Kpsc diabetes in pregnancy pathway 8.6.2012

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  • F.
  • HIGH RISK FOR GDM: Personal h/o GDM, Previous Infant >4000 g, BMI >/= 40, Prior shoulder dystocia, Ist trimester HbA1c 6-6.4%
  • Kpsc diabetes in pregnancy pathway 8.6.2012

    1. 1. KPSC DIABETES IN PREGNANCY PATHWAY Working Regional Guidelines
    2. 2. IMMEDIATE IMPACT FOR RIVERSIDE• Centers will be INDIVIDUALLY graded regarding COMPLIANCE of the pathway.• INDIVIDUAL MEDICAL CENTER PERFORMANCE and possibly some effect on BONUSES which will be determined by measuring the completion of TWO performance indicators MEASURED AS OF THIS JULY 1st 2012
    3. 3. MEDICAL CENTER PERFORMANCE INDICATORS TIED TO ACCOUNTABILITY/MONETARY INCENTIVE MEASURED AS OF JULY 1, 2012COMPLETION OF TWO INDICATORS:1.IN2.OUTAnticipate other indicators will be evaluated infuture
    4. 4. IN: HbA1c• IN: All OB patients get a Hemoglobin A1c with INTAKE prenatal labs -they will be measuring the percentage of patients getting their HbA1c test on the FIRST prenatal visit (a measurement of our centers compliance with the Clinical Pathway)
    5. 5. OUT: FBS2. OUT: All Patients with GDM COMPLETE a FBS test at the 6-week post partum appointment:A. Resolve GDM DiagnosisB. Patient to be coded with HISTORY OF GDMC. Patient will get a FBS test or a 2 hour GTT-if normal: patient to be flagged for annual HbA1c test,-if abnormal, refer patient to Primary care for diabetesdiagnosis confirmation and medical management.As you know, A Fasting Blood Sugar (may also be called FPG,fasting plasma glucose of 126 mg/dL or above is abnormaland needs to be confirmed. The patient must be fasting ofeverything except water for at least 8 hours prior to test)
    6. 6. KPSC DIABETES IN PREGNANCY CLINICAL PATHWAY COMPLETE PROGRAM REGIONAL GUIDELINES
    7. 7. Program Goals• Improve and maintain member’s self care skills and provide treatment to avoid higher level of care• Avoid Macrosomia, shoulder dystocia• Avoid other pregnancy complications such as Cesarean delivery, NICU admission• Intensive management to maximize proactive preventative therapy and medication monitoring• Minimize the risk of maternal complications including worsening retinopathy, nephropathy, or hypertension in Pre-gestational Diabetes (PGDM)
    8. 8. DIABETES SCREENING & EDUCATION FOR ALL OBSTETRIC PATIENTS HgA1c with prenatal labs Risk assessment for GDM @ 1st visit  HIGH RISK FOR GDM/NOT DM- Receive GCT/GTT ASAP  LOW RISK FOR GDM- GCT/GTT @ 24-28 weeks Nutrition, Balanced Diet, Exercise Information  Healthy Beginnings Newsletter AND/OR Prenatal Classes Proper weight gain during pregnancy  Healthy Beginnings Newsletter AND/OR Prenatal Classes Risk Stratification of Diabetic Patients to Low, Medium, or High  Based on history or documented laboratory criteria
    9. 9. DIABETES SCREENING AND EDUCATION FOR ALL OBSTETRIC PATIENTSOB INTAKE/FIRST PRENATAL VISIT:-ALL patients screened with hemoglobin A1cwith initial prenatal labs (first compliance measure)-ALL patients are assessed for risk for GDM atthe first prenatal visit
    10. 10. DIABETES SCREENING STRATEGY
    11. 11. FIRST PRENATAL VISIT GDM RISK ASSESSMENT FOR DIABETES SCREENINGHIGH RISK of GDM: (ANY OF THESE)-Personal history of GDM-BMI ≥ 40-Prior infant ≥ 4000 g (8 lbs 13 oz)-Prior shoulder dystocia-HgA1c 6.0 – 6.4 %
