Meet the New Quality Improvement Nurse at TCHMB!

Susan Dimitrijevic is the new Senior Nurse Program Manager at TCHMB! She will be working very closely with TCHMB’s newest project underway, Recognition and Response to Postpartum Preeclampsia in the Emergency Department (PPED). Learn more about Susan in this Q and A.

Tell us about yourself:

I’m Susan Dimitrijevic and just started with TCHMB as the Senior Nurse Program Manager. I know my last name is a whipper, it is pronounced D-me-tree-yay-vich, but please feel free to call me Susan D.

I’ve lived in Austin for the past 17 years with my husband and son, we love it here, more love is had for Austin in March than in August because of that unrelenting heat but that’s the way love goes, right? We have 2 “covid” dogs K.C. and Bear, I love to snuggle the pups, cook, craft, hang out with friends, and watch movies.

I have been a nurse for over 25 years with most of those years in the NICU. I spent the last 17 years as a leader in the NICU at Dell Children’s Medical Center in Austin as a supervisor, manger, and neonatal program manager. I was involved in and oversaw numerous quality initiatives, and I am extremely excited in my new role at TCHMB to work closely with maternal and neonatal leaders to impact safe care for both mothers and babies.

In the PPED project, I am here to support you with:

• Monthly check in meetings

• Assist with creating your hospital AIM and PDSA cycles

• REDCap assistance and data extraction from REDCap

• Hosting monthly Reinforcement Calls

• Connecting you with like hospitals for collaboration

What is the best way for hospitals who are enrolled in PPED to stay engaged?

• Frequent check in calls with QI nurse

• Small tests of change working toward a big goal, analyzing data to see you’re moving forward.

• Attend Office hours offered twice a month

• Collaboration with others facing similar obstacles and meeting with people who have been able to overcome the obstacle you’re facing. We will help connect you.

What should hospitals that aren’t enrolled know about the project?

We know that not everyone has the bandwidth or capability to be enrolled in the project. Changes made in the reinforcement hospitals and the metrics they’ve been able to achieve will be shared with the hospitals who are part of TexasAIM.

What is the best way to find information about the project if you are enrolled/not enrolled?

If your hospital is enrolled – check out Basecamp. All information including webinars and REDCap instructions, are listed there.

If you’re not enrolled, check out the PPED project page. It has all the information you need to know about PPED as well as the Recruitment Packet and Enrollment Form if you are interested in signing up.

How long is the project going to last?

The project aims are that:

• By September 2023, Emergency Departments will increase patients screened for postpartum status and for elevated blood pressure (SBP >/= 140 and/or DBP >/= 90) and symptoms of preeclampsia by 50% from hospital baseline.

•  By September 2023, Reinforcement Cohort hospitals will increase joint ED and OB unit case reviews performed for cases of postpartum patients with elevated blood pressure (SBP >/= 140 and/or DBP >/= 90) presenting through the emergency department by 50% from baseline.

We anticipate to be done with data collection and analysis in November 2023.

TCHMB Welcomes Four New Executive Committee Members

Read more about why they are a good fit to lead TCHMB’s efforts for quality care and safety for mothers and babies.

Vice-Chair of Executive Committee: Charleta Guillory, MD, MPH, FAAP

Professor of Pediatrics, Baylor College of Medicine

Why are you interested in serving as Vice Chair for TCHMB?

“As the Director of the Neonatal-Perinatal Public Health Program, and as immediate past Director of the Texas Children's Hospital Level II Nursery, I see firsthand, as a pediatrician and neonatologist, complications of prematurity, birth defects and metabolic disorders. These complications require many infants to be transferred into our center from across the state of Texas and beyond its borders.

I have always been an advocate to improve the health of mothers and babies and have recognized that vulnerable populations have poorer outcomes. I have dedicated my life, both professionally and personally, to decreasing infant mortality, improving infant and child health, and eliminating socio-economic, racial and ethnic disparity in maternal, infant and child health outcomes. Serving as Chair of the TCHMB is another opportunity to make an impact on the lives of Texas families. I bring to this committee a voice of experience and a voice of compassionate concern.”

