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The Florida Journey Adapting FIMR to Address Maternal Mortality Karen R. Coon, ARNP, MSN Florida Department of Health Division of Community Health Promotion Infant, Maternal & Reproductive Health "You can't really understand another person's experience until you've walked a mile in their shoes." . The Florida Journey: Adapting FIMR to Address Maternal Mortality Learning Objectives: The goals of my presentation:  To assist other states in understanding the processes involved in adapting of FIMR to Maternal Mortality Review / PAMR.  Provide ideas for other states to accomplish MMR. The Florida Journey: Adapting FIMR to Address Maternal Mortality Early Beginnings  In 1993, Florida was included in national initiative. The first Florida FIMR project was established in Broward County as one of 12 projects funded nationwide by ACOG.  That same year the state of Florida provided funding for approximately 19 FIMR community projects around the state. The Florida Journey: Adapting FIMR to Address Maternal Mortality Early Beginnings  A statewide training coordinator was hired (through grant funding) for the purpose of:  Establishing a network of FIMR projects  Providing training on the FIMR model  Providing technical assistance with abstracting and development of case reviews  The Florida FIMR projects utilized the standard abstraction forms and review process developed by ACOG and NFIMR. The Florida Journey: Adapting FIMR to Address Maternal Mortality  The establishment of statewide FIMR projects increased awareness of the need for continual quality improvement initiatives.  This commitment to a strong community based system of review laid the groundwork for the expansion into the review of maternal mortality. A historical / national perspective…  In 1986, CDC began raising awareness of the potential for under-reporting of maternal deaths  In the early 1990's a cluster of maternal deaths in a single Florida county caught the attention of the public health officials.  The state of Florida re-examined their MMR data from 1993-1995 utilizing an enhanced data linkage system and confirmed the significant under-reporting of maternal deaths through the standard system utilized by Vital Statistics hing to Maternal Mortality Review  In 1996, the Florida Dept. of Health formed an Advisory Council to conceptualize a plan for systematically reviewing maternal deaths.  Over a period of 6 months Florida's Pregnancy- Associated Mortality Review (PAMR) was developed.  The NFIMR model and materials served as the foundation for the PAMR process. To summarize… Reasons for PAMR development  CDC's publications confirming under- reporting of maternal deaths  Questions about changes in health care  Observed cluster of deaths (1999-2002 Florida PAMR Report) Establishing Pregnancy Associated Mortality Review (PAMR)  Many of the founding members associated with development of FIMR also participated in the development of PAMR.  Both FIMR and PAMR are covered under the same statutory authority, confidentiality protocols, and immunity protections.  The PAMR medical record abstractors were hired from the FIMR projects .  RN's with MCH experience Purpose of FIMR vs PAMR The goal is to address factors and issues The goal is to seek to that affect infant elucidate gaps in care, identify systemic service morbidity to empower delivery problems, and recommend areas in enhance services, which linkages between influence policy, and community resources can direct planning efforts be improved to facilitate improvements in the that will ultimately lower mortality rates. Stage I:: Link/find all Maternal Deaths Case Abstraction  Statewide review of all maternal deaths.  FIMR abstractors are hired to review selected possible PAMR cases/records in their areas.  As with FIMR, abstraction forms capture information from the medical and social history, prenatal, labor and delivery, Healthy Start records, Medical Examiner, and law enforcement reports. Stage II: Case Review  De-identified summaries of the cases are reviewed by team.  The team collaborates to identify trends and issues and to formulate recommendations for improvements to the system of care for women. Key question:
"If she had not been pregnant,
would she have died?"
PAMR Team Meetings  Held Quarterly (approx 15 cases/quarter)
In Tallahassee, central location, state
level process
Coordinated at Central Office
Budget overview/funding
IMRH Staff coordinate process
MCH Practice and Analysis Data System
PAMR Team Membership  Physicians
Social Workers
Certified Nurse Midwife
Domestic Violence Advocate
OB/GYN Specialists
Forensics professionals
Stage 1: Identification of Pregnancy-Associated Deaths
and Selection of PAMR Cases
Stage 2: The PAMR Process
Increase Awareness – Promote change

 Identify all deaths to women in Florida who have died within one year of termination of pregnancy.  Perform thorough medical record abstraction, in order to obtain details of events and issues leading up to the terminal event.  Perform a multidisciplinary review of cases to gain a holistic understanding of the issues (surrounding the death and life of mother).  Promote the translation of findings and recommendations into quality improvement actions at all levels. PAMR GOALS:
Increase Awareness – Promote change

