Oregon AWHONN

Promoting the Health of Women and Newborns

March 2019 Vol. 6 No. 1

In This Issue

2019 Is All About YOU

by Donna Talain, RNC-OB, BSN, MBA


This year, we're putting YOU in the spotlight. AWHONN is a place for learning, not just from journals and lectures, but from each other. That's why we're reaching out to YOU. We know that each of our members is a well of information, experience, and advice. From new grads to seasoned veterans, we could all learn from each other. So we've put together a little Member Spotlight contest. For each of you that is nominated or who puts her/his own name in the hat, you'll be entered to win one of several small prizes throughout the year. At the end of the year, we'll draw a name for the Grand Prize - a trip to the 2020 AWHONN Convention in Phoenix, Arizona (valued at $1,500)! Nominating is easy! You can even fill in the form for yourself because we should never be ashamed to toot our own horn. Be proud of what you've accomplished and know that others want to learn from you too. The forms are below. Fill one out today!


To get us started, we're Spotlighting three of our newest Oregon AWHONN Leaders. Let's welcome these amazing volunteers!

Kelsie Galusha - Mid-Willamette Valley Chapter Co-Chair

ORAWHONN: How long have you been a member of AWHONN? 

Kelsie: Since 2017, when I graduated nursing school!


ORAWHONN: What do you enjoy most about AWHONN?

Kelsie: AWHONN is an opportunity for me to follow my passions beyond the bedside. It allows me to explore my passions for women's health, research, and leadership, all while keeping me up-to-date on evidence based practice.


ORAWHONN: Describe your most memorable experience at work.

Kelsie: In general, I would say the entire first year of my nursing career. It was amazing to watch how much I changed from my first days on orientation, my first days off​ orientation, and the time ending my first year of work. Of course, my knowledge has expanded over the year. However, smaller changes occurred that really surprised me. I grew not only clinically, but personally as well. My whole being as a person has changed. I've become someone who continues to be able to cope with stress, change, uncomfortable situations, and the really difficult things in life. Coping at work has taught me to cope at home in my personal life and relationships. I also watched the amazing transition that everyone assures you will happen after working for a year or 2 years - the transition where I feel comfortable and fluid in my work (and not panicked 24/7!). 


Finally, most "memorably" is the family I have found myself so lovingly welcomed to. After nursing school I moved from the east coast (where all my family and friends are) to Oregon, where I knew no one except my partner, dog, cat, and few houseplants that traveled with me. My coworkers have adopted me into their family both at work and outside of work. I have found friends among my peers and have grown a truly diverse, healthy, and well-supported life in the last year. And, now, I look forward to the amazing family that is AWHONN!


ORAWHONN: What’s your favorite tip for your fellow women’s health, obstetric, or neonatal nurses?

Kelsie: Follow your passions wherever they take you. 

Audra Stauffer - Mid-Willamette Valley Chapter Co-Chair

ORAWHONN: How long have you been a member of AWHONN?  

Audra: Going on my third year I believe!


ORAWHONN: What do you enjoy most about AWHONN? 

Audra: I love the journals and most of all the conferences. What a great way to network! I feel like I am participating in furthering our practice by being a member of an organization specific to my specialty.


ORAWHONN: Describe your most memorable experience at work.

Audra: My most memorable moments have been the work I do with our neonatal opioid withdrawal syndrome families. We have come a long way since 2013 in the way we care for these babies and their families. Meeting and working with heroin survivors that are now parenting their child and thriving has been so rewarding. The work continues... but I feel we are headed in the right direction!


ORAWHONN: What’s your favorite tip for your fellow women’s health, obstetric, or neonatal nurses?

Audra: Get involved!! The dues are nothing for what you get out of paying attention to bettering our practice! We all can make a difference. This organization is full of amazing people I admire and I am so lucky to have access to meeting new folks and learning so much more!

Mary Hanson - PDX Metro Chapter Co-Chair

ORAWHONN: How long have you been a member of AWHONN?

Mary: I honestly have no idea. Off and on over the span of my 25 years in caring for women in labor and postpartum. 


ORAWHONN: What do you enjoy most about AWHONN?

Mary: Receiving journals and keeping up to date and practice changes. 


ORAWHONN: Describe your most memorable experience at work. 

Mary: I think my most memorable moment at work was when I had the privilege of caring for a family who’s husband was recently diagnosed with cancer and the prognosis was unknown. It was a beautiful birth and I felt so lucky to be part of their delivery. 


ORAWHONN: What’s your favorite tip for your fellow women’s health, obstetric, or neonatal nurses?  