Neonatal Committee Co-Chair: Gillian Gonzaba, NNP

Neonatal Nurse Practitioner, Associate Director for High Reliability/Patient Safety and Simulation, Pediatrix Medical Group, San Antonio

What do you hope to accomplish as Neonatal Co-Chair?

“I would like to work to improve access to care and diversity for all mothers across the state. With improved access to care, there is the potential for improved outcomes for our patients when they are born.”

New At-large EC Member: Jasmine Farrish CNM, MSN, MPH

Nurse Supervisor- Nurse Family Partnership University of Texas at Tyler Health Science Center

What strengths or unique perspectives do you bring to the Executive Committee?

“I have 10 years of maternal child experience in various settings mostly outside of the hospital setting. I believe the community perspective is important piece to serving the entire family in additional to addressing hospital policies. Serving families within the home as a nurse home visitor shed light on the importance of addressing the entire family unit in order to impact change.”

New At-large EC Member: Sonal Zambare, MD

Assistant Professor; Obstetric Anesthesiology, Baylor College of Medicine

What strengths or unique perspectives do you bring to the Executive Committee?

“As a fellowship trained anesthesiologist from a busy practice, I bring my experience in successfully managing many high risk, and complicated pregnant patients. I am the anesthesiologist on the MOM grant (a grant from CMS for helping pregnant patients with substance use disorders, especially opioids), which has broadened my reach to the community. I am the lead on establishing the Enhanced Recovery after Cesarean protocol at Ben Taub Hospital, which has been a successful program.”

Hospitals Are Moving the Needle on Data Collection

The Newborn Admission Temperature (NAT) Project aims to improve the proportion of newborn babies with normal temperatures. We completed more than one year of data collection and early this fall released example evidence-based guidelines that hospitals can choose to use.

The NAT project has also produced benefits for implementing future QI projects and initiatives. For example, we asked hospitals to rate the statement “Being part of the NAT project helps us better report data by race and ethnicity.”

The proportion of hospitals that reported that their participation in the NAT project is helping them improve reporting of data stratified by race and ethnicity increase over the course of the initiative. In the first two data reporting cycles, only about one third (33-38%) of hospitals agreed with this statement, compared to nearly half (47%) of hospitals by the most recent data reporting cycle. (Click here to view the graph.)

Looking at the critical factors and conditions (challenges or barriers) that ensure effective practices are carried out and sustained for future practices is part of implementation science and it is equally as important as improving health outcomes for several reasons:

• Routinely reporting race/ethnicity through the NAT project might have a trickle-down effect as hospitals begin to build these processes within their own systems and projects; and

• The NAT project is the first TCHMB project that has documented outcomes by race and ethnicity and has set the stage for future TCHMB projects to do the same.  This is a strategy that cannot be understated given the disparities in maternal and neonatal outcomes in Texas.

Texas’ perinatal population is diverse and rapidly growing, and despite considerable improvement efforts, disparities in several key perinatal health indicators persist or have widened. Black mothers in Texas had higher rates of severe maternal mortality (SMM) than mothers of any other race or ethnic group over the past decade, and this disparity has widened since 2016.

High-quality, stratified data including race and ethnicity, at a minimum, can help reveal how different subpopulations are faring and track efforts to advance equity in health care and health outcomes. In this way, through its data collection process and through the participation of hospitals, the NAT project is breaking barriers while also working to eliminate disparities in perinatal health outcomes.

Read more about the new CDC grant that will work towards eliminating disparities in Texas.  

A Few Good Reasons for Neonatal Hospitals to Access the NAT Data Dashboard

Timely and accurate data is critical for Texas improve its perinatal outcomes. The new NAT Data Dashboard provides hospitals the opportunity to make improvements that will benefit babies across the state, especially those who are most vulnerable and susceptible to abnormal temperatures at delivery.

