III.E.2.c. Perinatal/Infant: Annual Report    (FY18 10/12017 - 09/30/2018)

State Priority Need:

Infant Mortality 

National Performance Measure #3 (2016-2021):

Percent of very low birth weight infants born in a hospital with a Level III + Neonatal Intensive Care Unit 

The Obstetric and Neonatal Level of Care gap analysis centered on the Indiana Perinatal Hospital Standards, which define risk appropriate care. These definitions establish that all very low birth weight (VLBW) infants shall be born in a hospital with a level III plus NICU. During the gap analysis, nurse surveyors conducted a thorough review of VLBW infants born in Level I or II facilities. Surveyors assisted all facilities with the development of policies, protocols and guidelines to improve recognition of mothers requiring delivery at a higher level of care. There is a strong focus on timely consultation and transfer of such patients to birthing hospitals able to support the level of care required by the condition of the mother and infant.

National Performance Measure #3 (2016-2021):

Percent of very low birth weight infants born in a hospital with a Level III + Neonatal Intensive Care Unit

Throughout 2018 the nurse surveyor team edited the Indiana Perinatal Levels of Care Rules in preparation for final adoption into legislation. These rules define risk appropriate care with a goal of very low birth weight infants being born in a hospital with a Level III+ NICU. There is a strong focus on timely consultation and transfer to birthing hospitals able to support the level of care required by the condition of the mother and infant. To improve recognition of mothers and their infants requiring delivery at a higher level of care, surveyors assisted facilities with the development of policies, protocols and guidelines.

Evidence-Based/Informed Strategy Measure linked to NPM#3:

Number of hospitals provisional surveyed to determine Obstetric and Neonatal Level of Care

* We have accomplished this ESM and are working on implementing a new one once the rules become effective.”

Article 39: Indiana Perinatal Hospital Services rules, (levels of care) was designed to ensure all women of child bearing age receive risk-appropriate care before, during, and after pregnancy, with a long term goal of reducing infant mortality rates in Indiana. During the 2018 Indiana legislative session, ISDH was given the authority to establish a program to certify perinatal levels of care designations for every delivering hospital and birthing center in the state.  The related rules were revised in 2018 to ensure continued compliance with evidence-based practice guidelines and recommendations from national organizations such as American Congress of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and American Academy of Pediatrics (AAP). Indiana’s team of hospital surveyors have traveled to delivering hospitals to discuss and explain the rules, and offer assistance in compliance with each rule. A central goal of this process was to support all delivering hospitals in the evaluation of the level of care that most appropriately defines their practice. Surveyors remain in contact with delivering hospitals to foster relationships and networking throughout the state. The surveyor team will continue work with external partners and delivering hospitals to develop tool kits, educational resources, and formalized teaching to address identified priority needs.

S.T.A.B.L.E Program

The S.T.A.B.L.E. program offers practical and effective education to healthcare providers in an effort to reduce infant morbidity and mortality as well as improve neonatal outcomes.

A total of seven (7) S.T.A.B.L.E courses were offered in 2018. Two (2) at Indiana Birthing Centers, four (4) at Critical Access Hospitals, and one (1) at an Independent, non-network affiliated delivering hospital. A total of twenty-four (24) registered nurses, four (4) nurse midwives, one (1) physician, one (1) physician’s assistant, and one (1) Family Nurse Practitioner received the course. An additional three (3) courses are planned are planned for January 2019.

Electronic Fetal Monitoring:

Nurse surveyors developed a multidisciplinary fetal monitoring course focused on a change in culture to adopt standardized terminology in electronic fetal monitoring documentation and communication. Between January and September of 2018, 12 non-network affiliated self-declared level one delivering hospitals and one (1) non-network affiliated self-declared level two (2) delivering facility hospital received the electronic fetal monitoring course. A total of two hundred and ninety (290) participants received this education: two hundred fifty six (256) registered nurses, twenty-eight (28) physicians, twenty-five (25) OB/GYNs, three (3) Family Medicine), and four (4) Certified Nurse Midwives. Planning is underway for a “train the Trainer” course to occur in late 2019.

 Perinatal Centers: Article 39 Perinatal Hospital Services, define the qualifications and responsibilities of Perinatal Centers in Indiana. Perinatal Centers will assist all affiliates to provide high quality service throughout the system, and promote risk appropriate obstetrical and neonatal care through improved use of resources.

