trifecta for change: enhancing antenatal care in ontario tec talk may 27 th, 2013 mari teitelbaum...
TRANSCRIPT
Trifecta for Change: Enhancing Antenatal Care in Ontario
TEC Talk
May 27th, 2013
Mari TeitelbaumMichael Pluscauskas, Sandra Dunn, Tracy Carr, Brenda Bonner, Douglas Cochen
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BORN Ontario
The best possible beginnings for lifelong health
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Facilitation of Care: Access to Information
• Sarah, from Toronto, is having a weekend away with friends, she is 34 weeks pregnant
• Delivers unexpectedly at the London Health Sciences Centre
• How will the delivering obstetrician access her pregnancy health records?
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Pregnancy in Ontario140k women
Midwife Family doctor Community
obstetrician High risk obstetrician Nurse practitioner
LMP
TransmitForms toHospital
Newborn Screeningwithin 48 hrs of
birth
UltrasoundGBS
Screening
Pregnancy Care Reminders
PrenatalEducation
PrenatalScreening
Plan labour& birth
DiabetesScreening
Cared for by: Delivering:
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Antenatal Forms Consistent care Facilitates
communication Gold standard
✗ Up to 10% of the time the forms are missing – early delivery, unexpected location or lost
✗ Practices associated with the pathway change regularly
6Prenatal Genetic Investigations
First Visit(s): Early Prenatal Care
Ultrasound2nd Test: Hb, ABO/Rh, Repeat ABS
Fetal anatomy / morphology
18-20 wks Dating scan 11-14 wks (early if larger than dates) If 2 U/S, use 1st for EDB
IPS FTS NT
MSS
1 hr GCT
CVS / amnio
declined or twins
MSAFP
Diagnostic and Screening Tests
First Visit (s): Identify Risk Factors and Management Plan
Adjust EDB
Pregnancy SummaryLMP:Certain Y/N
Cycle q:Regular Y/N
Contraceptive TypeLast Used
GravidaTermPrematureAbortusesLiving
EDB by dates:
Dating Method: Dates T1 US T2 US ART (e.g. IVF)
Final EDB:
Obstetrical HistoryNo.YearSex M/FGest. Age (weeks)
Birth WeightLength of LabourPlace of BirthType of Delivery
Comments re: pregnancy and birth
Current PregnancyBleeding Y/N Occup / Environ Risks Y/NNausea, vomiting Y/N Dietary restrictions Y/NSmoking___cig/day Y/N Calcium adequate Y/NAlcohol, street drugs Y/N Preconceptual folate Y/N
Infectious DiseaseVaricella Susceptible Y/N
STDs / HSV / BV Y/N
Tuberculosis risk Y/N
Other Y/N
PsychosocialPoor social support Y/N Family violence Y/NRelationship problems Y/N Parenting concerns Y/NEmotional / Depression Y/N Relig. / Cultural issues Y/NSubstance abuse Y/N Family violence Y/N
Family History: At risk population Y/N
SOGC guidelines for screening options
Repeat 1hr GCT in high risk -ve
2 hr GCT
Value 7.8-10.3
Administer Rh-IG
Physical ExaminationHt BMI Wt BPThyroid N / AbN External Genitalia N / AbNChest N / AbN Cervix, vagina N / AbNBreasts N / AbN Uterus N / AbNCardiovascular N / AbN Size: _____ weeksAbdomen N / AbN Adnexae N / AbNVaricosities / Extrm. N / AbN Other N / AbN
High risk1 hr GCT
Second trimester screening (Quad)
10-13+6 wks
0- 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
WEEK
Medical History Genetic HistoryHypertension Y/N Surgery Y/N At risk population Y/NEndocrine Y/N Blood Transfusion Y/N Family History:Urinary tract Y/N Anaesthetic compl. Y/N Developmental delay Y/NCardiac/Pulmonary Y/N Psychiatric Y/N Congenital anomalies Y/N
Liver, hepatitis, GI Y/N Epilepsy / Neurological Y/N Chromosomal disorders Y/N
Gynaecology / Breast Y/N Other Genetic disorders Y/NHem/Immunology Y/N
Subsequent Visits: Ongoing Prenatal Care (see next page)
Soft Markers for Aneuploidy
(see box above)
Establish Risk + Counsel
Previous C-Section: Consider VBAC vs. Repeat C-Section
Laboratory Investigations
Urine C&SHIVHBsAgABO
VDRLSickle CellRh
GC/ChlamydiaRubella ImmuneMCV
Last PapAntibody ScreenHb
Rh -ve
Give Rh-IG (28wks)
If father known, consider Rh test
Father +ve
Glucose intolerance
Follow Canadian Diabetes
Association Guidelines
Diagnose Gestational Diabetes
1 AbN test
Glucose Level AbN
Placental Edge
Overlap
Abnormal Cervical Length Change
Fetal Structural Anomaly
EICF
Soft Markers for Aneuploidy:
establish risk + counsel
Single umbilical
artery
Enlarged cysterna magna
pelvis ≥ 5mm
pyelectasis
pelvis >10mm
3rd trimester scan
Mild ventriculomegaly
Fetal anatomy review
Neonatal u/s
Grade 2, 3 echogenic
bowel
Expert review + further
evaluation
Choroid plexus cysts
35+ or MSS +ve or other soft markersIsolated
+ risk > 1/600
Fetal karyotyping
Expert review
Other
Thickened nuchal fold
Adjust EDB
> 5 days discrepancy with LMP estimate
> 10 days discrepancy with LMP date
Finalize EDB
If 1st visit
14-20+6 wks
AbN level maternal serum marker
SOGC Guidelines Consult OB to establish fetal
surveillance plan
2nd trimester screen for open neural tube defects
3rd Trimester exam and follow-up re:
need for C-Section
Consult with specialist and genetic counselor
Refer to tertiary ultrasound unit
Repeat U/S, consider further imaging
Assess preterm birth risk
Value >10.3
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A1A2 Pilot Project• Launched in 2011, partnership between E-Health Ontario
and BORN, the project had 3 Goals1. Improve practitioner use of high quality clinical practice guidelines (CPGs)
and pathways for antenatal care. (partnership of BORN and Centre for Effective Practice)
2. Automate the flow of data collected on A1/A2 to facilitate care to women who may arrive at an Ontario birthing hospital without an antenatal record
3. Enhance the quality of data available to support QI, system planning and surveillance of pregnancy and birth
• Participants– 1 EMR Vendor (OSCAR)– 4 family health teams– 3 hospitals
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Clinical Input
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EMR Enhancements
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System Enhancements
BORNRegistryBORN
Registry
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System Impact
BORNRegistryBORN
Registry
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Trifecta: Pregnancy Pathway
Value to the provider beyond what is in their
chart
Trusted & Authoritative
Connection to the individual patient – clinical impact and
outcomesPatient information available when and where it
is needed
Clinical pathway embedded in primary care practice
Created by clinicians and subject matter experts using
OMA standard forms
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Pilot Learning
• 573 records in the BORN Information System• Preliminary evaluation findings: ‘Good’*
– Integration & Coordination of Care– Evidence-based Care & Patient Safety– Workflow Efficiency
• Critical Success Factors– Well defined scope– Governance– The Trifecta
• Many new opportunities!
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So many to Thank
• eHealth Ontario
• Participating family health teams
• OSCAR
• Perinatal Services BC
• Centre for Effective Practice
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Questions