Texas has 227 neonatal hospitals that provide critical care to infants and their families. A majority of these are participating in the NAT project, TCHMB’s largest initiative to date. Hospitals submitted one year of data to NAT thus far, and it is the first time the data have been recorded across race and ethnicity. Hospitals can use this data (accessible now through the NAT Data Dashboard) to better understand potential risk groups and opportunities for improvement. Some disparities noted in the data include:

• Infants of black mothers have significantly higher prevalence of hypothermia than any other race/ethnicity at both NICU and Mother-Baby Units. However, the disparity is more significant at NICU.

• Infants with low birth weight have significantly higher prevalence of hypothermia and hyperthermia at NICU.

A few good reasons to access the NAT Dashboard:

• To show hypothermia and other balancing measures varying across hospitals

• To improve the quality of data collection

• To track improvement before and after implementing components of the example evidence-based guidelines

Watch the tutorial video for the NAT Dashboard here.

September is National Suicide Prevention Month

In honor of National Suicide Prevention Month this September, let’s talk about mental health. Mental health is part of overall health – especially for pregnant and new moms. Perinatal mental health disorders are the leading causes of maternal morbidity and mortality – but they are preventable.

Consider these facts:

• Research shows that nearly half of perinatal women in Texas with depression do not get the treatment they need (Mathematica)

• Texas has continued to have high shortage in mental health (MH) professionals. Of these available MH health professionals, few have perinatal mental illness training.

Access to mental health professionals can be tough, but a new initiative launched a few weeks ago to help. We’ve shared information about PeriPAN before, but are excited to announce it is online!

The Perinatal Psychiatry Access Network (PeriPAN) is a new state-funded pilot project available to clinicians in four regions of Texas that are treating new and expectant mothers with mental health concerns. Its goal is to increase a provider’s capacity to treat maternal mental health conditions during the patient visit through a consultation phone line. PeriPAN can help with screening, treatment plans and medication management; the regional psychiatrists serve primary care physicians, family doctors, OB/Gyns, pediatricians and midwives in non-hospital settings in four regions.

PeriPAN is here for clinicians so that maternal mental health can be the first thing that you’re assessing and screening for and not the last. Doing this can help prevent the fatal impact perinatal mental conditions have on Texas moms every year.

For more information about where PeriPAN is offered as a pilot, and how to enroll as a provider, visit https://tcmhcc.utsystem.edu/peripan/.  The page includes other resources available statewide, such as.

o   Women & Children | Texas Health and Human Services

o   For immediate mental health resources, call 800-273-8255 or, visit MentalHealthTx.org.

o   Suicide prevention hotline: Call or text: 9-8-8; Chat online: 988lifeline.org

o   The Baby Blues | Texas WIC

NAT is TCHMB's largest Statewide Initiative to Date

The Newborn Temperature Admission (NAT) Project posted new data from the Jan.-March reporting period, showing a majority of hospitals participating, the largest initiative in TCHMB’s history. When the April-June 2022 data is complete (due July 31st), the hospital level data will be shared back via the dashboard. The hospital level dashboard can establish a “baseline” and prepare for implementing evidence-based guidelines to increase the proportion of newborn infants with admission temperatures within normal limits. Read the Jan.-March summary report here.

Key Points:

• An astounding 76 percent of enrolled hospitals reported data for the period.

• There are currently 160 hospitals enrolled, making it TCHMB’s largest statewide initiative to date.

• This is the first time a TCHMB initiative has tracked data by race/ethnicity.

Why it matters:

By tracking data from each hospital, the NAT project can complete statewide analyses, including by region or type and size of hospital, as well as hospital-specific analyses.

Testimonials from NAT Project Ahead of Hospital-Level Dashboard

Only July 31, 2022, hospitals actively participating in the Newborn Admission Temperature Project will submit another round of data, marking one full year of data collection. This data will allow TCHMB to provide participating hospitals with hypothermia prevalence at their own hospitals, and more. Having a full year of data means that the estimates are more reliable, and can provide meaningful insights into patterns at the state and regional levels.

