MHA OB Harm Improvement Initiative Overview

Sharon Burnett, R.N., BSN, MBA- HCA Vice President of Clinical and Regulatory Affairs

Your electronic devices

Sign in and evaluations

Lunch and breaks

Agenda

Your folders and conference materials

A Little Bit of Housekeeping

Meeting Purpose

Provide a forum for participants to share tools and resources and learn from early adopters of various components of the maternal hemorrhage and preeclampsia toolkits

Provide a platform for attendees to share their improving perinatal and maternal safety success stories and challenges

Learn how to use improvement tools to drive success

Leave with plan to get your team energized

Pre-work Assignment

Identify two things your hospital still needs to do to improve your identification and response to maternal hemorrhage

Identify two things your hospital still needs to do to improve your identification and response to preeclampsia

Identify two things your hospital still needs to do to ensure safe induction and augmentation of labor and safe use of Pitocin

Where We Have Been

Partnership for Patients Hospital Engagement Network kicked off in Missouri May 2012

OB Harm initiative – Reduce EEDs

September 2014, EED rate 1.7%, less than the national benchmark of 2%

Jan. 2014 added two additional initiatives, maternal hemorrhage and preeclampsia

Goal to get birthing hospitals to adopt recommended best practices in CMQCC toolkits

Survey Dec. 2014MO

HEN

Not

HEN

Survey Question% Yes

N=35

% Yes

N=19

Have you implemented standardized OB hemorrhage policies,

procedures? 97% 95%

Have you implemented standardized order sets for general and massive

OB hemorrhage?83% 74%

Do you have an obstetric hemorrhage rapid response team? 57% 39%

Do you have an obstetric hemorrhage cart or kit? 97% 68%

Do your physicians perform a hemorrhage risk assessment prenatally? 54% 42%

Do you perform a hemorrhage risk assessment upon admission? 77% 58%

Do you have protocols/checklists/charting tools for on-going objective

quantification of actual blood loss? 86% 68%

Do you have protocols/checklists/charting tools to objectively assess

maternal deterioration during and after all births?83% 72%

Do you hold regularly scheduled standardized training on formal

quantitative measurement of blood loss?60% 68%

Do you regularly hold on-site inter-professional hemorrhage drills? 60% 50%

Do you hold post OB hemorrhage debriefs? 63% 72%

Do you have standardized definitions and documentation to ensure

consistency in coding and reporting of maternal hemorrhage?69% 63%

Do you track your progress on maternal hemorrhage reduction with

process and outcome measures?60% 47%

Survey Dec. 2014

MO

HEN

Dec

Not

HEN

Dec

Survey Question% Yes

N=35

% Yes

N=19

Do you use a preeclampsia early recognition tool? 46% 26%

Have you adopted protocols/checklists for treating severe hypertension

including the use of magnesium sulfate? 86% 89%

Have you adopted order sets for treating severe hypertension? 74% 84%

Do you track the percentage of mothers who received timely treatment

(within 60 minutes) for severe hypertension (Systolic >= 160 or Diastolic

>=100)?

31% 16%

Do you educate patients on signs and symptoms of preeclampsia? 100% 100%

Have you educated ED staff on signs and symptoms of postpartum

preeclampsia? 35% 37%

Do you track your progress on preeclampsia harm reduction with process

and outcome measures?31% 16%

OB Manager Survey

Percent Rated Important or Very Important

Implementation of Preeclampsia Guidelines 100%

Safe Medication Administration Including Oxytocin and MgSO4 100%

Electronic Fetal Monitoring 99%

Safe C/S Including Reduction in Primary C/S 99%

Implementation of Hemorrhage Guidelines 98%

Rapid Response for Perinatal Safety 98%

OB Harm Reduction 2015

Continued adoption of best practices and protocols

preeclampsia

OB hemorrhage

Induction Bundles implementation of updated versions

HEN 2.0-Safety Across the Board

early elective deliveries – hold the gain

all OB Harm as part of Total Harm

Cesarean Section rate

Readiness…Recognition…Response

Revision of Sentinel Event Definition for Obstetrics: Jan 2015

Added cases of severe temporary harm and for OB defined as Severe Maternal Morbidity…. 1. Transfusion of ≥4 units of packed red cells 2. Admission of the mother to an ICU

• BUT: excluded cases as the result of the natural course of the underlying condition (eg transfusions for previas) • ALL cases should go to a multidisclipinary systems review committee (not peer review) for initial assessment

The Joint Commission. Comprehensive Accreditation Manual for Hospitals, Update 2, January

2015: Sentinel Events: SE-1. Also see the ACOG/TJC clarification. Available at:

http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf

AMCHP Every Mother

Initiative

First Do No Harm

Evidence-based practices incorporated in the maternal hemorrhage and preeclampsia toolkits are becoming the standard of care.

“We have, in short, somehow become convinced that we need to tackle the whole problem, all at once. But the truth is that we don’t. We only need to find the

stickiness Tipping Points.”