    12. 12. Possible Smart Phrase: GDM Risk Assessment. ANY Yes- Early GCT/GTTGDM RISK ASSESSMENT:1.Personal history of GDM: No/Yes2.BMI ≥ 40: No/Yes “.bmi”3.Prior infant ≥ 4000 g (8 lbs 13 oz): No/Yes4. Prior shoulder dystocia: No/Yes5.1st Trimester HgA1c 6-6.4%: No/Yes “.lasta1c” or“Ordered and Pending”ASSIGNED GDM SCREENING RISK:Low- Patient for 24-28 week glucose testing unlesspending HgA1c results score HIGHHIGH- Patient sent for GCT as soon as possible
    13. 13. FIRST PRENATAL VISIT ALL OB PATIENTS• Nutrition, Balanced Diet, and Exercise Information – Healthy Beginnings Newsletter AND/OR Prenatal Classes• Education regarding proper weight gain during pregnancy – Healthy Beginnings Newsletter AND/OR Prenatal Classes
    14. 14. Diabetic Patient Risk Stratification: Documented CriteriaLOW RISK: A1GDM-Diagnosed as Gestational Diabetes BUT WITH first trimesterHgA1c < 6.5 %MEDIUM RISK: A2GDM-good controlled-Well-controlled A2GDM (on Insulin or Glyburide)HIGH RISK: PGDM, A2GDM-poor control, 1st trimester A1c ≥ 6.5%-POORLY Controlled A2GDM OR Pre-Gestational Diabetes Mellitus(PGDM) (diagnosis at time of conception, or poorly controlledA2GDM, or first trimester HgA1c ≥ 6.5%
    15. 15. Risk Group Intervention *Refer to Diabetes Care Team (includes class, nutritional counseling, dietician, certified Diabetes educator, social worker)Low Risk *Issue Glucometer for blood sugar monitoring -FBS, 1 hour post prandial blood sugar after each meal *Blood sugar review at least every 2 weeks by OB Diabetes Care Team member *Consider Ultrasound to assess fetal growth between 36-38 weeks or when clinically indicated A1GDM with *If good glycemic control and no other complications, consider delivery NO LATER than 41 w 0 dFirst Visit *If other complications such as poor compliance, history of HTN, history of stillbirth; consider delivery before 40 w 0 d • If EFW ≥ 4500 grams, consider c-section *At postpartum appointment -resolve GDM diagnosis and code history of GDM diagnosis in problem list A1c < 6.5 % *Order FBS or 2 hour GTT between 6-12 weeks postpartum (patient must complete)Medium Risk * All "Low Risk" Interventions *Refer to Diabetes Care Team (includes class, nutritional counseling, dietician, certified Diabetes educator, social worker) Well *Blood sugar review at least every 1-2 weeks with adjustments of medication(s) by care provider controlled * Non-stress testing twice weekly at 32 -34 weeks, or when medications starts after 32 weeks gestation A2GDM Requiring Rx • Consider delivery between 39-0/7 weeks and 40-0/7 weeks gestational age * All "Low Risk" and "Medium Risk" Interventions * Refer to Diabetes Care Team (includes class, nutritional counseling, dietician, certified Diabetes educator, social worker) and Perinatologist for Consultation of management if clinically indicated * Blood sugar review at least every 1-2 weeks with adjustments of medication(s) by care provider * Non-stress testing twice weekly at 32 -34 weeks (consider earlier testing if retinopathy, nephropathy, hypertension, poorHigh Risk glycemic control, IUGR) • If poor glucose control or other risk factors, consider amniocentesis for fetal lung maturity and delivery prior to 39 weeks. Poorly- • If good glycemic control and no other complications, consider delivery at 39 w 0 d. Recommend delivery no later than 40 w controlled 0 d. A2GDM, or * Pre-Gestational Diabetes (PGDM):PGDM, or ***1st Trimester Labs: Serum Creatinine, TSH, ALT, AST, and random urine microalbumin (24 hour urine for total protein if 1st microalbumin > 30)Trimester A1c ***Eye photo (if not done 6-12 monhs prior to pregnancy); retinal eye exam (with dilation) if moderate or greater diabetic ≥ 6.5 % retinopathy *** EKG (if age 35 or older, or with vasculopathy, cardiac issues, or hypertension) ***Targeted ultrasound (including careful assessment of fetal cardiac structures) at 18-22 weeks to rule out congenital anomalies ***Repeat hemoglobin A1c in the third trimester (36 weeks) ***Serial ultrasounds for fetal growth at 28 weeks gestation