 Recommend improvements to care at the
individual, provider and system levels with the potential for reducing or preventing future events.  Prioritize the findings and recommendations to guide the development of effective messages.  Disseminate the findings and recommendations to a broad array of individuals and organizations.  Promote the translation of findings and recommendations into quality improvement actions at all levels. Issues Identified
 Nutrition issues  Access to prenatal care (including  Substance use  Absence of prenatal risk  Lack of social support  Problems with housing  Mental Health issues Issues Identified
 Family violence or neglect  Social issues  Access to transportation  Problems with provision or design of  Environmental or occupational  Concerns about family planning access or contraceptive method RECOMMENDATIONS/Results (what we know now) From PAMR Reviews Risk factors significantly associated with pregnancy-related mortality in
1999-2008 were:
• Being obese class III (morbidly obese) (BMI of 40.0 or +) (RR 9.0).
• Not receiving any prenatal care (RR 6.9).
• Having a cesarean delivery (RR 4.6).
• Being 35 years or older (RR 4.1).
• Having less than a high school degree (RR 3.7).
• Black race (RR 3.3).
Another major risk factor or contributor to pregnancy-related mortality is chronic disease including
preexisting hypertension, asthma, heart disease, and other conditions. Of 368 pregnancy-related
deaths, 358 (97%) had information available on medical problems prior to pregnancy, and 153 (43%)
had a history of at least one chronic disease.
RECOMMENDATIONS/ regarding areas for improvement From PAMR Reviews The PAMR process has identified priority areas where improvements can be made to reduce the number of pregnancy-related deaths. The identified issues and recommendations are divided into four improvement categories: 1) clinical factors, 2) system factors 3) death review process factors 4) individual and community factors. Florida PAMR Issues and Recommendations for 58 Pregnancy-Related
Deaths in 2009
After reviewing pregnancy-related deaths, the PAMR committee identifies relevant issues related to the death and makes recommendations in an effort to prevent such future deaths. The following text summarizes the identified issues into four prevention categories: Clinical Factors, System Factors, Individual and Community Factors, and Death Review Factors. CLINICAL FACTORS: Relates to services provided by the entire health care
Issues – A lack of services evidenced by:
1. Incomplete assessment.
2. Inadequate documentation.
3. Lack of coordination and follow-up, particularly of high-risk women.
4. Deficient communication between staff and patients.
5. Lack of association between a change in mental status and deteriorating
medical condition. 6. Prevention-Patient Education (Preconception/Pregnancy/Postpartum) SYSTEM FACTORS: A lack of policies and procedures may lend itself to
deficient quality of care, which potentially can affect a woman's health
1. Barriers to accessing care: lack of insurance, provider shortage,
2. Lack of standardized policies and procedures. INDIVIDUAL/COMMUNITY FACTORS: It has been established that a
woman's health prior to her pregnancy can greatly affect the birth outcome,
as well as the woman's health status after birth. Some deaths may be
associated with a woman's personal decision regarding her health and her
care. It is important that healthcare providers enable women to make
informed decisions.

1. Women presenting in pregnancy with pre-existing medical conditions, such as
hypertension, obesity, diabetes, and asthma. 2. Lack of documentation of patient education and counseling regarding a woman's risk factors.  DEATH REVIEW FACTORS: The PAMR process
relies on information from death certificates and autopsy reports for the identification and evaluation of pregnancy-related deaths. 1. Lack of autopsy on unexplained or inconclusive 2. Death certificates not always completed 3. Missing prenatal records in hospital charts. 2009 RECOMMENDATIONS:
Cause of Death: Hemorrhage

It is important to be prepared for increasing potential for percreta / acreta in patients with previous cesarean deliveries. Be aware of appropriate use and timing for administration of pitocin after delivery. Be aware of and monitor for signs of impending hemorrhage and know the factors that increase a woman's risk for hemorrhage. Maintain high index of suspicion for women of reproductive age presenting with bleeding and pain. Providers who deliver care to women in prison should have protocols to routinely test women routinely for pregnancy and be aware of symptoms of ectopic pregnancy. Educate the community on signs and symptoms that may signify a potential complication in pregnancy and stress the importance of seeking prompt care. Recommend inclusion of potential complications in early pregnancy and warning signs on home pregnancy tests kits. It is important for all hospital facilities to have procedures in place for addressing medical emergencies in obstetric deliveries. Cause of Death: Infection