The NAT project is the largest in TCHMB history with 160 hospitals enrolled. During the most recent round of data reporting, over 75% of enrolled hospitals submitted data to TCHMB. See what some hospitals are saying, after nearly one year of participating in the NAT project:

With 25,000 deliveries a year, we were faced with a daunting project to obtain race and ethnicity on each newborn and collect temperatures according to the different parameters for well baby and NICU. We leveraged our ability to create documentation reports and perform data analysis to avoid the manual tracking and chart review, cutting down manual validation by an estimated 95%.

- Memorial Hermann Health System

The project was a definite challenge for our institution because of the large number of patients we care for. Obtaining data was very labor intensive and required working with a data architect to get a custom report built. Building the report, obtaining data outside of our NICUs and validating data were all challenges we encountered which required a lot of time, but we eventually overcame those challenges.

- Texas Children’s Hospital

In 2019-2020, Doctors Hospital of Laredo (DHL) solely tackled the newborn admission temperature QI project knowing that thermoregulation is the holy grail of neonatology. Huge strides were made towards adequate thermoregulation of the newborn, bringing DHL very close in achieving the goal.

In late 2020, when TCHMB announced the QI initiative of Newborn Admission Temperature (NAT) to increase newborn health care quality and patient safety; DHL did not hesitate in enrolling.  We are hopeful in reaching the goal and provide quality care to every single baby born at DHL by participating in the state-wide NAT project.

Thank you for allowing us to participate.

- Doctors Hospital of Laredo

If your hospital has questions about the project or needs technical assistance in reporting to the project, visit NAT Office Hours, every Wednesday from 12-2 p.m. CST.

Q&A with Dr. Sarah Wakefield

Dr. Sarah Wakefield, Chair of the Department of Psychiatry at Texas Tech University School of Medicine, joined as Medical Director of the new Texas Perinatal Psychiatric Access Network (TX PeriPAN) in March 2022. The new pilot initiative officially kicks off in late summer 2022, and Dr. Wakefield will lead the team to get every detail in place so that four health related institutions can provide support and services to providers who see pregnant women and new mothers suffering from maternal related mental health issues.

We spoke to Dr. Wakefield to learn more about her experience and what drives her to be successful in leading PeriPAN’s charge.

What drew you to the initiative and to become medical director for TX PeriPAN?

I became interested in maternal mental health when I was in my child and adolescent psychiatry fellowship. At the time I was pregnant with my first child and really feeling the weight of all it is to carry a child and be a mother. I would complete assessments with kids, and so many of the moms had untreated mental health distress or pathology. Many of them had been suffering since their pregnancy or postpartum time and were only seeking care now to aid their children. I just realized how many moms out there are suffering silently.

My favorite thing about treating children is that you really can change the trajectory of a someone’s life the earlier you intervene. It became apparent to me that if we could have treated mom when she was pregnant or postpartum, or even before, we could have prevented so many of the things that are happening with the child or at the very least better equip mom to respond in a therapeutic way.

Then I met Susan Kornstein, a founder and leader  in reproductive psychiatry, at a conference. I was finishing my training and contemplating jobs. We talked about women’s mental health and what impacts it could have downstream. She inspired me to set up a reproductive psychiatry clinic at my university, and I had a very supportive chair who gave me the greenlight. So as a brand-new junior faculty member, I set up both a clinic and a psychiatry training experience in perinatal psychiatry. Since then, I have spent a lot of time educating and treating women in this population and advocating for how important this care is. At the same time, reproductive psychiatry initiatives have developed around the country, and we all continue to share resources to improve both care and training. This has reinforced to me how crucial and critical this work is, but also how doable it is. I feel like things are coming full circle to be able to help bring this to Texas.  

Are there any particular stories or experiences that exemplify the dire need for these types of services, especially due to the shortage of mental health providers and needs of women in Texas?

