OBI Data Variables and Definitions
APRIL RICHMOND, BSN, RN SARAH EVILSIZER, BSN, RN OBSTETRICS INITIATIVE DATA MANAGERS [email protected] Module Objectives
• Become familiar with the OBI Data Manual (v2) • Explore the different OBI data sections and associated variables • Identify additional resources and support OBI Program Manual
2019 Data Collection Manual v2 obstetricsinitiative.org/data-abstraction Important Documents
• Section: OBI Data Variables and Definitions Demographics Neonatal Outcomes Labor Management Maternal Outcomes Delivery Post Discharge Events Cesarean Delivery Arrest Disorders DEMOGRAPHICS Demographics
• Hospital Name • Ethnicity • Patient Last Name • Race • Patient First Name • Patient Postal Zip Code • Medical Record Number • Patient Insurance Type • Maternal Birthdate Demographics
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Mouse Minnie
1234 01/01/1990
✔ 48888 ✔ LABOR MANAGEMENT Labor Management
• Admission • Maternal Comorbidities Present on Admission • Planned Mode of Delivery • Admission with Labor for Planned Vaginal Birth • Pain, Discomfort, and Coping During Labor • Labor Support Admission Date & Time
• Record the date and time the patient was admitted to L&D Unit for care • Become familiar with your hospital’s admitting processes Examples: – IF inpatient admission orders are placed right before or at time of birth THEN use the time patient was placed in labor room or unit
– IF the patient is in observation status during workup for HTN to determine whether or not to admit THEN use date/time patient was placed in labor room or unit Admitting Provider and Nurse Provider Admitting Patient to L&D • Focus on the provider who made the decision to move the patient to the next level of care Select the Attending Physician or CNM from the drop down in the registry – If provider is not found in the list, follow instructions in the manual to add a new provider. Admitting Nurse • L&D Nurse receiving the patient from triage The admitting RN will most likely be the Nurse completing the admission intake assessment Free Text Field, enter as: Last Name, First Name Gravidity and Parity on Admission
• OBI only includes nulliparous patients (P0) If parity is documented as 1 or more then re-review the OBI case selection criteria for inclusion!
• Make sure you are reviewing G&P status BEFORE delivery as this status will update following delivery Maternal Height & Weight
• Height entered as inches or centimeters • Weight entered as pounds or kilograms Admission weight: The most recent weight prior to delivery Pre-Pregnancy weight: The last pre-pregnancy weight (up to 12 weeks gestation) Prenatal Care
• Determine if the patient received prenatal care If prenatal care is not discussed in the EMR, select “Unable to Determine”
• If Yes is selected, enter the date (or estimated date) prenatal care started If the month is known, but not the exact te day, use the 15th of that month If you can not reasonably estimate the start of prenatal care, leave it blank Comorbidities Medical • Pre-Pregnancy Diabetes Hx of diabetes prior to pregnancy • Gestational Diabetes Developed for the first time during pregnancy • Pre-Pregnancy Hypertension Chronic Htn diagnosed on or before 20 weeks • Gestational Hypertension Gestational Htn, pre-eclampsia, eclampsia, HELLP syndrome during pregnancy • Asthma Comorbidities Substance Use • Alcohol use anytime during pregnancy • Tobacco use before or during pregnancy If yes, record quit smoking status • Opioid use during pregnancy See Appendix D for a reference list of Opioids For MAT therapy, select the appropriate Medication used as part of the program Planned Mode of Delivery
What was the planned mode of delivery AT TIME OF ADMISSION?
