Perinatal Hepatitis B Program Evaluation

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Perinatal Hepatitis B Program Evaluation
Department of Public Health
Immunization Program
Pat Hoskins-Saffold, RN, MSN and Steven
Terrell-Perica, MA, MPH, MPA April 23, 2008
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Overview

• Hospital recruitment
• Mailings
• Volunteer recruitment
• Sampling methodology
• Hospital audits
• Feedback sessions
• Results

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Hospital Record Reviews

• Chicago Demographics
• Population size 2,896,016
• Number of birthing hospitals 24
• Number of live births 47,958
• Expected HBsAg births 286
• Identified HBsAg births 141

US Census, 2000 CDC, 2004 CDPH, 2004
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(No Transcript)
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Timeline

• February 1, 2006 - January 15, 2007
• Week 1 Identified delivery hospitals
• Week 2 Mailed CDCs audit packets to 5
  hospitals
• Week 3 Mailed CDPH packets to 24 hospitals
• Week 4 Recruited volunteer auditors and
• scheduled audits
• Week 5 Trained auditors
• Week 6 Hospital audits began

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Timeline-Contd

• March 5 - August 24, 2006
• Hospital audits
• August 1, 2006 - January 5, 2007
• Data entry
• September 26, 2006 - January 15, 2007
• Feedback sessions

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February Week 1

• CDPH clerical staff contacted 24 Chicago
  hospitals
• Determined if Labor Delivery units were still
  open
• Obtain current information on the maternal child
  health (MCH) administrative teams
• Chief Obstetricians and Pediatricians
• Nursing Directors
• Infection Control Practitioners (ICPs)

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February Week 2

• Began CDC Audits
• CDCs National Audit
• Chicago 5 participating hospitals
• 25 mother-baby pairs
• 250 records total
• CDC and CDPH worked together to modify the data
  abstraction tools
• Mailed CDCs packets

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February Week 3

• Mail, e-mail and faxes
• Notifications sent on Official CDPH letterhead
  to 24 ICPs and MCH Nursing Directors
• Letter contents
• CDPH objectives
• Policy survey
• HIPAA disclosure
• Participants roles and expectations during the
  chart audit
• 2005 ACIP Childhood Hepatitis B Recommendations

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February Week 4

• Recruited auditors
• Within CDPH Immunization Program
• 10-12 volunteers
• Began scheduling hospital audits
• CDCs 5 participants
• Chicago participants

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March Week 5

• Training Auditors
• Auditors from various programs within the
  Immunization Division were trained to review and
  abstract information from medical records
• 2 groups
• Morning
• Afternoon
• Several private sessions

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March Week 6

• Began chart audits
• 2-3 days prior to scheduled visits, appointments
  were confirmed for readiness
• Audit dates, times, space locations, parking
  availability, and completion of the Policy
  Surveys
• Policy Surveys were picked up on the day of the
  audit
• Extended deadlines were discussed and arranged
  between nursing administration or their delegates
  and the PHB Coordinator

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Sample

• Sample Selection
• October 2005 to present
• The first 60 pairs, beginning October 1st, 2005
  to current date, audits ended August 2006
• Sample Size
• Maternity wards prepared a delivery list
• Health Information Management (HIM) often pulled
  the charts
• 60 mother-baby medical pairs (120 records per
  hospital)
• 1,453 chart pairs reviewed for 24 birthing
  hospitals

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Data Collection Tool

• Mother datasets
• Demographics
• DOB, Admit date and time, Race/Ethnicity, and
  Insurance information
• Prenatal Testing
• Provider and type
• HBsAg/HIV screening and results, date, and time
• Admission testing
• Provider and type
• HBsAg/HIV screening and results, date, and time

Screening Assessment Tally Sheets (SATS) were
used to collect data.
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Data Collection Tool-Contd

• Infant datasets
• Delivery
• Date/time/weight
• Documentation of maternal HBsAg/HIV results
• Medications
• Documentation of HBV-1 dose and/or HBIG, when
  needed
• Time/date
• Reasons for not Vaccinating
• lt2000gms
• Infant medically unstable
• Mother Refused, etc.