    16. 16. PGDM Retinal Exam Algorithm1. GDM: No DR(Diabetic Retinopathy)screening2. PGDM: (Never had screening): Photo during pregnancy –No dilation*3. PDGM: (No DR, screen < 1yr): Photo during pregnancy4. PGDM: (No DR, HgA1c >7.5, screen > 6 mo ago): Photo during pregnancy –No dilation*5. PGDM: (Minimal DR with HgA1c 6.5 – 7.5, screened > 6mo ago): Photo during pregnancy: No dilation*, otherwise photo 1 year6. PGDM: (Minimal DR with HgA1c 6.5 – 7.5): Photo during pregnancy –No dilation*7. PGDM: (Moderate DR): EXAM DURING PREGNANCY WITH DILATION*unless moderate or greater DR detected
    17. 17. OUT: Post-Partum Appointment ALL Patients diagnosed with Gestational Diabetes Resolve GDM diagnosis and code with history of GDM diagnosis on patient problem list Fasting Blood Sugar (FBS) or 2 hour GTT is ordered and completed Patient is counseled regarding increased risk of GDM in future pregnancy Discuss options for birth control Patients less than 50 years old
    18. 18. Post Partum FBS Test by InterventionsOB/GYN< 126 mg/dL • No interventions from OB/GYN Needed • Patient with be “flagged” for Annual HbA1c test (results go to Diabetes Case Managers from Adult Primary Care)≥ 126 mg/dL • OB/GYN refer patient to adult primary care for diagnosis for Diabetes Mellitus and managementAnnual HbA1c Screening* by InterventionsPCP≤ 5.6% Continue annual HbA1c screening test5.7 – 6.4 % • Diabetes Case Managers will contact patient with results • Patients will be given resources to address exercise, weight loss, nutrition, and diabetes prevention (either Health Education Classes or Patient handouts) • Patient screened for reproductive plan: “Are you planning to become pregnant in the next year?” o No- assess for birth control and given referral for birth control if appropriate o YES- referral from preconception counseling (OB/GYN)≥ 6.4 % • Diabetes Case Mangers will refer patient to adult primary care for diagnosis of Diabetes Mellitus and management • Patients will be given resources to address exercise, weight loss, nutrition, and diabetes prevention (Heath education classes and/or Patient handouts) • Patient screened for reproductive plan: “Are you planning to become pregnant in the next year?” o No- assess for birth control and given referral for birth control if appropriate o YES- referral from preconception counseling (OB/GYN) *1. A1c will be specifically labeled for post partum or pregnancy related- using batch order functions or manual batch orders 2.Patients who miss their annual screening may receive a reminder outreach letter 3.Explore the possibility that results go into a pool
    19. 19. Possible Outcome Reports1. Percentage of patients getting A1c on first prenatal visit (AS OF JULY 1 2012)2. Postpartum Appointment Percentage Patients who: A. Had GDM and COMPLETED FSB or 2 h GTT ordered (AS OF JULY 1 2012) B. Has PGDM got an A1C ordered3. For all Mothers with GDM or PGDM, # of neonates ≥4500 grams4. For all Mothers with GDM/PGDM, the primary C-section rate5. For all Mothers with GDM/PGDM, the number of NICU admissions at term (≥37.0 weeks)6. For all Mothers with PGDM, the percentage of patients who have a 1st trimester A1c < 6.5% and the percentage of patients who have a A1c <6.5% in the third trimester (~36 weeks)

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