• Admission with labor for planned Planned vaginal birth Labor for • Pain, discomfort, and coping Vaginal Delivery during labor • Labor Support Delivery Section Planned • Primary Indication for Planned Cesarean Cesarean Delivery Planned Vaginal Birth
Labor Status at Admission • Determine if the patient was admitted for Induction vs Spontaneous Onset of Labor and membranes status • If being admitted for induction, determine primary reason Secondary reasons will be entered in separate field Planned Vaginal Birth
Ripening Prior to Admission • Outpatient methods prior to admission Transcervical Catheter – Balloon Catheter, Foley Balloon, Cook Catheter Prostaglandins – Cervidil, Misoprostol Planned Vaginal Birth
Ripening/Induction Interventions During Admission • Determine all interventions utilized Transcervical Catheter intended to be used simultaneously with a medication should be captured as combined interventions Individual Interventions Combined Interventions • Amniotomy • Transcervical catheter and oxytocin as • Cervidil a concurrent intervention • Membrane Stripping • Transcervical catheter and misoprostol • Misoprostol Alone as a concurrent intervention • Oxytocin Alone • Transcervical Catheter Alone Planned Vaginal Birth
Cervical Exam at Time of Admission • Select Yes if: Cervical exam was done 30 minutes before or after admission Cervical exam was done in clinic within 4 hours prior to admission – When Yes is selected *Abstraction Tips: Enter details about dilation, station, and effacement Dilation • Round to the nearest 0.5 cm • Closed = 0 cm • Complete = 10 cm Effacement • Thick = 0% Effaced Station • High = -5 Station Planned Vaginal Birth
Fetal Monitoring Type Ordered at Admission • Intent is to identify what type of fetal monitoring was planned/ ordered upon admission Review Admission Orders and H&P to determine the initial plan for fetal monitoring If plans change and actual monitoring type differs from orders, still only capture what was ordered Planned Vaginal Birth
Rupture of Membranes • Determine if ROM occurred spontaneously or via amniotomy • Record date and time of ROM, if unknown check “Not Documented” • Record cervical dilation at time of ROM Use the exam closest to, but within 60 minutes before or after ROM Round to the nearest 0.5 cm Planned Vaginal Birth
Oxytocin • Determine if Oxytocin was administered prior to delivery for induction or augmentation • If Yes is selected in the workstation, additional questions will populate: Planned Vaginal Birth
Active Labor! Planned Vaginal Birth
Fetal Monitoring Used for Active Labor • Actual fetal monitoring type(s) used during active labor Continuous Electronic Fetal Monitoring Intermittent Auscultation – Doppler Checks – Intermittent Monitoring Not Documented Planned Vaginal Birth
Nurse Supporting Active Labor • Free Text Field, enter as: Last Name, First Name
• Provider Supporting Active Labor • Physician or CNM at the time of the first exam describing dilation of 6 cm or more Select the Attending Physician or CNM from the drop down in the registry – If provider is not found in the list, follow instructions in the manual to add a new provider. Planned Vaginal Birth
Clinical Chorioamnionitis • Suspected intrauterine infection based on clinical assessment during labor Assisted Delivery • Forceps or Vacuum extraction were attempted to assist with vaginal delivery If either method is attempted, determine if the attempt led to the outcome of vaginal delivery (successful) or not (unsuccessful). Pain, Discomfort, Coping During Labor
Methods Used to Assess Pain, Discomfort, and Coping Capture all assessment methods used during labor
Pain Management Techniques Capture all pain management methods used during labor Pain, Discomfort, Coping During Labor
Regional Anesthetic used during labor • Determine if regional anesthesia was used for labor management, NOT as part of a cesarean procedure Labor Support Shared Decision Making Discussion with patient about preferences specific to labor and delivery – Birthing Plan – Labor Partnership – Discussion about birthing preferences
Labor Support Person Doula Support Person DELIVERY Delivery
• Complete Dilation and Pushing • Provider and Nurse at Birth • Mode of Delivery • Delivery Outcomes Complete Dilation and Pushing
• Date and time of Complete Cervical Dilation If the patient did not reach complete dilation then select not applicable
• Date and Time Patient Started Pushing If the patient did not start pushing then select not applicable Delivering Provider and Nurse at Birth
• Delivering (Attending) Provider - Provider who was present and providing hands on delivery care Select the Attending Physician or CNM from the drop down in the workstation. – If provider is not found in the list, follow instructions in the manual to add a new provider
• Delivering RN – RN providing maternal care at time of delivery Free Text Field, enter as: Last Name, First Name Actual Mode of Delivery
• Select the actual mode of delivery This may be different that the planned mode of delivery Selecting a cesarean mode will populate the Cesarean Delivery Section Lacerations