Mary: Trust your patient!  If they say something isn’t right, it most likely isn’t.  

Nominate a Colleague

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Or Nominate Yourself

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Women's Health Update

Perinatal Patient Safety

by Kara Johnson, DNP, RNC-OB, CNS


Every year, in the United States, almost 4.8 million hospital patients suffer serious harm that is preventable. A 2017 survey of 2,536 people revealed that 21% of respondents had personally experienced a medical error, while 31% reported that someone else whose cared they had been involved with had experienced an error (Clapper, Merlino, & Stockmeier, 2019). Despite the landmark Institute of Medicine 1999 report To Error is Human the number of deaths due to errors and omissions in healthcare are still high despite safety improvement work by many healthcare systems.


Stories of families and pregnant/postpartum women that have experienced morbidity or mortality have recently been highlighted in the media. Many factors contribute to an increase in maternal morbidity and mortality over the last decade, but multiple studies have demonstrated that almost half of pregnancy-related deaths are preventable (Ozimek & Kilpatrick, 2018). One study reported the highest rates of preventability among hemorrhage (70%) and preeclampsia (60%) maternal deaths (Main, McCain, Morton, Holtby, and Lawton, 2015). Many of us were shocked by the NPR story released almost a year ago on Lauren Bloomstein, a NICU nurse that died of HELLP syndrome and hemorrhagic stroke soon after giving birth at the hospital where she worked. The healthcare team failed to recognize and intervene when she developed RUQ pain and severe hypertension. Lauren’s story is one of many stories of women with pregnancy-related deaths in 2016 in Propublica’s Lost Mothers (2017). 


How do we improve perinatal patient safety?

  1. Have a designated clinical and administrative leader for perinatal patient safety
  2. Work with department leadership to review current outcomes data and clinical processes to identify the highest-need perinatal patient safety problems
  3. Share information on safety cases, near misses, and perinatal patient safety trends at department meetings
  4. Seek input from team members on safety concerns and potential solutions
  5. Review available resources for perinatal patient safety improvements, including standardization of care, and consider implementation

Toolkits, patient safety bundles, and other patient safety resources:

Council on Patient Safety in Women’s Healthcare

https://safehealthcareforeverywoman.org/

 

California Maternal Quality Care Collaborative (CMQCC)-Maternal Quality Improvement Toolkits

https://www.cmqcc.org/resources-tool-kits/toolkits

 

Agency for Healthcare Research & Quality (AHRQ)-Toolkit for Improving Perinatal Safety

https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/perinatal-care/index.html

 

Advisory Board-Perinatal Patient Safety Toolkit

https://www.advisory.com/technology/crimson-continuum-of-care/members/resources/2015/perinatal-safety-toolkit?WT.mc_id=Email|DailyBriefing+Headline|DBSecondCTA|DBA|DB|2018Aug22|ATestDB2018Aug22||||&elq_cid=3430025&x_id=003C000002DsfeFIAR#element5

References


Clapper, C., Merlino, J., & Stockmeier, C. (2019). Zero harm: How to achieve patient and workforce safety in healthcare. New York: McGraw-Hill.


Main, E.K., McCain, C.L., Morton, C.H., Holtby, S. & Lawton, E.S. (2015). Pregnancy-related mortality in California: Causes, characterisitics, and improvement opportunities. Obstetrics & Gynecology, 125, 938-947. doi: 10.1097/AOG.0000000000000746


Martin, N., Cillikens, E. & Freitas, A. (2017). Propublica: Lost mothers. Retrieved from https://www.propublica.org/article/lost-mothers-maternal-health-died-childbirth-pregnancy


Ozimek, J.A., & Kilpatrick, S.J. (2018). Maternal mortality in the twenty-first century. Obstetrics Gynecology Clinics North America, 45, doi: 10.1016/j.ogc.2018.01.0040889-8545

Neonatal Update

Newborn Blood Spot Screening Update 2019

by Pat Scheans, DNP, NNP-BC


Newborn blood spot screening is a public health program that is carried out in every state and many countries worldwide. Since infants with the screened-for conditions often appear normal at birth, early detection and intervention is critical to help prevent the development of impairments such as mental disability and neurological deficits, delayed physical growth, severe illness, and death. 