Malcolm Gladwell, The Tipping Point: How Little Things Can Make a Big Difference

Minimal Requirements For Standard Process For Preeclampsia

Notification of physician or primary care provider is systolic BP ≥ 160 or Diastolic BP ≥ 110 for two measurements within 15 minutes apart

After the second elevated reading, treatment should be initiated ASAP (ideally within 60 min)

Process must include timing for use of magnesium

Describe postpartum follow up within 7 to 10 days of birth

Describe postpartum education

n READINESSEveryunitü Adoptstandarddiagnosticcriteria,monitoringandtreatmentforsevere

preeclampsia/eclampsiatoincludeordersetsandalgorithmsü Unitteameducation,reinforcedbyregularunit-baseddrillsü Processfortimelytriagingofpregnantandpostpartumwomenwithhypertensionincluding

EDandoutpatientareas

ü Rapidaccessusedforseverehypertension/eclampsia:MedicationsshouldbestockedandreadilyavailableonL&Dandinotherareaswherepatientsmaybetreatedwithbriefguideforadministrationanddosage

ü Systemplanforescalation,obtainingappropriateconsultationandmaternaltransport,as

needed

n RECOGNITION&PREVENTIONEverypatientü AdoptionofastandardprocessforthemeasurementandassessmentofBPandurineprotein

forallpregnantandpostpartumwomenü Implementationofstandardresponsetomaternalearlywarningcriteria

ü Implementationoffacility-widestandardsforeducatingwomenonsignsandsymptomsof

preeclampsiaandhypertension–prenatalandpostpartum

n RESPONSEAllseverehypertension/preeclampsiaü Facility-widestandardprocesseswithchecklistsformanagementandtreatmentof:

o Severehypertensiono Eclampsia,seizureprophylaxis,andmagnesiumoverdosageo Postpartum,emergencydepartmentandoutpatientpresentationofsevere

hypertension/preeclampsia

ü Supportplanforpatients,familiesandstaffforICUadmissionsandseriouscomplicationsofseverehypertension

n REPORTING/SYSTEMSLEARNINGEveryunitü Implementationofahuddleforhighriskcasesandpost-eventteamdebriefü Reviewallseverehypertension/eclampsia/ICUcasesforsystemsissues

ü Monitoroutcomesandprocessmetricsü Documentationofeducationofpregnantandpostpartumwomenaboutsymptomsof

preeclampsia

PATIENT SAFETY BUNDLE

PR

EE

CL

AM

PS

IA

This bundle was developed by the Council On Patient Safety in Women’s Health Care, National Partnership for Maternal Safety 2014

California Partnership for Maternal Safety

ACOG - Managing Clinical Emergencies

Availability of appropriate emergency supplies in a resuscitation cart (crash cart) or kit

Development of a rapid response team

Development of protocols that include clinical triggers

Use of standardized communication tools for huddles and briefs (eg, SBAR)

Implementation of emergency drills and simulations

Source: ACOG, Committee Opinion, Number 590, March 2014

ACOG - Limits Of Trigger Thresholds For Meows Parameters

MEOWS Parameters Red Trigger Yellow Trigger

Temperature: °C < 35 or > 38 35-36

Systolic BP; mmHg < 90 or > 160150-160 or 90-

100

Diastolic BP; mmHg > 100 90-100

Heart rate; beats.min1 < 40 or > 120100-120 or 40-

50

Respiratory rate; breaths.min1 < 10 or > 30 21-30

Oxygen saturation; % < 95 —

Pain score — 2 - 3

Neurological responseUnresponsive

or only to painVoice

Source: ACOG, Committee Opinion, Number 590, March 2014

Leading The First Do No Harm Campaign

Alison R. Williams, R.N., BSN, MBA-HCM Vice President of Clinical Quality Improvement

Missouri Hospital Association

Readiness…Recognition…Response

MHA Quality Division

Goals and Objectives

demonstrate consistent, measureable outcomes

identify and share Missouri best practices

increase organizational effectiveness and efficiencies

Organized February 2014

Clinical quality, emergency preparedness, performance measurement and population health

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Strategic Member Support

Technical Support

publications

strategy papers

toolkits

best practice resources

immersion/pilot projects

webinars

seminars/conferences

data collection/analysis

Strategic Member Support

Adaptive Support

immersion/pilot projects

networking platforms & opportunities

regional workshops

mentor/mentee organizations

coalitions

external stakeholder relationships

Foundations for Quality in 2015…& Beyond

Safety Across the Board-”Total Harm” as a metric

Transparency

High Reliability Organization principles

Building resiliency

Patient and family engagement

Care coordination

Financial incentives/payment models

Hospital Engagement Network 2.0

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2015 Missouri Outcome Measures

Value-Based Purchasing – FFY 2017

Clinical Care Process – 5%

Patient and Caregiver Centered

Experience - 25%

Clinical Care Outcomes –

25%

Efficiency and Cost Reduction – 25%

Medicare Spending Per Beneficiary

Safety – 20%

*New for FFY 2017 (October 1, 2016 – September 30, 2017)

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AMI-7a – Fibrinolytic

therapy received within 30 minutes of hospital arrival

IMM-2 – Influenza immunization

PC-01 – Elective delivery prior to

39 completed weeks gestation

Communication With Nurses

Communication With Doctors

Responsiveness

Pain Management

Communication About Medicines

Clean and Quiet Discharge Info

Overall Rating

Consistency Score

AMI 30 Day Mortality

HF 30 Day Mortality

Pneumonia 30 day

mortality

Patient Safety Indicator - 90

Central Line- Associated

Blood Stream Infections (CLABSI) Catheter-

Associated Urinary Tract

Infection (CAUTI) Surgical Site Infection

– Colon and

Abdominal Hysterecto

my Clostridium difficile

Infection (C diff)

Methicillin-Resistant Staphlococcus aureus Bacteremia (MRSA)

Maternal Mortality

The World Health Organization estimates the US maternal mortality ratio (MMR) increased 136%, from 12 deaths per 100,000 live births in 1990 to 28 deaths per 100,000 live births in 2013.18

Other estimates of US MMR are more conservative, but also show an increase in contrast to decreasing MMRs in the majority of developed and developing nations.19

Maternal mortality is rare, but the consequences are devastating and believed to be highly preventable

HEN 2.0

OB harm reduction is a major component

Mix of abstracted and AHRQ data conferral

If Quality Works client, can also pull PC-01

Data submission will be through one of two options

access HIDI’s quality collections portal

submit excel spreadsheet to quality collections portal

Monthly data submission is expected

Pay-for-performance model is proposed by MHA

Consideration of all-cause OB harm

Outcome and Process Measures*

Early Elective Delivery (PC-01, OB-40)

