Executive Summary

Four years of data has provided the Network with a good understanding of some of the key challenges confronting the perinatal health system in the Greater Toronto Area (GTA) and the types of issues that need to be addressed to improve patient access and strengthen our collective commitment to improving quality and consistency of care delivery across the Network. The Fourth Annual Niday Perinatal Database report presents a comparison and contrast of the GTA maternal-newborn population and the perinatal obstetrical services accessed in 2006/07. The analysis is presented in three ways.

  1. The LHIN perspective profiles the characteristics and outcomes of mothers and their infant(s) based on the region in which they reside. The analysis was inclusive of all maternal residents from Mississauga/Halton, Central West, Toronto Central, Central and Central East LHIN. This analysis provides important information to support population needs based planning.
  2. The hospital perspective profiles human resources, intrapartum interventions and maternal/newborn outcomes based on LHIN regions, designated levels of care, size of hospital (i.e., birth volumes) and provides a comparison of trends over the last four years, where appropriate. Interpretation and discussion of the analysis of service provision provides an understanding of some of the challenges that to be addressed to meet population needs. The analysis included all birth records from all CHN member hospitals.
  3. The population health perspective looks at some of the reproductive health indicators that may assist in planning and managing services to promote, enhance and protect the health of mothers and infants. The analysis was inclusive of all maternal residents who live in one of the health units included in the GTA. The analysis illustrates the value of the Niday Perinatal Database across sectors and the challenges for health planning when looking at data based on different geographic boundaries.

[DOWNLOAD FULL REPORT HERE]

NIDAY PERINATAL PROJECT
The Child Health Network of the Greater Toronto Area released the results of its first regional system study, the "Perinatal Pilot Project Report", in June 2002. The project was undertaken as a starting point for assessing whether maternal/newborn services are provided at the most appropriate level of care. Key questions addressed in the project were:

  • Is the system of perinatal care in the GTA integrated?
  • Does a regionalized approach to result in greater continuity of care?
  • Are mothers and babies receiving appropriate care according to their needs?
  • Are mothers and babies receiving appropriate care in the appropriate place?

This study provided initial indications of early progress – and future opportunities for developing a regional health system for mothers, newborns, children and youth in the GTA.

Over 17,000 records for select high-risk newborns – those who were born at less than 36 weeks or who required transfer soon after birth, during 1999-2001, were analyzed. Key findings included the following:

  • Consistent with the CHN model, hospitals with different level of care designations have been managing clinically different patient populations.
  • Most births occurred at appropriately designated hospitals, however based on general parameters such as gestational age, a quarter of neonates born under 32 weeks are delivered at Level II facilities where Level III care is considered optimal.
  • The movement of newborns both to and from higher and lower levels of care regularly occurred. This coordination is consistent with a network that ensures newborns are in the most appropriate facility to meet their specific health care needs.
  • Transfers to facilities outside the GTA are also evident, attesting to the role of the CHN as a provider of care well beyond immediate catchment areas.

PAEDIATRIC INDICATOR PROJECT

HIGHLIGHTS OF THE 2007 BENCHMARKING REPORT: PAEDIATRIC INDICATOR PROJECT

Highlights arising from the data in this report are as follows:

  • The GTA hospitals' contribution to paediatric inpatient care is significant and amounts to over 45% of the total Ontario volume of paediatric inpatient care
  • Paediatric patient transfer activity within the GTA indicates that GTA hospitals function, for the most part, as a system and that the concept of "appropriate care closer to home when possible" is supported
  • Non-tertiary hospitals have a strong role in managing acutely ill and complex neonatal and paediatric patients and at times provide tertiary and quaternary care to these patients
  • The 'regional maternal/newborn and paediatric health care system' is still evolving and requires continued attention and commitment to improve
  • Both similarities and differences in clinical practices are evident between the CHN hospitals

It is expected that comparing data across the Network will help the member organizations accelerate their rate of improvement by:

  • Identifying quality improvement opportunities based on demonstrated levels of performance of hospitals across the province
  • Providing opportunities for collaboration to implement improvement strategies that will benefit the system and avoid duplication of efforts to achieve the same goals

The CHN members remain committed to appraising the indicators to be included in future reports. It is also the intention to expand the indicators profiled in the PIP report as data quality and availability improves and as priorities regarding the desired information needs become clearer.