 Transport Programs: Maternal-Fetal and Neonatal Transport programs are essential requirements of perinatal centers and bring higher levels of care to outlying delivering hospitals by supporting safe and timely transfer of patients to tertiary centers. Article 39 Perinatal Hospital Services includes the Indiana Perinatal Transport Guidelines, which were written in accordance with evidence-based Certified Air and Medical Transport Systems (CAMTS) and Air and Ground Transportation guidelines from the American Academy of Pediatrics (AAP). Transport guidelines, center on safety culture routines, quality assurance measures, education, competencies, and certifications of the transport team members and leadership. Evaluation of transport programs includes these essential standards for inter-facility transfers and management of maternal/fetal and neonatal transport teams.

State Performance Measure #2 (2016-2021):

Infant Mortality Rate per 1,000 live births

State Priority Need:

Breastfeeding

National Performance Measure #4A) (2016-2021)

Percent of infants who are ever breastfed

National Performance Measure #4B) (2016-2021)

Percent of infants who are breastfed exclusively through 6 months

The breastfeeding coordinator has been able to grow partnerships with Indiana chapters of professional organizations who are in position to support improved breastfeeding rates in Indiana.  In Feb 2017, the topic of breastfeeding was included in the state meeting of IN-ACOG and is included routinely in the calls of the IN-AAP. The Division of Primary Care and Rural Health focused on breastfeeding for a one-hour learning collaborative for staff.  The concept of weaving breastfeeding into more conversations, instead of isolating it as a stand-alone part of perinatal care, has been very well-received. 

Breastfeeding updates and education were included as a break-out session in the Infant Mortality Summit in 2017.  This opportunity was attended by physicians, nurses and community health workers from around the state. 

Indiana also began the creation of a state-wide program to recognize those hospitals that provide optimal maternity care practices and provide care based on the Ten Steps to Successful Breastfeeding.  Through focus groups and surveys, ISDH learned that a significant portion of birthing facilities have no interest in Baby-Friendly designation because of cost or other real or perceived barriers.  The state’s recognition will be offered at no cost, but will require some documentation of practice, measurement of compliance, and quality improvement around breastfeeding support practices. The Indiana Hospital Association is in support of this project and will help promote it to hospital administrators.

For the first time in recent history, Indiana was above the HP2020 goal for breastfeeding initiation in 2016.  Duration of breastfeeding continues to be the opportunity for the most improvement.  Work is being done to improve collaboration between hospitals and WIC peer counselors during the admission process, in an effort to achieve more seamless support for mothers after hospital discharge.  More hospitals are supporting outpatient breastfeeding follow-up visits.  The biggest barrier to breastfeeding is separation from the infant when a mother goes back to work.  A goal for 2018 is increasing support for mothers in the workplace and a broader understanding of the employer’s responsibility to support them will help mothers continue to breastfeed after going back to work.  Increasing knowledge and support from child care providers is also part of the state’s plan. 

In 2018, the Indiana Breastfeeding Alliance (IBA) was formed with internal ISDH and external community partnerships, including the Division of Nutrition and Physical Activity, State Office of Rural Health, WIC, Primary Care, the Milk Bank, Indiana Breastfeeding Coalition, Indiana Black Breastfeeding Coalition, IN-AAP, and local hospital affiliates.  Strategic planning addressed lack of lactation education provided to OB and Pediatric providers, Registered and Advanced Practice Nurses, and other health related professions.  Plans include implementing lactation curriculum within collegiate courses and offer learning collaborative projects with lactation education to practicing providers.  The IBA also prioritized addressing implicit bias in breastfeeding care by partnering with the Indiana Black Breastfeeding Coalition and the Indiana Minority Health Coalition to offer training to the IBA and partners around the state.  By addressing implicit bias in breastfeeding, the IBA seeks to reduce and eliminate health disparities in both breastfeeding initiation and duration.

In 2016 Indiana entered into a collaborative agreement with the CDC to issue the Pregnancy Risk Assessment Monitoring System (PRAMS) survey to Indiana women.  Data collected from this survey will allow MCH and statewide stakeholders to better understand attitudes, behaviors, and expectations of women shortly before, during and immediately following their most recent pregnancy. From there, tailored programming can be implemented to better address the needs that women identify as obstacles. Topics addressed in the survey include breastfeeding, drug use, insurance status, baby sleeping practices, dental care, and more.

State Performance Measure:

Infant Mortality Rate per 1,000 live births.