EED hard stop policy implementation

OB hemorrhage

total OB blood transfusions (OB-117)

hemorrhage risk assessment on admit rate (OB-116)

OB trauma:

with instrument (PSI-18)

without instrument (PSI-19)

*measures are tentative pending HEN 2.0 contract award

Outcome and Process Measures*

OB preeclampsia

ICU utilization during birth hospitalization (OB-120)

implementation of treatment protocols/checklists for acute onset severe HTN and safe/effective magnesium sulfate use (OB-119)

*measures are tentative pending HEN 2.0 contract award

Immersion Project

Rapid-process improvement model

Quarterly guided participant calls

Quarterly guided deliverables

Ability to network across group participants

End-of-project report out

BHAG

Polling Question

Which topic would your organization like to work on as the immersion project for OB harm reduction?

A. EED

B. OB hemorrhage

C. OB Trauma

D. OB preeclampsia

Induction/Augmentation Bundles Overview and Buzz Session

Alison Williams V.P. of Clinical Quality Improvement Cathy Abrams, Director, Maternal/Child Health Services St. Anthony’s Medical Center

Louise Wilson, Clinical Educator OB/GYN St. Luke’s Hospital

Key Components

Understand the goal

Utilize a checklist

Appropriate patient selection

Bishop score

medical necessity

Standardized language and criteria

Management of tachysystole

Staffing requirements

High Reliability

Organization Design

Principles

Successful Induction Definition

Vaginal delivery within 24 to 48 hours of induction of labor

Other considerations:

Suspected fetal macrosomia (EFW > 4000 grams) in and of itself is not an indication for induction

Inductions should not be based on patient or provider preference – at any gestation

Induction is indicated when the risk of continuing the pregnancy – for the mother or fetus – exceeds the risk of inducing labor and delivery

Consider evidence-based alternatives to induction

Factors Affecting Induction Success

Bishop score

Parity

BMI >30

Maternal Age >35

EFW >4000 grams

Diabetes

Anecdotally:

CPD

malpresentation

Post-Dates Induction

Women should be offered induction of labor between 41+0 and 42+0 weeks as this intervention may reduce perinatal mortality and meconium aspiration syndrome without increasing the Cesarean section rate

Women who choose to delay induction > 41+0 weeks should undergo twice-weekly assessment for fetal well-being

Utilize a Standardized Checklist

The use of a checklist is highly recommended when administering oxytocin. Checklists provide prerequisites at the point of patient care to safely initiate oxytocin and help to identify situations that require its discontinuation.

Review of medical malpractice claims reveals that oxytocin use is involved in more than 50% of the situations leading to birth trauma.

Example Checklists

Induction/Augmentation Bundles

Reliable design reduces unintended variation and perinatal harm

Bundles themselves do not improve outcomes the ability of the team to reliably implement

every bundle element for all patients, unless medically contraindicated, advances care to achieve the improved outcomes

The most important idea underlying bundles is the all-or-none concept

Measuring compliance with each bundle element, as well as all-or-none compliance, is the first step in building a reliable system

What changes can we make for improved patient safety?

Implement ACOG criteria for accurate determination of GA as the organizational standard

Require verification criteria are met prior to every booking of an elective delivery or scheduled cesarean

Use a checklist of GA determination criteria

Use standardized guidelines supported by the medical staff, with a clear escalation policy when recognition reveals gestation dating is not accurate.

Engage prenatal office staff in the process

Review all cases of deliveries occurring prior to 39 weeks of gestation

Engage patients in the process early in the pregnancy to establish confirmation of the estimated due date

Educate staff and new OB providers regarding indications and criteria during their initial training, as well as during ongoing educational programs

Collect data transparently on all deliveries occurring in the GA group of 37.0 through 38.6 weeks and provide this data to the medical staff

Consider collecting data on all inductions/augmentations for appropriate selection

NICHD Criteria Use

• The goal of using a standard terminology to describe fetal heart rate monitoring and then developing an agreed upon action plan to ensure compliance with this bundle element

NICHD Criteria Use

• Use multidisciplinary education and a structured algorithm in order to train staff to identify or recognize failures in oxytocin administration

• Adopt a standardized, mandatory fetal monitoring educational program for both medical and nursing staff, and develop credentialing standards to be supported by the organization

• Provide ongoing education in the form of fetal monitoring case reviews that are multidisciplinary in focus

• Incorporate NICHD terminology in all documentation and communication of fetal heart rate status

• Adopt fetal heart rate management algorithms based on the three-tiered NICHD Fetal Heart Rate Status Categories, with clear action plans to guide the multidisciplinary team to respond appropriately for each category.

How Do You Communicate?

-is it standardized?

-does everyone have

the same definitions?

-does everyone understand the

intervention algorithm?

-what is your

escalation plan?

Bishop Scoring Model variation

objective vs. subjective measurement

– transvaginal ultrasound for cervical length vs. cervical exam, fetal fibronectin

traditional vs. modified vs. simplified

Should be documented prior to scheduling and starting induction

Score variation: 6 or 8 or greater has been established as indicative of induction success

initially based on multiparous, uncomplicated pregnancies at term (40 weeks), then later to include nulliparous

scores of 4-6 showed significant increase in C/S rate

Laughon, et al. (2011, April). Using a simplified Bishop score to predict vaginal delivery. Obstet Gynecol; 117(4): 805-811.