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Audit Time Needed at Hospitals

• Between 2-6 hours, depending on
• Sample Size (i.e., 60 record pairs)
• Number of available auditors
• Appropriateness of the sample
• Correctness of the review period
• Completeness of the sample
• Appropriate mother-baby pairs

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Staffing

• 6 auditors recommended for 60 chart pairs
• 1 auditor per 12 record pairs (Approx. 2-3 hours
  with appropriate sample preparations)
• 1 coordinator
• Assessing the sample to ensure the sample review
  period is correct and mother-baby pairs are
  matching (approx. 15 to 30 minutes).
• Troubleshooting problems, i.e., call medical
  records for mismatched records, locating a
  document, or selecting and replacing pairs
  (approx. 10 to15 minutes).
• Reviewing audit forms for completeness and
  accuracy
• Covering breaks (15 or 30 minute)

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Time Consumers!!!

• Hardcopy files
• Electronic medical records
• Hospitals in transition of changing to an
  electronic medical records system

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Hard Copy Files

• 7-12 minutes per record
• Records may not be matched or in the appropriate
  sequence
• Difficult searching through admission profiles,
  physician orders, laboratory reports, L/D OB
  records, progress notes, etc.
• Concerns with legibility and readability (i.e.,
  Hand written vs. typed documents)
• Medically unstable infant charts contained more
  records and took longer to review

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Electronic Medical Records

• 7-15 minutes (per record)
• Omitted data must be retrieved from hard copy
  files
• Baby not linked to mother via her Medical Record
  Number (MRN)
• Maternal screening results (HBsAg) were not
  always entered on the computer laboratory page
  but was embedded in admission profiles
• Hepatitis B vaccine and HBIG administrations were
  frequently documented in the L/D, OB or nursing
  pages, rather than on the medication page

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Transitioning Hospitals

• 15-30 minutes
• Waiting around
• System clearance
• Access codes
• Records may have been in the data entry process
  
• Could not be located, waiting to be processed
• Critical information often omitted during the
  data entry process

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Feedback to Hospitals

• Time between audits and hospital feedbacks
  averaged 6-7 months
• Audit results were mailed 2-3 weeks prior to
  scheduled feedback sessions
• Permitting hospitals time to review results and
  validate current practices
• Discuss concerns with staff and ancillary teams
  (i.e., CNE, ICPs, QA management, obstetricians,
  pediatricians, and the pharmacists).
• Prepare relevant questions for the feedback
  session

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Feedback Session Invitations

• Invitations mailed to MCH nursing directors
• Invited policy makers
• Chief Obstetricians
• Chief Pediatricians
• OB and L/D Nurse Administrators
• Infection Control Coordinators
• Quality Assurance Managers
• Pharmacists
• Clinical Nurse Educators

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Feedback Session Content

• Results of the chart audit and policy surveys
• Recommendations for the areas needing
  improvements
• Practice issues
• Policy issues
• Access to free vaccine
• Vaccine For Children (VFC) was introduced and
  enrollment encouraged for hospitals not currently
  signed up

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What did CDPH Learn?
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2006-Chart Audit Findings

• Improvements (4 years later)
• 16 increase in prenatal HBsAg screening
  documentation
• 2 increase in screening on admission for women
  with no prenatal screening
• 49 increase in maternal screening results
  documented in infant records
• 22 increase in infants receiving the first dose
  of hepatitis B vaccine before leaving the hospital

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Hospital Policy Survey Results, 2006
N24 hospitals, response rate 100
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Percentage of Infants Receiving Hepatitis B
Vaccine before Discharge
Many hospitals expressed surprise at falling
behind other hospitals in their area. Hospitals
were pleased CDPH did the audit. Hospitals with
low percentages promised to improve perinatal
hepatitis B prevention services.
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Challenges Conducting the Reviews

• Lacked coordinating secondary contacts who
  understood the records review process
• Policy surveys were incomplete
• Inadequate health department staff
• Sample
• Records did not coincide with the record review
  period
• Incomplete documentation
• Illegible documentation
• Unavailable records (i.e., records stored off
  site)