Oregon was an early adopter of blood spot screening (1963- yay, us!), which originally began for Phenylketonuria (PKU), hence the misnomer “PKU test”.  The cumbersome, but correct term “newborn blood spot screening” (NBS) covers over 40 rare conditions that, when added together affect 1 out of 250 infants. These conditions include metabolic disorders, hemoglobinopathies (sickle cell), cystic fibrosis, and most recently, lysosomal storage disorders. Our Northwest Regional Newborn Screening Program is a collaborative of several state groups: Oregon Health Authority (OHA), Oregon Health & Science University (OHSU), Hawai’i Department of Health, Idaho Department of Health and Welfare, and New Mexico Newborn Screening Program.


The OHA NBS manual (71 pages!) covering the processes, rules and regulations governing blood spot screening has been updated (effective January 2019), and includes NEW recommendations, information about the conditions, and tips on specimen collection.


The chance that a screening condition will impact any single infant is remote. However, the cost of not detecting an affected infant is immense, both in human suffering and financial terms. Some of the reasons that newborn screening is so important are:

  • Approximately 20 disorders can kill or severely harm an infant in the first two weeks of life.
  • Approximately 20% of infants with a screening condition will be symptomatic within one week of birth.
  • Approximately 10% of infants with a screening condition could die within one week of birth, if untreated.
  • Affected infants may lose significant IQ points, leading to lifelong impairment, if some screening conditions are not treated within 2 weeks of birth. (OHA, p.5).

The NEW timing for specimen collection is:

(OHA, p. 17)


So, what are the definitions of “preterm, low birth weight, or sick”?


Preterm = infant born prior to the start of the 37th week of pregnancy. (OHA, p.7)

Low birth weight = birthweight less than 2500 grams (World Health Organization)

Sick = needing special care/intensive care (Newborn Screening for Preterm, Low Birth Weight, and Sick Newborns; approved guideline: CLSI NBS03-A)  


There are myriad state regulations about blood spot screening, including:


  • Preterm = infant born prior to the start of the 37th week of pregnancy. (OHA, p.7)
  • Low birth weight = birthweight less than 2500 grams (World Health Organization)
  • Sick = needing special care/intensive care (Newborn Screening for Preterm, Low Birth Weight, and Sick Newborns; approved guideline: CLSI NBS03-A)

There are myriad state regulations about blood spot screening, including:

Oregon statute (ORS) 433.285: requires every infant to be tested


Oregon Administrative Rule (OAR) 333-024-1020 and 333-024-1025: responsible “practitioner” is defined as physicians, nurses and midwives who deliver or care for infants (basically everyone) in hospitals, birth centers or homes (basically everywhere).


 OAR 333-024-1030:  practitioners unable to determine the screening status of an infant under six months of age must screen them within two weeks of their first visit.


OAR 333-024-1080(4): practitioners must communicate abnormal results to the parent or guardian and recommend appropriate medical care.


OAR 333-024-0225: infants transferred within 48 hours of birth should be tested by the receiving facility. 

FUN FACTS to know and tell about newborn bloodspot screening:

  • Collect the specimen prior to blood transfusion, otherwise you are essentially testing the donor, not the baby. It may take up to 4 months for baby’s levels to accumulate post-transfusion, potentially leading to significant delays in diagnosis and treatment. 

  • Some antibiotics (those containing pivalic acid such as pirampicillin, pivmecillinan, cefditorempivoxil) given to mothers during labor or to newborns may cause false elevation of isovaleryl/2-methyl butyryl carnitine. 

  • Always collect the first specimen before early discharge, even if less than 24 hours of age, due to the risk of lack of follow up.

  • Opting out due to religious beliefs opposed to this testing requires signing the Religious Objection to Newborn Screening Blood Test (informed dissent form). Copies must be forwarded to the Newborn Blood Screen Follow-up Team within 30 calendar days of birth, included in the medical record, and given to the parents and primary care provider. 

  • Capillary blood obtained from a heelstick is the preferred specimen. Samples obtained from venipuncture, arterial stick, or intravenous peripheral or central lines are acceptable, but ideally, should not be drawn from lines used to for parenteral hyperalimentation or antibiotics. Always clear the line adequately of hyperalimentation or antibiotics prior to drawing the specimen.

  • Maternal conditions that may affect the results include thyroid dysfunction, Illicit drug use, steroids, fatty liver of pregnancy, hemolysis/elevated liver enzymes/low platelets syndrome (HELLP), congenital adrenal hyperplasia (CAH), PKU, carnitine deficiency and B12 deficiency.