PSI-18

134

135

136

137

138

139

140

141

FY 2014 FY 2015

Ra

te

Fiscal Year To Date

Obstetrical Trauma Rate-Vaginal Delivery with Instrument

Obstetric Trauma Rate-Vaginal

Delivery with Instrument

Expected Rate

2010 National Benchmark

PSI-19

19

19.5

20

20.5

21

21.5

22

22.5

23

FY 2014 FY 2015

Ra

te

Fiscal Year to Date

Obstetric Trauma Rate-Vaginal Delivery without Instrument Expected Rate 2010 National Benchmark

ACOG Definition: Tachysystole

American Congress of Obstetricians and Gynecologist describes uterine activity:

Normal: Five contractions or less in ten minutes averaged over a 30-minute window

Tachysystole: More than five contractions in a 10-minute window and averaged over 30 minutes

– with FHR changes (hyperstimulation)

– without FHR changes (hypertonus/hypercontractility)

Miller LA. Oxytocin, excessive uterine activity, and patient safety: Time for a collaborative approach. PerinatNeonat Nurs. 2009; 23(1):59-68.

Tachysystole Management

Must be identified using a standard definition and documented

Characteristics of uterine contractions:

tachysystole should always be qualified as to the presence or absence of associated FHR decelerations

tachysystole applies to both spontaneous and stimulated labor

Tachysystole Management • Multidisciplinary adoption of

the NICHD/ACOG definition for tachysystole

• Standardize the recognition and management of tachysystole by developing algorithms and a standard order set

• Staff/provider education • Provide informed consent to

the patient regarding the risks and benefits of the use of the drug oxytocin for induction of labor

• Develop an escalation policy to standardize the provider response

• Standardize protocols for administering oxytocin to a minimum of one low dose protocol and one high dose protocol that are linked to the documentation system

• Provide case reviews and real-time feedback to nursing and providers on compliance rates: bundle compliance/tachysystole management

• Collect data on the use of terbutaline and emergency cesareans performed as a result of the overuse of oxytocin.

Staffing Requirements

1:2 during induction/augmentation with oxytocin

1:1 with high risk and active labor management

RN must be able to clinically evaluate the effects of oxytocin at least every 15 minutes

The oxytocin infusion should be discontinued if this level of RN staffing cannot be provided for patient safety.

A provider who has privileges to perform a c-section should be “readily available”

AAP and ACOG Guidelines for Perinatal Care, 2007.

BUZZ Session

Identifying the Pre-eclamptic Patient

Bernadette Hill, BSN, RNC-OB Manager – Mother/Baby Unit Mercy Hospital-Jefferson

About Us

Mercy Hospital-Jefferson is located in Crystal City, MO

We serve southern Jefferson county, Ste. Genevieve, St. Francois, and Washington counties.

Average deliveries per month:40

Primarily a low risk facility, with ready access to MFM at Mercy STL for high risk pregnancies.

Best Practice(s) We Implemented

Education of Frontline Coworkers to recognize early pre-eclampsia

Includes recognizing that healthcare workers tend to minimize early signs & symptoms

Ensuring that each patient has the proper size blood pressure cuff

Clearly defining pre-eclampsia as occurring after 20 weeks gest. BP ≥ 140mm/Hg or ≥ 90 mm/Hg diastolic. Proteinuria +

What Went Well

Using Evidence- Based guidelines and inserting Best Practice Advisories into the E.H.R.

Case Study Reviews for all severe

pre-eclamptic patients!

What Have We Learned So Far?

We still have some work to do!

Mock events (eclampsia) help keep frontline skills sharp

These events allow for a review of the situation, staff can identify what worked and what can be improved upon

Integration of BPA’s into the electronic health record are not the cure-all – obstetricians and nursing staff must review these prompts

What Were Our Barriers?

Resistance to Change!!

Ensuring competency in all Labor and Birth Staff

How Did We Overcome These Barriers?

Communication is Key!

Use of Shared Governance Council to allow for

input and dissemination of information.

Providing individual feedback to coworkers.

Focus on patient safety!

What Can We Teach From Our Journey?

Do your research!

Expect pushback!

Be persistent!

Celebrate your successes!

Remember not to take criticism personally – learn

from mistakes. (These make for great case

studies!)

What We Plan To Do

Continue to review all severe pre-eclampsia events, looking for earlier intervention possibilities.

Ongoing education for frontline coworkers during bed huddles and floor meetings.

Communicate with physicians and nursing staff regularly to solicit feedback and answer questions.

Feel Free to Contact: Bernadette Hill, BSN, RNC-OB Mercy Hospital-Jefferson Mother/Baby Unit 1400 US HWY 61 S. Crystal City, MO 63019 636-933-1385

Reference: California Maternal Quality Care Collaborative Preeclampsia Toolkit & Preeclampsia Care Guidelines 12/20/2013

Amanda Gruen Team Leader Family Birth Place

SSM DePaul Health Center

Postpartum Hypertension and

Preeclampsia

Tram Wallen APRN-CNP

Barnes Jewish Hospital

St. Louis, Missouri

Incidence of Postpartum

Hypertension and Preeclampsia

• The exact incidence of postpartum hypertension and preeclampsia is difficult to ascertain because most women in the postpartum period will not have their blood pressure checked until the six week postpartum visit.

• Postpartum hypertension and preeclampsia are either secondary to persistent hypertension or exacerbation of hypertension in women with previous gestational hypertension, preeclampsia, chronic hypertension, or because of a new onset condition.

Incidence of Postpartum

Hypertension and Preeclampsia

In women with preeclampsia or

superimposed preeclampsia, the blood

pressure usually decreases within 48 hours

following delivery, but then increases again

3-6 days postpartum.

BJH Objectives in the Management

of Postpartum Hypertension

• Coordinate care for our patients with

hypertensive disorders of pregnancy.

• Recognize and bypass barriers to

obtaining outpatient care in the postpartum

period.

• Early recognition of worsening clinical

status and prevention of complications

Prior to Discharge

• Initiate anti-hypertensives if BPs>150/100 on two occasions 4-6 hours apart

• Nifedipine XL preferred

• Discontinue NSAIDs for those with hypertension that persists for more than one day postpartum

• Patient education: recognizing and reporting signs and symptoms of preeclampsia (severe headaches, visual changes, altered mental status, RUQ/epigastric pain, nausea/vomiting, shortness of breath).