• Episiotomy • Third Degree Laceration • Fourth Degree Laceration CESAREAN DELIVERY Cesarean Delivery
• Cervical Dilation at Cesarean Delivery Use the cervical exam closest to the Cesarean
• Primary Indication for Cesarean Delivery Review the Op Note to determine the primary indication of cesarean – Secondary Indications will be entered in a subsequent field The following primary indications will prompt Labor Arrest Disorder section: – Latent Phase Arrest of Dilation – Arrest of Descent- First Stage – Active Phase Arrest of Dilation – Arrest of Descent- Second Stage LABOR ARREST DISORDERS Labor Arrest Disorders
• Latent Phase Arrest (Less than 6 cm) Refers to patients in spontaneous labor Induced patients that did not progress to 6 cm -> “Failed Induction” Labor Arrest Disorders
• Active Phase Arrest (6 cm or More) Labor Arrest Disorders
• Arrest of Descent- First Stage • Arrest of Descent- Second Stage Prophylactic Antibiotics for Cesarean
• Determine if IV antibiotics were initiated prior to the Cesarean Incision Select Yes if IV abx were started prior to the incision – Select the prophylactic abx given Select No if abx were started after the incision or if not administered at all Measured Blood Loss During Delivery • Select appropriate unit of measure for blood loss Estimated blood loss or Quantified blood loss – When both a QBL and EBL are documented, record QBL – If provider documentation suggests that QBL is questionable, use clinical judgement and report the EBL Birth Details
Gestational Age at Delivery • Weeks and Days If less than 37 weeks re-review to determine if the case meets NTSV definition
Birth Weight • Record in Grams If weight entered is less than 2500 or more than 5000, a warning will appear – confirm the out of range birth weight by selecting “OK” Count of RNs & OB Providers
• Count of RNs Include all Registered Nurses from admission through delivery that have documented in the maternal chart such as primary RNs, break coverage, medication administration, procedure assist Do not include RNs present during delivery to care for the baby or provide additional staff support without hands on maternal care.
• Count of OB Providers Include CNMs, PAs, Attending and Resident Physicians involved in the patient’s direct care from the time of admission through delivery NEONATAL OUTCOMES Neonatal Outcomes
• 1 and 5 minute APGAR • Arterial Cord pH • Shoulder Dystocia • Assisted Ventilation • Birth Injury • NICU, Special Care, Hospital Transfer Neonatal Outcomes
1- And 5-Minute APGAR • Enter APGAR scores between 0-10 If the APGAR Score is not documented, select “Not Documented” Neonatal Outcomes Arterial Cord pH • Enter a pH value between 6.00-8.00 In the event that the pH was drawn but too low to register, select “Too Low to Calculate” When a pH value is not found in the chart, select “Not Documented” Neonatal Outcomes
Shoulder Dystocia • Determine if Shoulder Dystocia occurred during delivery If Yes, Enter length of time in minutes, rounding to the nearest minute When documented as less than 1 minute, enter length of 1 minute Neonatal Outcomes
Assisted Ventilation • Determine if Nasal Cannula, CPAP, or Intubation was required within the 2 hours after delivery PPV is not considered assisted ventilation
• If yes, select the type and record if it was required for >6 hours Neonatal Outcomes
Admission to NICU or Other ICU • Intent is to determine if the neonate required NICU or ICU care during the delivery admission Examples: – IF the neonate was in the NICU only for resources not otherwise available (ex. to receive phototherapy) but is still being managed by the well baby team THEN Select No, as the neonate did not require a higher level of care
– IF the neonate was transferred to a NICU or ICU within the delivery facility or transferred to an outside facility for a higher level of care. THEN Select Yes for Admission to NICU or Other ICU Neonatal Outcomes
Indication for Admission to NICU or Other ICU • If yes is selected for admission to NICU or Other ICU, you will be prompted to select the primary reason for NICU /ICU admission Neonatal Outcomes
Significant Birth Injury • Significant birth injuries to look for include: Skeletal fracture(s) Neurologic injury, central – Humerus or Clavicle Soft tissue injury – Other than Humerus or Clavicle Solid organ injury Hemorrhage Demise – Intracranial – Intrapartum – Non-Intracranial – Neonatal Nerve injury Other – Peripheral brachial plexus injury – Description required – Peripheral facial nerve MATERNAL OUTCOMES Maternal Outcomes
• ICU Admission • Discharge Transfer to Another Hospital
• Opioid Prescribing • Post Discharge Events • Outcomes and Procedures • Death Maternal Discharge or Transfer
Maternal Admission to ICU • Enter the date This variable applies only to the delivery encounter
Maternal Discharge Date and Time • Enter date and time of discharge or transfer orders written If a discharge order was written in anticipation for the future (e.g. next day) then record date and time patient was officially discharged from the hospital.