Monitoring vital signs are extremely important and can be a first indicator of a serious problem. Promote the importance of influenza vaccination for pregnant/postpartum women. Maintain a high index of suspicion of H1N1 in pregnant and postpartum patients even those with subtle respiratory symptoms. Recommend performing PCR testing opposed to rapid Influenza testing (due to decreased sensitivity of rapid test). Provide prompt antiviral treatment for pregnant/postpartum women who present with flulike symptoms. Important to follow up on influenza vaccination for pregnant women who have previously denied vaccination. Increase community awareness of need to access prompt care for influenza symptoms particularly if pregnant. Raise awareness on benefits of immunizations and influenza vaccinations particularly for pregnant/postpartum women with asthma. Increase provider awareness of low tolerability of respiratory conditions in pregnancy. Encourage coordination and collaboration of services for pregnant women with acute and chronic medical conditions. Consider performing electrolyte studies in patients with gastrointestinal conditions. Be alert to a patient's changing mental status due to hypoxia and the effects that hypoxia may have on an individual's ability to make medical decisions and/or sign informed consents. It is important to assess childcare support and resources, for single women with acute/chronic medical conditions. Cause of Death: Thrombotic Embolism

It is important to consider options for thromboembolism prophylaxis. Cause of Death: Hypertensive Disorders

Provider training is important to promote early recognition and treatment of hypertension and preeclampsia. Important to include shortness of breath as a potential warning sign on postpartum discharge instructions.
Cause of Death: Cardiomyopathy

Important to provide focused preconception counseling to patients with a family history of chronic conditions including cardiac problems, hypertension and asthma. Increase community awareness of pregnancy risks when a patient has chronic cardiac
Cause of Death: Other Cardiovascular Problems

It is important to stress to patients the benefits of compliance with medical treatments. Be aware of contraindication of administering brethine in women with cardiac conditions. Provide a thorough cardiac assessment and/or obtain cardiac consult prior to discharge for women with known or suspected cardiac conditions. Patients presenting with unusual or atypical symptoms may require a collaborative assessment by providers. Perform thorough cardiac/lung assessments on initial prenatal visits.
Cause of Death: Other Conditions

All healthcare providers must remember the importance of reviewing vital signs. OB providers need to closely monitor pregnant women with chronic illness and provide referrals to specialist for unstable conditions. Increase provider understanding of the unique needs of a pregnant sickle cell patient. Evaluate the level of care required for women with chronic illness based on the individual and status of their condition. It is important for obstetric providers to evaluate liver function tests on pregnant women presenting with right upper quadrant pain. Be aware of contraceptive benefits/risks associated with chronic conditions. Include Healthy Start staff as part of healthcare team. (Care and services should be coordinated). Pregnant women with uncontrolled seizure disorder should be referred to a neurologist for evaluation and consultation for appropriate medication dosing. Providers should consider performing baseline electrolytes and 24 urine test in women with a history of anemia/bulimia. Healthy Start (HS) may need to find creative ways to engage women with multiple social issues to encourage HS participation.
Other Recommendations

Encourage Medical Examiners to perform autopsy on sudden unexplained deaths even if substance abuse is a factor. It is important for prenatal records to be sent to delivering hospital prior to the 36th week. Consider adding a special category for coding of pregnancy-related deaths due to respiratory infection. The entire medical chart should be made available for medical chart reviewers. Electronic records should include the nursing progress notes. It is important to document the cause of death (COD) completely and correctly on death certificates. In 2009, the pregnancy-related mortality ratio in Florida was 26.2. This was a significant increase from the 2008 pregnancy-related mortality ratio of 14.3 (p= 0.004). The increase in pregnancy-related deaths in 2009 is largely attributed to the deaths due to ectopic pregnancy and influenza. A special analysis is currently underway to examine the increase in the number of deaths due to ectopic pregnancy. It is our hope that recommendations for improvements in providing care will result in a reduction or prevention of pregnancy-related deaths in the future. Postpartum Education Systems need to be in place to assure that the needs
of the postpartum woman are being met.
Women and their families need to know the "danger
 Shortness of breath
 Chest pain
 Palpitations
 Syncope
 Severe or prolonged headache
PAMR Successes (recent)  (include article that references specific abstraction forms) Additional Resources:  The ‘real Florida PAMR expert'  Deborah Burch, R.N., M.S.N., C.P.C.E.
PAMR Coordinator/RN Consultant Infant, Maternal, and Reproductive Health Unit Florida Department of Health Thank you for this opportunity to represent the work of FIMR/PAMR professionals in Florida.  What it takes…  The ability to ‘Walk a Mile'  Leadership, Vision, Action.  Annette Phelps, ARNP, MSN (she is an essential component to development of FIMR/PAMR thus far in Florida and Nationally).  Infrastructure – Healthy Start Coalitions  Boots on the ground  Excellent team of professionals…  diverse, opinionated, motivated, respected by colleagues. Meena Abraham, DrPH, MPH Director of Epidemiology Services Baltimore City Health Department 271 Neighborhood Statistical Areas Statistical Areas Baltimore City
Total Population Below Poverty Level Baltimore City 2008-10 = 73.3 yrs CSA Range = 20 yrs Maryland 2008-10 = 78.7 yrs Priority Areas
1. Promote access to quality health care
2. Be tobacco free
3. Redesign communities to prevent obesity
4. Promote heart health
5. Stop the spread of HIV and other
sexually transmitted infections
6. Recognize and treat mental health care 7. Reduce drug use and alcohol abuse
8. Encourage early detection of cancer
9. Promote healthy children and
10. Create health promoting neighborhoods Communities