• Arrange for patients to have their blood pressure evaluated 5-10 days postpartum

• Encourage patients to establish/re-establish care with their PCP for long term BP monitoring

Post Discharge Follow-up

• Home visit by Home Health or Nurses for

Newborns (parameters and instructions

provided)

• Home BP monitoring for those with access to a

blood pressure cuff (parameters and instructions

provided)

• Outpatient follow-up (5-10 days postpartum)

Barriers

• Regulatory changes with Insurance companies

and Home Health agencies/Nurses for

Newborns

• Difficulty tracking patients post discharge

• Patient issues with access to healthcare (ie.

transportation)

Overcoming Barriers

• Schedule follow-up (5-10 days postpartum) for all postpartum patients with hypertensive disorders prior to discharge

• Allow patients to “walk in” for their blood pressure check (Monday-Friday between the hours of 9AM-3PM)

• Fax patient discharge order to clinic/office (clinic/office to follow-up with patient if “no-show”)

• This is a work in progress…

Thank You!

Contact Information

Tram Wallen APRN-CNP

One Barnes-Jewish Hospital Plaza St. Louis, MO 63110

ttw3634@bjc.org

314/362-1388

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Postpartum Hemorrhage

Guy Venezia, MD, FACOG

Medical Director, Obstetrics & Gynecology St. Clare Health Center Medical Director Ob Governance, SSM Health Care

Medical Director Simulation Program, SSM St Louis Network

Guy_Venezia@ssmhc.com

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Health Care Simulation

“…medicine is the last high-risk industry that expects

people to perform perfectly in complex, rare emergencies but does not support them with high-quality training and practice throughout their careers.”

Dr. Paul Preston, M.D.

February 2007

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Flight 1549 – Chesley B. “Sully” Sullenberger

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Postpartum Hemorrhage - Relevance

#1 cause maternal mortality worldwide

Developed countries 1/100, 000 births compared to 1/1000 births in developing countries

Obstetric hemorrhage is a major cause of maternal morbidity – 2.9% of birth 2006 (Callaghan et al., 2010)

Obstetric hemorrhage is the leading cause of maternal mortality in the United States (Berg et al., 2010)

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Postpartum Hemorrhage

U.S. Maternal Mortality Trends

The U.S. Maternal Mortality Rate increasing – 1999-2010

1999: 9.9 maternal deaths/100,000 live births

2002: 8.9 maternal deaths/100,000 live births

2010 16.8 maternal deaths/100,000 live births

HP 2020 Objective:

11.4 maternal deaths per 100,00 live births

82 7

Postpartum Hemorrhage Major Cause of Morbidity/Mortality

The rate of maternal deaths has nearly tripled from 6 per 100,000 in 1996 to 17 per 100,000 annual births in 2006.(1)

Alarmingly, the rate for African American women has risen from 28.7 to 54.9 per 100,000 live births between 1999 and 2006.(1)

Nationwide, blood transfusions increased 92% during delivery hospitalizations between 1997 and 2005.(3)

1. Department of Public Health, Maternal, Child, and Adolescent Health Division Public Released Data

available at: www.cmqcc.org

2. Lu MC, Fridman M, Korst LM, et al. Variations in the incidence of postpartum hemorrhage across

hospitals in California. Maternal Child Health Journal. September 2005;9(3):297-306.

3. Kuklina E, Meikle, S., Jamieson, D., Whiteman, M., Barfield, W., Hillis, S., Posner, S. Severe

Obstetric Morbidity in the US, 1998-2005. Obstetrics and Gynecology. 2009;113:293-299.

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Postpartum Hemorrhage Summary: Key Survey Findings

40% of hospitals DO NOT have a hemorrhage protocol

Inconsistent definitions

70% of hospitals DO NOT perform drills

Most have access to all 4 uterotonics

Many hospital report they do not have access to alternative treatment methods, e.g., Balloons

84

85

Postpartum Hemorrhage

A G2P1 Twin IUP at 38 weeks seen in office for delivery plan:

Vaginal Delivery:

C-Section:

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Postpartum Hemorrhage – Risk Factors

Retained Placenta (OR 3.5)

Failure to Progress 2nd Stage (OR 3.4)

Placenta Accreta (OR 3.3)

Lacerations (OR 2.4)

Instrumental Delivery (OR 2.3)

Large For GA Newborn (OR 1.9)

Hypertensive Disorders (OR 1.7)

Induction of Labor (OR 1.4)

Augmentation of Labor With Oxytocin (OR 1.4)

DM – 30-35% compared to 5-10%

Coagulopathies

Asian or Hispanic ethnicity

Obesity

Post dates > 42 wks

Previous PPH

Placenta Previa

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Postpartum Hemorrhage

Patient taken to O.R. for C-Section

Baby A = 10 lbs 4 oz

Baby B = 9 lbs 8oz

Primary C-Section -- normal placental implantation site

Normal Placenta Pathology

EBL = 700cc

Patient taken to recovery. Placed in normal Postpartum unit bed.

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Postpartum Hemorrhage

Two hours post-op, called by nurse because patient was bleeding heavy with clots….

BP reported 80/40, Pulse reported 120

Immediate Actions:

On Way To Room Thoughts:

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Postpartum Hemorrhage Initial Management

CAB (ABC ??)

Call for help

Mobilize team (staff, anesthesia, blood bank, etc.)