[DOWNLOAD FULL REPORT HERE]

GUIDELINE DEVELOPMENT
Facilitating development, implementation and monitoring of a common and consistent set of clinical, organizational and system guidelines across the Network is a key goal of the CHN. To date, the Network has identified "priority" guidelines to be developed in each of these areas and has agreed to act as a clearinghouse for compilation of existing guidelines.

GUIDELINE DEVELOPMENT
Facilitating development, implementation and monitoring of a common and consistent set of clinical, organizational and system guidelines across the Network is a key goal of the CHN. To date, the Network has identified "priority" guidelines to be developed in each of these areas and has agreed to act as a clearinghouse for compilation of existing guidelines.

CLINICAL GUIDELINES

  • GUIDELINES FOR PAIN MANAGEMENT – The CHN has developed standards and a series of educational modules to manage pain in children. Six education modules are included in the document "Building the Blocks Towards Understanding of Pain in Neonates, Infants, Children and Youth". The education modules cover the following areas:
    Module I: Understanding children's pain: an overview
    Module II: Pain assessment and management in the neonate
    Module III: Non-pharmacological management of pain
    Module IV: Procedure-related pain management
    Module V: Pain assessment and measurement in children
    Module VI: Pharmacological management of post-operative pain in children

  • GUIDELINES FOR THE TREATMENT OF ACUTE ASTHMA IN CHILDREN – These guidelines were developed to assist practitioners in providing best-practice in the emergency and inpatient care of children with asthma.

  • CANADIAN PAEDIATRIC TRIAGE AND ACUITY SCALE – The CHN facilitated the roll-out of the first paediatric supplemental guidelines to the Canadian Triage and Acuity Scale (CTAS) to improve triage of paediatric patients. A paediatric competency-based self-assessment tool for emergency nurses has also been developed to ensure system-wide standards of practice.

  • NARCOTICS POSTER (Intermittent Narcotic Analgesia Dosing for Infants and Children) – This tool was developed to improve the safety of narcotic administration for newborns and children by providing an easily accessible reference for staff involved in administering medication.

  • GUIDELINES FOR DISCHARGE OF THE HEALTHY NEWBORN – These guidelines were developed to assist care providers in decision-making concerning newborns that can safely be discharged at 24 hours of age.

  • URINARY TRACT INFECTION – A guideline for identification, treatment and follow-up of infants and children with infections of the urinary tract.

  • SICKLE CELL DISEASE – A guideline for emergency and inpatient treatment of children with Sickle Cell Disease and presenting with pain, acute chest syndrome (pneumonia) and fever (infection).

  • CONSCIOUS SEDATION – A guideline for administration of medication and post-sedation monitoring for children receiving procedural sedation in emergency departments, imaging departments and inpatient units.

  • PERINATAL SUBSTANCE ABUSE – A guideline for the management of the mother who ingests potentially toxic substances during pregnancy and a guideline for identification and monitoring the neonate.

ORGANIZATIONAL GUIDELINES

  • EMERGENCY MEDICAL DIRECTIVES - Guidelines to enable nurses to initiate treatment in the Emergency Department for children requiring:

    • Oral rehydration
    • Management of respiratory distress
    • Fever management
    • Pain management

SYSTEM GUIDELINES

  • Three sets of transport protocols have been developed to facilitate transfer of mothers and newborns within the regionalized model of CHN:

    • MATERNAL ANTENATAL TRANSFER PROTOCOL - A protocol to facilitate transfers of high-risk pregnant women within the regionalized model of CHN.
    • NEONATAL TRANSFER PROTOCOL - A protocol to facilitate transfers of acutely ill newborns within the regionalized model of CHN.
    • NEONATAL RETROTRANSFER PROTOCOL - A protocol to facilitate effective retro-transfers for newborns from a higher level facility to a less acute level of care within the regionalized model of CHN.

A copy of the various CHN Guidelines are included under the Publications section of this website.