Maternal Transfer to Another Hospital Opioid Prescribing at Discharge
Opioid Prescription at Discharge • Determine whether a patient was prescribed an opioid at discharge In efforts to decrease opioid prescribing, it is important to know whether or not the patient received a prescription. If the patient was given an opioid prescription then select yes which will open an Opioids tab to enter prescription details Post Discharge Events
ED Visit, Triage Visit, or readmission within 30 days postpartum (delivery date) • Select Yes or No Select yes for any ED visit, triage visit or readmission that happened within 30 days postpartum Use records available in hospital EMR. Contacting outside facilities is not necessary at this time.
• If yes is selected, this will enable an Post Discharge Events tab to enter further details Maternal Outcomes
During delivery through 30 days postpartum Use records available in hospital EMR. Contacting outside facilities is not necessary at this time. • Maternal Morbidity Complications • Maternal Morbidity Procedure • Access to Postpartum Clinical Notes • Maternal Death Maternal Outcomes
Complications • The maternal complications comprises Severe Maternal Morbidity indicators Other complications of interest • Select all documented complications OR none A date box will appear for each complication selected Enter the date that the complication began Maternal Outcomes
Procedures • The maternal procedures comprises Severe Maternal Morbidity indicators Other procedures of interest
• Select all documented procedures or none A date box will appear for each procedure selected Enter the date that the procedure was started Maternal Outcomes
Access to Postpartum Clinic Notes • Select yes if you were able to access postpartum notes to inform 30 day maternal outcomes It is only expected that the CDA use their hospital EMR Depending on hospital and private practices, this may mean very little to no follow up is available This variable helps to provide context behind hospital morbidity and mortality rates Maternal Outcomes
Maternal Death • Enter the date of death OPIOIDS Opioid Prescribed at Discharge -> Yes
The opioid tab is referred to as a “one to many tab”. To begin entering an opioid prescription, click on the + sign. Each entry is considered a “row”. Opioid Prescribed at Discharge
Type of Opioid Prescribed • Select the opioid type from the drop down list For combination medications like Norco (hydrocodone/acetaminophen), select hydrocodone Opioid Prescribed at Discharge
Unit of Opioid Prescribed • Select the unit prescribed If you cannot determine the unit or dose, select Not documented. You will not need to enter any further information. Opioid Prescribed at Discharge
Dose of Opioid Prescribed • Enter the dose For combination medications like Norco (hydrocodone/acetaminophen) 5/325 mg -> enter 5. There is 5 mg of opioid in 1 tablet, 325 mg is the amount of Acetaminophen. Opioid Prescribed at Discharge
Quantity of Opioid Prescribed Once all fields are complete, click save to save the row • Enter the quantity Opioid Prescribed at Discharge
If there was more than one opioid prescribed… • Enter all of the opioid prescriptions given the patient at discharge You will see the event entry that was previously saved as a row in the box. Click on the + sign to add another opioid entry POST DISCHARGE EVENTS Post Discharge Event -> Yes
Once all fields are complete, click save to save the row
ED or Triage Visit
Select the event type Click on the + sign to add an event Type in key terms to select the best ICD 10 code associated with the visit or readmission Enter the date of the event Post Discharge Event -> Yes
If there was more than one post discharge event… • Enter all of the events that occurred for any reason within 30 days postpartum You will see the event entry that was previously saved as a row in the box. Click on the + sign to add another event entry Obstetrics Education and Resources
• The Obstetrics Initiative (OBI) https://www.obstetricsinitiative.org
• American College of Nurse-Midwives (ACNM) https://www.midwife.org/default.aspx
• American College of Obstetricians and Gynecologists (ACOG) https://www.acog.org/
• Birth Tools Toolkit http://www.birthtools.org/
• California Maternal Quality Care Collaborative (CMQCC) https://www.cmqcc.org/
• Michigan Alliance for Innovation on Maternal Health (MI AIM) https://sites.google.com/miaim.us/miaim/home
• Reducing Primary Cesareans Health Birth Initiative https://birthtools.org/Reducing-Primary-Cesareans-NEW Next Steps We are here to support you! OBI Data Management Team
Sarah Evilsizer, BSN, RN April Richmond, BSN, RN Kirsten Bonawitz, BS OBI Data Manager OBI Data Manager OBI Program Associate
After reviewing the data manual and resources, please send questions to [email protected] Thanks for watching!
HAVE QUESTIONS? WANT TO CHAT? CONTACT US AT: [email protected] OR VISIT: WWW.OBSTETRICSINITIATIVE.ORG