IV access

Fluid resuscitation

Examine patient including fundal massage, dx trauma/ inversion/ other etiologies, and fundal massage

Foley catheter

Blood work (CBC, Coag profile, Cross Match)

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Postpartum Hemorrhage

Definition

SVD > 500cc blood loss

C/S > 1000cc blood loss

Hematocrit Change: change > 10%

Quantification of Blood Loss

Visual estimation consistently underestimates large volumes (Brant, 1967; Duthie et al., 1990; Stafford et al., 2008) such as >1000 ml (Stafford et al., 2008) and overestimation increased with smaller volumes of blood loss (Dildy et al., 2004)

Visual estimation can be underestimated by up to 33 – 50% (Patel et al., 2006)

Weigh all blood-soaked materials and clots to determine cumulative volume.

1 gram weight = 1 milliliter blood loss volume

WET Item Gram Weight - DRY Item Gram Weight = Milliliters of Blood

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Etiology Process Clinical Risk Factors

Tone Overdistended Uterus Polyhydramnios, Multiple Gestation Macrosomia

Uterine Muscle Fatigue Rapid Labor, Prolonged Labor High Parity

Intra Amniotic Infection Fever, Prolonged ROM

Functional/Anatomic Distortion of the Uterus

Fibroid Uterus Placenta Previa Uterine Anomalies

Tissue Retained Products Abnormal Placenta

Incomplete Placenta at Delivery Previous Uterine Scar High Parity

Retained Blood Clots Atonic Uterus

Trauma Lacerations Precipitous or Operative Delivery

Extensions at C/S Malposition, Deep Engagement

Uterine Rupture Previous Uterine Surgery

Uterine Inversion High Parity, Fundal Placenta

Thrombin Pre-existing Coagulopaties, Liver Disease

Acquired in Pregnancy ITP, DIC

Therapeutic Anti-coag History of clots

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Drug Therapy For PPH

Drug Dose Side Effects Contraindications

Oxytocin 10 IU IM/IMM

5 IU iv bolus

10-40 IU/L

-Usually none

-ctx

-N&V

-water intoxication

-hypersensitivity

Ergot 0.25mg IM

0.125 mg IV

Q5mins X 5 doses

-peripheral vasospasm

-HTN

-N&V

-HTN

-peripheral disease

-Raynauld’s

-hypersensitivity

Hemabate

(PGF2α)

0.25 mg IM/IMM

Q15mins X 8 doses

-flushing

-diarrhea/N&V

-O2 desats

-bronchospasm

-restlessness

-hypersensitivity

-asthma

-active cardiac, pulmonary, renal,

or hepatic disease

Misoprostol

(PGE1)

400-1000mcg PR/PV/PO X 1

dose

-pyrexia/flushing

-N&V/diarrhea

-abd pain

-HA

-hypersensitivity

-pregnancy

Vasopressin 20U/100ml saline

Inject 1ml at bleeding site

-acute HTN

-bronchospasm

-N&V/cramps

-HA, vertigo

-angina

-death if iv

-coronary artery disease

-hypersensitivity

93

Postpartum Hemorrhage

Upon Arrival:

BP 70/30, Pulse 120, Pulse Ox 90%, Pale, Responsive

Actions:

Uterine atony noted, Vaginal exam expressed blood / blood clots

Fundal Massage

Patient received IV Oxytocin, Methergine, IV Hespan

Blood Products ordered – 4 units PRBC / 4 units FFP

Set Up OR

Uterine Atony, Bleeding

BP 90/40, Pulse 120, Color improved, Responsive

94

Postpartum Hemorrhage Surgical Management

Curettage (Ultrasound)

Embolization

Tamponade (Balloon, packing etc…)

Compression Sutures

Vessel ligation

Hysterectomy

95

SOS BAKRI

TAMPONADE

BALLOON

CATHETER

The Simple Solution for Postpartum Hemorrhage

Illustration by Lisa Clark

96 SOS Bakri Tamponade Balloon Catheter

Contraindications (cont.) The use of this product is

contraindicated in the presence of:

– Disseminated intravascular coagulation.

– A surgical site which would prohibit the device from effectively controlling bleeding.

27

Lessons from Combat in Iraq

Lowest losses ever from hemorrhage

Key: increased FFP:RBC ratio

98 28

Postpartum Hemorrhage Blood Products

After 2u PRBCs, start FFP

Massive transfusion protocol: 1:1 ratio FFP/RBC

– 6 RBC + 4 FFP + 1Plt pack (Stanford+)

– 4 RBC + 4 FFP, Plts and Cryo on request

Two Stages: Resuscitation and Treatment

Resuscitation, transfuse per clinical signs

DIC treatment, transfuse per lab parameters

Supportive measures are critical

Warm patient (Bair Hugger®, fluid warmer)

Correct metabolic acidosis

99

100 16

Active Management -- 3rd Stage

Oxytocin IV or IM with delivery of infant or placenta

Controlled cord traction

Cord clamping not delayed beyond 2 min

Vigorous fundal massage (at least 15 sec) after placenta

Denial

Delay

101 17

Meta Analysis of Active vs. Expectant 3rd Stage

Management at vaginal birth:

Outcome of postpartum EBL ≥ 500 ml

62% fewer PPH in Active Management group versus

Expectant Management

Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the

third stage of labour. Cochrane Database Syst Rev 2000; 3: CD000007

102 30

Postpartum Hemorrhage What’s New--Summary

Quantification of blood loss for all

Active management of the 3rd stage for all

Vital sign triggers

“Move along” on uterotonic medications

Bakri intrauterine balloon

A new approach to blood products

A role for rFactor VIIa?

The value of a formal protocol

Denial

Delay

103

Postpartum Hemorrhage

Definition

SVD > 500cc blood loss

C/S > 1000cc blood loss

Hematocrit Change: change > 10%

Quantification of Blood Loss

Visual estimation consistently underestimates large volumes (Brant, 1967; Duthie et al., 1990; Stafford et al., 2008) such as >1000 ml (Stafford et al., 2008) and overestimation increased with smaller volumes of blood loss (Dildy et al., 2004)

Visual estimation can be underestimated by up to 33 – 50% (Patel et al., 2006)

Weigh all blood-soaked materials and clots to determine cumulative volume.