NEW INITIATIVES TO ENHANCE PRACTICE STANDARDS TO IMPROVE PATIENT CARE

Fetal Fibronectin Testing: As the incidence of preterm birth continues to rise and the stress on tertiary beds increases, the importance of identifying those mothers in true preterm labour will become even more important. Many mothers exhibiting signs and symptoms of preterm labour are not in true labour and will not deliver a preterm baby. However, in the past, it was difficult to predict which mothers would actually give birth prematurely. A test for the presence of fetal fibronectin in a vaginal swab has now been developed and the CHN has embarked on a Network-wide practice initiative to test all mothers with signs of pre-term labour to determine those at risk of delivering a preterm baby. All CHN members are participating in adoption of a universal testing program. It is anticipated that the use of the test will result in better utilization of scarce maternal antenatal beds and resources in regional and tertiary hospitals. Those mothers with negative test results will no longer need to be transferred to tertiary hospitals and those truly needing tertiary care will have improved access to those resources. It is also hoped that this will address the one-third incidence of preterm babies less than 32 weeks gestation currently not having access to birthing services at a tertiary centre.

Neonatal Resuscitation Program: The Neonatal Resuscitation Program (NRP) developed by the American Heart Association and the American Academy of Pediatrics has long been the standard for resuscitation of the newly born infant in Canada. Recently, the responsibility for setting standards and overseeing the practice guidelines in Canada was assumed by the Canadian Paediatric Society (CPS). The CPS has recently adopted standards that are unique to Canada. The CHN has been instrumental in implementing these new guidelines into practice within the Network hospitals. Numerous workshops were held across the Network to familiarize the NRP Instructors with the practice changes. The work of the CHN in updating Instructors will ensure that babies born within network hospitals receive quality, evidence-based care at the moment of birth should they require assistance.

Acute Care of the at-Risk Newborn(ACoRN): In addition to the NRP Guidelines, the CPS has recently released an education program entitled Acute Care of the at-Risk Newborn, otherwise known as the AcoRN Program. In June 2007, the CHN offered the first in a series of sessions to implement this program and enable upgrading of nurses delivering care to babies within the NICUs of the Network hospitals. This program will ensure high-quality, evidence-based care to all newborns experiencing problems around the time of birth.

Caesarean-section review: The CHN has initiated a 'voluntary review' of the caesarean-section (C/S) rates in CHN member hospitals. The intent of this review is to raise awareness of the current C-section rates in a way that will allow for consistent understanding and interpretation of current practices and suggest areas where practices could possibly be improved. The review is assessing the current C/S trends using Robson's 10 point classification system based on analysis of information from the Niday dataset (2003/04 -2006/07). It is also anticipated that this work will be used as the basis for development of continued local monitoring of C/S rates and indications. The findings will be disseminated to CHN members to inform discussion and possible strategies for further improvements in quality of care and service provision for maternity care for specific prospective groups of women.

Appropriateness of Care for Newborns (<32 Week Project): The CHN is engaged in a project to learn more about why infants less than 32 weeks gestation are not being born in tertiary centres. The project involves a retrospective review of current practice to help the system gain a better understanding of the specific issues related to "appropriateness of care." This issue was identified as a priority by the members of the CHN Maternal Newborn Services Task Force.

There is abundant evidence supporting the fact that newborn outcomes are greatly improved if babies &32 weeks gestation are born at tertiary centres where adequate resources are available to provide immediate intensive care, stabilization, and monitoring. Notwithstanding the evidence, about 30% of preterm births in the Greater Toronto Area occur outside a tertiary setting. Despite concerted efforts to improve access to tertiary centres, there has been no improvement in this rate over the past five years. Investigation into the reasons why births are not occurring at the appropriate sites offers the Network an opportunity to embark on a quality improvement plan to enhance the quality of care and improve outcomes for high-risk newborns.

The impetus for this quality improvement initiative arose from observations arising from data in the Niday Perinatal Database. and has been approved by the CHN Coordinating Committee. The project is being led by Dr. Hilary Whyte, a neonatologist and medical director of the Acute Care Transport Services team at SickKids.