Helpful links and for more information:

Comprehensive information about screened-for conditions: Baby’s First Test: http://babysfirsttest.org/


Oregon Health Authority’s Oregon Newborn Bloodspot Screening Practitioner’s Manual, 10th ed., 2018:

https://apps.state.or.us/Forms/Served/le8189.pdf


Religious Objection to Newborn Screening Blood Test form: http://www.healthoregon.org/nbs

Legislative Update

I Am Learning I Have a Lot to Learn

by Amy Brase, MSN, RN, CNE


In December, Michelle Hirschkorn, Nancy Alt, and I went to an Oregon Health Forum. The focus was the 2019 Legislative Session: Which Health Care Bills Will Emerge? There was a panel of four Representatives and a Senator, and they all spoke to what their agendas related to health issues would be for the legislative session that opened January 22nd. It was interesting and illuminating, but frankly some of it was over my head. They spoke quite a bit about CCO 2.0 (as in two-point-oh) and I really had no idea. So, I came home and did some research. I am thinking some other AWHONN members may have the same confusion, and CCOs are going to be a hot topic for 2019 Legislative session. If you are like me, you may be asking, “What is a CCO”? It turns out…it is complicated.


A CCO is a Coordinated Care Organization which is a network of health care providers (health, addiction, mental health, dental) who work together in their local communities to serve people who receive health care coverage under federally funded Medicaid, which in Oregon is called the Oregon Health Plan (OHP) (Oregon.gov, 2018). An important piece of information for AWHONN members is that implementation of CCOs in Oregon has resulted in an increase in receiving timely prenatal care for low income pregnant women (Oakley, Harvey, Yoon & Luck, 2017).


In 2012, Oregon transformed its Medicaid Program by establishing 16 CCOs to care for its OHP population. This change occurred due in part to an arrangement with Centers for Medicare and Medicaid Services (CMS) which provided 1.9 billion over 5 years to support the transformation. The goal was to reduce the rate of Medicaid spending growth from 5.4% to 3.4% within 3 years. This reduced rate would result in a huge financial return on investment for the federal government. (McConnell, 2016). 


The arrangement with CMS is strongly incentivized to meet targets and avoid penalties. If costs decrease AND there is no change (or an improvement) in quality, then the CCOs got a bonus. If they over spend then they pay a scary penalty (like $185 million over 2 years). The first 5 years of the program have met the goals as initially set up. The concerning thing is that the CCO costs for 2019 are not within the 3.4% growth, thus the concern from the legislators. The increases in costs are attributed to three primary factors: pharmacy costs, changes in membership due to the renewals process, and fluctuation in rural hospital costs (Oregon.gov, 2018).


From 2014-2018, the state held spending growth of OHP to the goal of 3.4 percent. In 2017 the growth was 3.2%. In 2018 the growth rate was 3.3%. In 2019 the growth was 4.35%--one can see why the legislators are in an uproar about this. A 1% increase in spending equates to $4.3 million from the general budget—I think. My math gets sketchy with numbers this big. 


So what does this mean for the 2019 session and CCO 2.0? Legislators will be working to address the major cost drivers in the health care system, further incentivize CCOs for performance, and find areas of opportunity for improved efficiency (Oregon.gov, 2018). Costs will definitely be a focus and how to get closer to the acceptable 3.4% increase rather than the unacceptable 4.35% increase with the 2019 growth rates. We heard a lot from the legislators on the panel last month about pharmacy costs and rural access—all part of the bigger picture with CCOs. 


Much more to learn. See…I told you it was complicated.

References


McConnell, K.J., (2016). Oregon’s Medicaid coordinated care organizations. JAMA. 315(9), 869-870. DOI: 10.1001/jama.2016.0206


Oakley, L.P., Harvey, S.M., Yoon, J., Luck, J. (2017). Journal of Maternal and Child Health 21, 1784-1789. DOI: 10.1007/s10995-017-2322-z


Oregon.gov (2018). Retrieved from: https://www.oregon.gov/oha/ERD/Pages/OHAReleases2019CCOCapitationRates.aspx

Save the Date!

We've got the dates for the 2019 Oregon AWHONN Fall Conference!

Grow Your Practice Rooted in Excellence
September 29 - October 1
Oregon Garden Resort, Silverton, OR

Your Oregon AWHONN Fall Conference Committee is hard at work finalizing the agenda and getting some amazing speakers. Visit oregonawhonn.org/or-fall-conference often for updates.

Upcoming Events

Central Oregon Chapter Meeting

Tuesday, May 14 at 8:00 AM - Friday, May 17 4:30 PM
Wednesday, May 29 at 6:00 PM - 8:00 PM
Tuesday, Aug 27 at 8:00 AM - Friday, Aug 30 4:30 PM
Thursday, Sep 5 at 7:30 AM - Friday, Sep 6 4:00 PM

A superstar doesn't just use the spotlight for themselves.

Sasha Velour