1 gram weight = 1 milliliter blood loss volume

WET Item Gram Weight - DRY Item Gram Weight = Milliliters of Blood

104 31

Postpartum Hemorrhage Systems Approach

Department: OB Hemorrhage Protocol with stages

Hospital: Massive Transfusion Protocol

Summary Flow algorithm: graphic or tabular

Nursing checklist by stages

Documentation forms: OB Hemorrhage Report

Worksheets to assist with assessment of blood loss

Hemorrhage cart/kit

Instruction cards for new procedures in cart or OR

Drills

105

AWHONN PPH Project Goals

Goal 1: Promote equal access of evidence-based care practices Goal 2: Support effective implementation strategies and tactics to improve clinician practice Recognition - Readiness - Response

Goal 3: Identify facilitators and barriers to making improvements and disseminate lessons learned

www.pphproject.org

106

107

Guy_Venezia@ssmhc.com

108

Recombinant Activated Factor VIIa

Tx of bleeding disorders

Dose up to 120mcg/kg q2h until hemostasis

Promising but needs more studies

$10,000/mg

Risk thromboembolism

TEAMSTEPPS 05.2 Mod 1 05.2 Page

Introduction

Mod 1 06.2 Page

Why Teamwork?

To prevent serious and sentinel events

To make work more enjoyable and effective

To improve communication and coordination of care

Care is delivered by many individuals, safety is in teamwork

Current safety initiatives are not enough

110

Benefits of OB Simulation

Ascension Health – Reduced birth trauma

Obstetrics & Gynecology 2006 – Simulation Training and Resident Performance of Singleton Vaginal Breech Delivery

Obstetrics & Gynecology 2004 – Improving Resident Competency in the Management of Shoulder Dystocia With Simulation Training

Beth Israel in Boston – Decreased the number of adverse events in obstetrics by 50% since they instituted a simulation-based risk reduction program

Harvard Medical Group – Reduced Malpractice Premiums

Teamwork Session - Process Improvement Methodology

Be Safe, Be Reliable, Use Your Tools, Rely on Your People

High Reliability Organizations

HRO is not a process improvement program…it is an organizational culture designed to reduce the

frequency and severity of catastrophic events

HRO Principles

Anticipation-3 Elements—”Stay Out of Trouble”

preoccupation with failure

– all near-misses and errors are proof of system errors

– causality is pursued, no matter how small (avoidance of the Swiss cheese effect)

avoid simplifying interpretations

– details matter in error prevention

– encourage diversity in experience, perspective, and opinion

HRO Principles

situational awareness

– continual mindfulness by all staff of risks and failure opportunities

– continual review with staff of the risks involved with their professional functions

– paying attention to what’s happening on the front lines

HRO Principles (cont)

Containment: 2 elements—”Get Out of Trouble”

deference to expertise

– senior managers and leaders of organizations generally have no idea (or no current idea) of how to perform the detailed elements of subordinates’ jobs

– because of this, performance and expertise are critical in shaping performance and preventing harm

– push decision-making down and around to the person with the most directly related knowledge and expertise

– design for minimal process variation

HRO Principles (cont)

resilience

– develop capabilities to detect, contain, and bounce-back from events that do occur

– in the real world…failures still happen

– maintain functions during high demand

– all errors in health care are catastrophic

Provider/Staff Accountability (Just Culture algorithm)

Standardized communication pathways

Drills

Gemba Leadership

Standardized management work

Examples

Care bundles

Checklists

Intervention Protocols and Algorithms

Modified Early Obstetric Warning System (MEOWS)

Obstetric Vital Sign Alert (OBVSA)

Waste reduction efforts

Categorize Harm by Causality

Errors of commission

Errors of omission

Errors of communication

Errors of context

Diagnostic errors

Errors in failing to care across the continuum

James, JT. “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care.” J Patient Saf. 9:3, Sep, 2013.

Management by Improving Process

Pick a process/focus area

Compare baseline rates to current rates

Flowchart process as designed vs. reality

CONSIDER

Are there steps where….

people must rely on memory to complete any portion of the step (no reference, tool, etc.)?

a distraction or interruption during the step would likely lead to failure of the step?

are there >10 things a person must do at this step?

a new or untrained person is much more likely to encounter error or failure with the step?

Make Work and Systems Automatic

Address human factors:

avoid reliance on memory

make processes visible

review and simplify processes – remove waste

decrease reliance on vigilance

Assign new processes to a role or function,

not a person

Systems are Supported By People

Engage staff at all levels

Leadership support is crucial

Middle management support is the most crucial

Map out how the process improves efficiency, safety, benefits to patients and/or staff

DRIFT

Situational Awareness

Safety Across the Board

TRIPLE AIM

Gemba-based leadership: Not just laissez-faire – step out of the way, “it’s

up to you”

Not just MBWA – “slapping backs and offering praise”

Not just MBO – “okay, you’re empowered, get the numbers – I don’t care how you do it.”

Gemba-based leadership: Rather, leaders who say:

My job is to develop you, so I need to hear your thinking, and develop you through coaching you on the job to design a reliable,

safe work environment. (staff are valued) I will give you expectations that are clear and challenging.

(outcomes)

I will give you a deadline. (accountability) I will expect you to report out on everything, all the time.