e birthsliv 10 000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010  Established in 1993  Tri-Partnership  Baltimore City Health Department  Baltimore City Healthy Start  Maryland State Medical Society  Developed process for conducting FIMR  Engaged health and human service providers and community stakeholders in improving perinatal systems of care • Women have multiple risk factors for poor pregnancy outcome. • Women are not always aware of their risks or ways to reduce them. • Providers and the women they care for are often not aware of support services and community resources. • Opportunities exist to improve services and increase awareness of ways to reduce risks. Fol ow up care for women with poor pregnancy outcome to reduce repeat poor Perinatal infections screening and re- screening for early diagnosis and treatment Family planning and preconception/ inter- conception care for adequate pregnancy interval and improved maternal health Adequate utilization of prenatal care for early and continuous care Perinatal Outcomes I.
Congenital Syphilis II. Fetal Alcohol Spectrum Disorder III. Perinatal HIV Transmission  3rd trimester repeat syphilis screening effective  Syphilis testing at delivery essential for women – With no prenatal care – Not tested at 3rd trimester visit – Infected after 3rd trimester screening – Re-infected after 3rd trimester screening  Opportunity for improved coordination between providers, and between providers & health dept  Need to educate providers regarding health department resources  Case review meetings held annually by Baltimore City FIMR  Case management coordinated between maternal and infant nursing and STD staff  Women with syphilis followed through delivery, not just treatment completion  Congenital syphilis cases are reviewed by all FIMR programs in Maryland "Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus." Report to Congress, 1996  Fetal and Infant Deaths  Alcohol Use – 10%  Cigarette Use/Smoking – 28%  Drug Use – 25%  One or more substance use – 39%  Maryland PRAMS 2001-2003  19% not asked about alcohol use during PNC  50% used alcohol in 3 months before pregnancy Identify opportunities for prevention within existing service systems  Analyzed Baltimore City Healthy Start client enrol ment data and conducted focus groups II. Identify contributors to alcohol use during pregnancy  Conducted case reviews of women with alcohol use during pregnancy in partnership with Sinai Hospital  27% pregnant Healthy Start enrollees used alcohol around conception or while pregnant  Alcohol use occurs with other substance use  Women not routinely screened for alcohol use in pregnancy – more emphasis on illegal drug use  Providers and pregnant women lack awareness of range of effects from alcohol exposure during  Poor relationship with baby's father as stressor  Alcohol use instead of drugs because of Child Protective Services reporting  Identified opportunities for prevention in Healthy Start intake and case management  Educated Healthy Start staff about FASD  Formation of Coalition for FASD Prevention  Maryland Coalition for FASD Prevention  Baltimore-Towson MSA ranked third nationally for rates of adults living with HIV disease (2009)  Majority (80%+) of HIV-exposed births occur in Baltimore City.  17% of post-partum women participating in the Maryland PRAMS survey reported that no healthcare provider had talked with them about HIV during pregnancy (2001-2006) Indicator
2006 2007 2008 2009 2010
HIV-infected women of 6,784 7,144 7,368 7,351 7,216 reproductive age
Reported Perinatal HIV
Confirmed Perinatal HIV
Perinatal HIV Transmission
1.7% 4.0% 2.9% 1.8% 1.6% Source: Enhanced Perinatal Surveil ance, Maryland DHMH  National partners: CDC, ACOG, and  Local partners: Maryland State Medical Society and Sinai Hospital of Baltimore, with participation of Baltimore City FIMR  In 2010, nine cases of perinatal HIV exposure reviewed to examine opportunities for HIV testing and linkage to care for births occurring to HIV positive women in  Inconsistent documentation of patient education  Inconsistent family planning education/counseling  Poor utilization of partner services  Lack of support systems due to HIV/AIDS stigma  Need for intensive case management and support services for engagement in care and treatment adherence  Domestic violence and substance abuse issues  Housing and transportation needs  Baltimore FIMR-HIV Team established  IRB approvals at several hospitals  Included in CDC HIV Prevention FOA  Developing plan to coordinate resources and tasks between city and state for case reporting and to conduct reviews  Sentinel event – "reportable" health outcome  Adapt FIMR process and materials to review the specific sentinel event  Engage key partners – hospitals, programs, service providers, etc. in project  Ensure appropriate expertise available to review case summaries and participate in case review team deliberations  Provide training on FIMR process  Provide training on standards of care for the sentinel event under review



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