During this reporting period, the Fatality Review and Prevention (FRP) division staff, recognizing the need for improved consistency in investigation, classification and coding of infant deaths to inform prevention efforts, provided Sudden Unexpected Infant Death Investigation (SUIDI) training to professionals responding to infant fatalities, including coroners, law enforcement, Indiana Department of Child Services, fire/EMS, prosecutors and physicians.  During this reporting period, more than 50 professionals have received this training and accompanying program materials.  To date, FRP staff have trained more than 550 death scene investigators, and this training class has now been recognized by the Indiana Law Enforcement Training Academy to be offered by FRP staff through their facility on an annual basis.

FRP staff also worked on ways to support investigators and promote SUIDI outreach by improving evidence and data collection, and standardizing child death/injury investigations.  As a result of this collaboration, FRP staff provided dolls to investigators in an effort to ensure resources were available for complete scene reenactments.

The ISDH FRP program provides technical assistance and training to the local child fatality review and Fetal-Infant Mortality Review (FIMR) teams across the state.  FRP staff traveled to over 21 local CFR team meetings to guide them in the review process, offer resources and assist with data collection.  FRP staff have also worked to expand our FIMR network during this reporting period.  Title V funding helped support FIMR implementation in four counties, but FRP staff have worked with local partners and stakeholders to increase the number of counties with FIMR teams to nineteen.  A focus has also been on the collaboration among review processes, so most of the CFR and FIMR teams collaborate or share membership to exponentially increase the weight of their recommendations and share resources toward collective impact.

In addition, the ISDH provided mortality and morbidity data to local CFR team members and stakeholders across the state.  This information can be used by local injury prevention experts to implement evidence-based, data-driven prevention programming in their communities.

Direction On-Scene Education (DOSE) is an innovative attempt at eliminating sleep related infant death due to suffocation, strangulation or positional asphyxia by using First Responders to identify and remove hazards while delivering education on scene during emergency and non-emergency 911 calls. During this reporting period, FRP staff trained 83 responders and home-based service providers as DOSE trainers.  The ISDH FRP program has trained first responders and home-based service providers in DOSE in 81 of Indiana’s 92 counties, and to date, there are 550+ DOSE trainers in Indiana. Many of these trainers have gone on to train their own departments and other agencies. As a result of FRP program staff efforts, in FY2018, a DOSE influenced training was offered as the statutorily mandated “SIDS” training for all law enforcement, fire and EMS in Indiana. Additionally, a more thorough DOSE specific training will be added to the training portal for all first responders in FY2019.

The Title V funded Safe Sleep Program offered an in-depth training for safe sleep educators in six locations throughout Indiana. This training highlighted included the release of a Title V funded Field Guide that allows for comprehensive education, with graphics and helpful diagrams, that educators can use no matter where they are offering education. The Field Guide also provides talking points, including guided responses for challenging questions educators may receive when discussing the importance of practicing safe sleep with caregivers. FRP staff also began working closely with the Indiana Hospital Association to standardize education and training methods throughout Indiana’s hospitals. IHA is not funded through Title V efforts but their work is a critical piece of the efforts of FRP to reach the goal of ensuring consistent and pervasive education related to SUID prevention and safe sleep. FRP continued to engage nontraditional partners and expanded partnerships to reach educators working in jails, State Prisons, mental health facilities, and substance abuse programs. FRP has also increased education and resources provided to Community Health Workers and home visitors.  During this fiscal year, FRP program staff were able to providing service in all 92 Indiana counties.  These sites ordered 5384 crib/kits and provided sleep sacks to 2672 infants. During this reporting period, there were gaps in procuring resources due to contract and vendor supply issues.

FRP staff requested SUID specific data at regional, county, and zip code levels. Historically, this data has not been broken down by cause beyond the state level. This additional information allowed FRP staff and partners to target areas with high SUID rates, not only areas with high infant mortality rates. High infant mortality rates can be attributed to many causes and intervention or prevention efforts may not be needed equally throughout the entire state. Several maps were created to inform prevention at each level. These maps include aggregated data, annual data and zip code heat maps. Data sheets were also created for use in education, providing the educators with their specific SUID data. 

During this reporting period, FRP staff also expanded their collaborative partnership with the Indiana Department of Child Services (DCS) to increase ISDH capacity to identify real-time SUID data.  In March 2018, DCS began sharing, on a daily basis, all child fatalities reported to the DCS hotline.  Because DCS investigates all SUIDs, this has allowed the FRP division to track these deaths as they occur, and over time will allow for more targeted prevention.