Perinatal HIV Chart Review - Florida

Perinatal HIV Chart Review - Florida JoNell Potter, PhD Robert Lawrence, MD Sheryl Carney, RN

Background- Why Did We Do This? • Review of cases (missed opportunities) from DOH data; • Developed a chart review tool headed by Rivero & Potter; • Met with Florida Perinatal Nurse Coordinators at Annual Florida AETC meeting in October 2012 to engage & inform about the process; • January 29, 2013: Letter to RPICC Medical Directors from DOH announcing the plan for a quality review of perinatal HIV (9 Centers in Florida); • Some sites resistant - no outside reviewers, need IRB approval, no response from some, logistics complicated at some sites (multiple providers).

Plan: What We Did & How We Did It • Develop & Refine Perinatal Chart Review Tool • Pilot Tool in S. Florida (WPB, Broward, Miami-Dade) • Host a Statewide Summit for Key Stakeholders • DOH & AETC to Co-Host: Invite & Engage RPICC Medical Directors & Florida Perinatal Nurse Coordinators • DOH to Present Data on History of Perinatal HIV in the State and on New Perinatal HIV cases • AETC to Present Summary of Findings from South Florida Perinatal Chart Reviews • Develop a Strategic Plan for the Future

Regional Perinatal Intensive Care Centers (RPICC)Centers in Florida • Tampa General Hospital - Tampa, FL • Shands Teaching Hospital - Gainesville, FL • Shands -Jacksonville - Jacksonville, FL • Jackson Memorial Hospital, Jackson Health System - Miami, FL • Sacred Heart Hospital - Pensacola, FL • Winnie Palmer Hospital at Arnold Palmer Med. Center - Orlando, FL • All Children’s Hospital - St. Petersburg, FL • Bayfront Medical Center - St. Petersburg, FL • St. Mary’s Medical Center - West Palm Beach, FL • Broward General Medical Center - Ft. Lauderdale, FL • Memorial Regional Medical Center - Hollywood, FL • Lee Memorial Health System - Ft. Myers, FL

Significant Findings from Pilot Perinatal Record Reviews • Lack of communication and consistent documentation between HIV providers, prenatal providers, L&D providers & pediatric providers; • EMRs on different operating systems & not available to all providers across disciplines, clinics & hospitals.

From Our Reviews: Specific Guidelines Not Being Followed • Vaccinations in pregnancy; • Tuberculosis screening; • Hepatitis testing – A, C in particular; • Accurate history of cART use in previous pregnancies; • VL done 2-4 weeks after initiating or changing cART; • VL at 34-36 weeks gestation to guide decisions for delivery mode; • Documented resistance testing – prior, current, and in patients with elevated VL despite therapy; • Accurate documentation in L&D notes of cART used during pregnancy, last dose (date & time) once admitted to L&D; • Documentation of whether the mother received a prescription or the actual medication (ZDV) for the infant before discharge.

Significant Findings from Pilot Perinatal Record Reviews • Little documentation of appropriate standard counseling of risks associated with cART during pregnancy, the impact of poor adherence & risk to sexual partners/neonates, pre-mastication, & follow-up care for mother & newborn. • Gaps in communication regarding pertinent data on mother (VL at/prior to delivery, no PNC, etc.) to create a strategic plan for management in L&D & an emergency consultation to pediatrics for evaluation of risk and “does this baby need more than ZDV?”

Problems to be Addressed with Non-Compliance with Guidelines • Problem- Inappropriate Management Issues Solution- Engage providers & offer education & training through F/C AETC; • Problem-Despite education and training, individual providers not willing to accept intervention/education and/or follow guidelines, placing women & neonates at risk; Solution- How can this be addressed appropriately & by whom?

Proposed Ideas for the Future • Use of a Perinatal Chart Review Tool - Use as a Quality Measure or use components as individual - Performance Measures to review practice and improve performance • Tracking - Reporting of HIV positive deliveries at time of delivery or earlier - Reporting and Tracking of HIV exposed infants thru DOH • Data Management / Exchange / Communication - Standard information to be reported - Electronic record and exchange of information overseen by DOH • Local Perinatal HIV Transmission Prevention Team  Best Practices Model - Reproduce the model in each area around the state - Adapt the model to specific issues in different locales

Perinatal Chart Review Tool Subject #: Reviewer: Review Date: Demographics - SECTION 1 1. Mother’s Age at 1st Visit 2. Race: 1. African American/Black 2. White 3. Asian 4. American Indian/Alaska Native 5. Native Hawaiian/ Pacific Islander 3. Hispanic, Latino, or Spanish Origin? O Yes O No 4. Primary Language:_______ Translator O Yes O No

Perinatal Chart Review Tool 5. Payment Source: • 1. Medicaid • 2. Private Payer • 3. Self Pay • 4. SSI • 5. Medicare • 6. Other ______

Perinatal Chart Review Tool Comments:

Perinatal Chart Review Tool HIV Management in Pregnancy – SECTION 2

Perinatal Chart Review Tool Yes No N/A Comments:

Perinatal Chart Review Tool Monitoring During Pregnancy – SECTION 3 Comments:

Perinatal Chart Review Tool Baseline Labs/Testing – SECTION 4

Perinatal Chart Review Tool Vaccines and TB Screening – SECTION 5

Perinatal Chart Review Tool Hepatitis – SECTION 6 Comments:

Perinatal Chart Review Tool CD4 – SECTION 7 Comments:

Perinatal Chart Review Tool Viral Load – SECTION 8 Comments:

Perinatal Chart Review Tool Resistance Testing – SECTION 9 Comments:

Perinatal Chart Review Tool Opportunistic Infections – SECTION 10 Comments:

Perinatal Chart Review Tool Initiation of ARV Therapy – SECTION 11

Perinatal Chart Review Tool Antepartum ARV Therapy – SECTION 12

Perinatal Chart Review Tool

Perinatal Chart Review Tool Labor and Delivery – SECTION 13

Perinatal Chart Review Tool Delivery Information – SECTION 14

Perinatal Chart Review Tool Testing/Care of Infant if Mother’s HIV Status is Unknown SECTION 15

Perinatal Chart Review Tool Follow Up: Mother – SECTION 16

Perinatal Chart Review Tool Infant Antiretroviral Prophylaxis – SECTION 17

Perinatal Chart Review Tool

Perinatal Chart Review Tool Follow Up: Baby – SECTION 18

Perinatal HIV Chart Review - Florida