100,000 NICU babies within
Pediatrix Medical Group
 Build a reusable national infrastructure for
continuous quality improvement in neonatal
intensive care
 Extend campaign to include academic centers

 The problem is not the clinician, it is the complex
system in which the clinician practices (Institute of
Medicine)
 The most efficient and productive way to
improve outcomes is by re-engineering care to
produce optimal outcomes
 Imploring clinicians to “try harder” is not productive: we must fix the system,
not fight the system
 Re-engineering requires accurate, detailed data
 BabySteps DataWarehouse and QualitySteps for data
collection

Enhance Nutrition:
 Maximize breast milk use, use a standardized feeding protocol, and provide
early protein
Improve Medication Use:
 Optimize use of antenatal steroids, caffeine, and surfactant. Optimize
antibiotic choice and exposure, decrease cephalosporin use, H-2 blocker
use, and postnatal steroid use, standardize oxygen management
Minimize MechanicalVentilation:
 Minimize ventilator duration, Optimize nasal CPAP technique
Optimize Central Line Use:
 Standardized central line insertion process, standardized central line
maintenance process, and minimize central line duration
Reduce Suboptimal AdmissionTemperatures:
 Standardize initial thermal management

Catheter Associated Bloodstream Infection (CABSI)
501-1500 gm, all PDX sites.
2010 is a partial year
CABSI Toolkit
100000 Babies

Breast Milk in the First Week

Admit Temperature (Inborns)

CLD at 28 Days

0
5
10
15
20
25
2004 2005 2006 2007 2008 2009 2010
Cefotaxime
Metoclopramide
H2 Blockers
Postnatal Steroids

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