Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality

ABSTRACT Childbirth is the most common indication for hospitalization the United States; more than 3.8 million women and their infants are discharged from postnatal care each year. Rapid patient turnover, as early as 24-48 hours following vaginal birth and 48-96 hours following cesarean birth, limits time for clinical staff to educate families on priority health issues. Currently, the high volume, relatively short stays, and multiple administrative tasks to be completed prior to discharge, in the absence of effective tools for morbidity detection, increases risk for patient harm. This high throughput system fails to adequately serve infants and mothers: The United States ranks 24 of 35 OECD countries for infant mortality, and we are the only high income country in the world in which maternal mortality rates are rising, with rates 3-4 times greater for non-Hispanic Black women than for non-Hispanic White women. Transdisciplinary collaboration is needed in order to identify underlying contributors to postnatal morbidity and mortality and co-develop more effective, sustainable, and scalable postnatal care. Our long-term objective is to redesign systems of clinical maternity care to better enable new families to thrive. The objective of this proposal is to define postnatal unit problems and create an innovative, individualized delivery system for more effective mother-infant management during postnatal hospitalization and the discharge transition to home. The University of North Carolina at Chapel Hill, in partnership with Systems Engineering at The Ohio State University and the North Carolina State University College of Design, will establish North Carolina Women's Hospital as transdisciplinary Learning Laboratory for mother-infant dyadic management on the postnatal hospital unit and during the transition home. We will evaluate our systems redesign using the primary outcome of a 20% reduction in emergency department visits and readmission from discharge to 90 days postpartum for mothers and infants. To achieve this reduction in postnatal morbidity, we plan to improve patient safety and care value in three intersecting domains: Mother/Baby Recovery, Precision Clinical Care, and Care Transition from Hospital to Home. We will achieve our objectives through the following Specific Aims: Aim 1) Define Priority Areas. Using mixed methods, we will analyze current processes and procedures for maternal-infant dyadic evaluation and management during the postnatal unit stay and discharge transition through the lens of mothers, clinicians, EHR data, and other key stakeholders; Aim 2) Iterative prototyping and evaluation of interventions. Building on identified design seeds, we will alternate between idea generation and evaluation until prototypes emerge that can be implemented and assessed in a low-stakes laboratory setting for refinement and then in the clinical setting; Aim 3) Implementation and dissemination. In this phase, we will use PDSA cycles to fully implement bundles of successful innovations on the postnatal unit at NC Women's Hospital and evaluate our primary outcome of acute care utilization within 90 days postpartum. The result of this work will be a human-centered redesign of postnatal care to ensure safer transitions for growing families. The project will enable a stronger start for mothers and their infants, as well as offering a more integrated, value-based model for care that can be shared with other hospitals for widespread implementation.