There are two primary categories that stand out to me as points we could have easily changed the trajectory for a mom and her babies if we just did a little better job of working together and collaborating. One is the mom who has just been sick for a really long time. She’s been functional but she’s been sick, and she only justifies treatment in order to give her child a better life. This might even be her second or third child, and she has been through pregnancy, postpartum, and well-child checks without anyone offering her screening, intervention, or resources. The other group is the mom who has been misdiagnosed and has suffered because her treatment doesn’t match her needs. This seems to especially happen in the context of trauma. We have got to do a better job of assessing and responding to the traumas that so many women experience. I think we can help with both of these with appropriate screening.

What challenges do we face with providers serving pregnant women and new mothers who might need help?

When you look at the statistics of how frequent depression, anxiety, trauma and PTSD are, mental health issues should be the first thing that we’re assessing and screening for and not the last. This is a huge shift in medical care but one that is absolutely supported by the evidence.

We know that it takes about 15-20 years on average for research to make it into practice. And this conversation about trauma is a fairly new one respectively in our medical training. The adverse childhood experiences study from the 1990s showed us that the more adverse trauma and childhood experiences you have, the more likely you are to have GI issues, cancer, hypertension, diabetes – in addition to being more likely to present for depression and anxiety. 

Mental health distress like postpartum depression and anxiety are the most common complications of pregnancy, and so for us, it’s about trying to teach mom and teach clinicians that the healthiest mom creates the healthiest possible baby. This concept of epigenetics: what is happening to mom is affecting how your genes are expressed and how genes are passed on, so you have this downstream positive or negative effect. We want babies to have the healthiest start and the healthiest environment in which to grow.

How do you plan to inspire providers to utilize these services?

First you have to tell the story. Mental health feels like such a big vacuum and it feels so complex. In many ways it is and people don’t know what to do about it.

But we can tell people that improving mental health isn’t rocket science. It’s about building relationships and supportive community. It’s about screening early and often as a part of routine medical care. It’s about having an expert you can call for consultation and recommendations, and it’s about utilizing the tools that we have to treat mental health distress.  

Women should know it’s typical to screen when you come into your family medicine doctor, obstetrician or your pediatrician. With the ability to provide support in real time, through lines like the Perinatal Psychiatry Access Network, we can create that culture of support and relationships for clinicians, for moms, for families, and ultimately for the children we are all trying to raise.

A Majority of Birthing Hospitals Enrolled in NAT Project

The Newborn Admission Temperature (NAT) Project is a TCHMB Quality Improvement project to increase the number of newborn infants with admission temperatures within the normal limits – released hospital-reported data from Oct.-Dec. 2021. The project uses this data to inform hospital quality assurance and performance improvement programs, ultimately affecting positive outcomes for infants who are at risk for illness, disease or death if they do not fall in the normal limits.  

From October to November 2021:  

• 3.1% of infants had hypothermia and 5.9% of infants had hyperthermia at admission to the NICU;  

• 0.5% of infants had hypothermia and 3.3 % of infants had hyperthermia at admission to the Mother-Baby Unit;  

• Very low birthweight infants were significantly more likely to have hypothermia and hyperthermia at NICU admission. 

TCHMB continues to work with the RAC Perinatal Care Region (PCR) Alliance in order to connect with every single hospital stakeholder across the state. The current number of enrolled hospitals is 158. It continues to be geographically well-represented across TX. In this reporting period, NAT project covered approximately 58% of annual deliveries in Texas (compared to 51% for the July-September 2021 reporting period).  

The summary is available on the NAT project page. 

Newborn Admission Temperature (NAT) Project Update

The Neonatal Committee of the Texas Collaborative for Healthy Mothers and Babies (TCHMB) has completed two data collection periods for the Newborn Admission Temperature (NAT) Project. Of the 157 hospitals enrolled, 110 (70%) have submitted data for the most recent (second) data collection period. Overall, data quality has improved since the first data collection period, with more hospitals submitting data stratified by race/ethnicity. The NAT team is currently working on a report that will be published to the website in the coming month.

For hospitals needing additional support, we will provide weekly “NAT Office Hours” on Wednesdays from 12-2pm. Please feel free to drop in any time during these sessions for individual support. If you need the link for the meeting or if this time does not work for you, please reach out to us at nat@utsystem.edu.