Perinatal Hepatitis B Program Evaluation

Department of Public HealthImmunization Program

Pat Hoskins-Saffold, RN, MSN andSteven Terrell-Perica, MA, MPH, MPAApril 23, 2008

Overview

Hospital recruitmentMailingsVolunteer recruitmentSampling methodologyHospital auditsFeedback sessionsResults

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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Chicago Birthing Hospitals

N=24

Timeline

February 1, 2006 - January 15, 2007

Week 1: Identified delivery hospitals

Week 2: Mailed CDC’s 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

Timeline-Cont’d

March 5 - August 24, 2006 Hospital audits

August 1, 2006 - January 5, 2007 Data entry

September 26, 2006 - January 15, 2007 Feedback sessions

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)

February: Week #2

Began CDC Audits

CDC’s 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 CDC’s packets

February: Week #3Mail, e-mail and faxes

Notifications sent on “Official CDPH letterhead” to 24 ICP’s 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

February: Week #4

Recruited auditors: Within CDPH Immunization Program 10-12 volunteers

Began scheduling hospital audits: CDC’s 5 participants Chicago participants

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

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

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

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.

Data Collection Tool-Cont’d

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:• <2000gms• Infant medically unstable• Mother Refused, etc.

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

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)

Time Consumers!!!Hardcopy filesElectronic medical recordsHospitals in transition of changing to an

electronic medical records system

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

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

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

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, ICP’s, QA management, obstetricians, pediatricians, and the pharmacists).

Prepare relevant questions for the feedback session

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

Feedback Session ContentResults of the chart audit and policy

surveysRecommendations 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

What did CDPH Learn?

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

Hospital Policy Survey Results, 2006

Maternal Policy Standing Order

Review HBsAg status on admission 67% 42%

Screen on admission if no prenatal screening

67% 50%

Repeat HBsAg screening for high risk mothers

25% 0%

InfantDocument maternal HBsAg status in infant chart

63% 0%

Universal birth dose 79% 83%

HBsAg-positive, HBIG/HepB, within 12 hrs 79% 83%

HBsAg-unknown, HepB, within 12 hrs 67% 67%N=24 hospitals, response rate 100%

Percentage of Infants Receiving Hepatitis B Vaccine before

Discharge

20022006

“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.”

Challenges Conducting the Reviews

Lacked coordinating secondary contacts who understood the records review process

Policy surveys were incompleteInadequate 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)