(accountability) I will ask you what you need; I’ll see what you need and provide

on-going support and coaching as required. (staff are valued, mgmt. accountability)

And I will be back to check on how things are going. (mgmt. accountability)

PDSA +

Gemba

Be Strategically Transparent

Visuals

post-its/easel pads to track progress

stand-ups/huddles-

– STAFF LED

medical staff meetings/board meetings

non-traditional methods

Storytelling

3 Patients w/ C. Diff

1 Patients w/ MRSA

1 Patients w/ CAUTI

5 Patients w/ sepsis

Take-Away

As we learn from others today and start to strategize next steps for improvement focus

areas, consider how you/your organization/your staff can integrate HRO concepts and utilize process improvement

tools in the day-to-day operations of providing safe and reliable patient care to.

We must create urgency and devise ways to achieve rapid-process improvements and

identify the ROI.

The Shift

133

SAFETY = #1 CORE VALUE

Quality Compliance

Employee Engagement

& Satisfaction

Patient Satisfaction

& Loyalty

Financial Margin

TRIPLE AIM

Because if people are safe…the rest should

follow

Designing a Process Improvement Project

Tabletop: FMEA & PDSA

We say PDSA is our

improvement model…but do we really

do it? Do staff do

it? How do they

know??

Step One

Compile a list of reasons a project to decrease OB harm or implement a bundle might fail

examples

– no collaboration with providers

– lack of buy-in

– too many steps

– lack of staff experience

Step Two

Prioritize and rank your list

Report your top three reasons

Step Three

Prioritize your list again and choose your top reason why your project could fail

This will become your change project we will cycle through the PDSA

Tip: be sure you can scope it down to a manageable project

Step Four — Start with the Model for Improvement

Aim — set the scope and boundaries

timeframe

location — pre op, peri op, post op or across the continuum

Measure

outcome and process measures

Change

what is your change project that you will PDSA?

Step Five — Plan

Who are your stakeholders?

Build your team

who is on your lead team, lead physician, day-to-day leader, C-suite champion(s), non-clinical

State the objective of the project

Ask: Who? What? When? Where?

Data

how to gather, who will gather, where to report, how often will it be gathered

Step Six — Do

Carry out the test

problems — solicit, document and solve

– don’t forget to include the patient observations

display — how will you display the results to your staff?

clear — think about how you will clear any issues and ask for feedback; huddles? when? where?

acknowledge — think about how you will recognize the direction of the project

Step Seven — Study

Imagine your data isn’t trending to support your hypothesis. How will you act? What will you change and why?

What if your change project was implementing a policy and the steps aren’t getting carried out as planned? (quality and quantity)

Step Eight — Act

How will you plan to decrease variation across units/physicians/patient populations?

How will you expand your scope?

Are you ready for implementation?

Did your change show

an improvement?

Yes; the test was conducted as planned, data collection went smoothly, and the

data show improvement

No; the test was conducted as planned,

the data collection went smoothly but the

data do NOT show improvement

Unsure

The test did not go as planned

There was a problem with data collection

Wrap Up

Volunteers willing to share their project?

Maternal Levels of Care Sarah Kilpatrick, MD, PhD, Cedars-Sinai

Closing Remarks and Wrap-Up

Member Resources and Support

http://web.mhanet.com/strategic-quality/

Join MHA on LinkedIn

LinkedIn: MHA Strategic Quality

Quality Transparency and Data Measurement Resources

149

Clinical Quality and Patient and Family Engagement Resources

150

Next Steps

HEN end-of-project report Issue Brief series: Readmissions and Care

Coordination Continued Issue Brief series: Patient and Family

Engagement HEN 2.0 project and resource planning

OB Harm Immersion Project Quality assessments evaluation eCQM and ICD-10 implications IPPS FY 2016 quality strategy implications

151

Upcoming Events, April & May

May 8, 1-2:30 p.m. CT Premier Webinar “Improving Outcomes In Hypertensive Disorders Of Pregnancy” http://offers.premierinc.com/ALWBN2015-05-08hypertensivedisordersofpregnancy.html?mkt_tok=3RkMMJWWfF9wsRokuqzJZKXonjHpfsX66uolWbHr08Yy0EZ5VunJEUWy2YoERNQ%2FcOedCQkZHblFnV8AS627XqINr6cI

May 20, 1 p.m. CT Premier Webinar “What OBGYNs Should Know About Opioid Use and Abuse” http://offers.premierinc.com/ALWBN2015-05-20opioiduseandabuse.html?mkt_tok=3RkMMJWWfF9wsRokuq3IZKXonjHpfsX66uolWbHr08Yy0EZ5VunJEUWy2YoHSdQ%2FcOedCQkZHblFnV8AS627XqINr6cI

May 12, 12-1 p.m. CT Perinatal Regionalization 101 Webinar https://attendee.gotowebinar.com/register/2106465633269801474

Upcoming Events, April & May

May 20-21 – Quality 101 Conference, Hilton Garden Inn, Columbia (Register)

May 27, noon – 1 p.m. MHA Clinical Quality Quarterly Webinar: Using a Community Health Needs Assessment to Drive the Triple Aim

Visit MHA’s website for additional events and links

Thank You for Your Support

March of Dimes Greater Missouri Chapter Trina Ragain, State Director of Program Services 314/513-9963 tragain@marchofdimes.com

Every Mother Initiative Missouri DHSS Dr. Sharmini V. Rogers, MBBS, MPH, Chief Sharmini.Rogers@health.mo.gov Tel: 573-751-6214

AWHONN of Missouri Judy Wilson-Griffin, RNC, MSN, PNCNS, Section Chair St. Louis, MO Jennifer Bliven, RNC-OB, MBA, MPA, CCE, CIME Section Secretary/Treasurer Lees Summit, MO 64081

MHA:SQI - http://web.mhanet.com/strategic-quality/

Leslie Porth, Ph.D., R.N.

Senior Vice President of Strategic Quality

Improvement

Triple Aim

Population Health

Oversight of division (Quality Improvement,

Quality Works, Emergency

Preparedness)

Alison Williams, R.N., BSN, MBA-

HCM

Vice President of Clinical Quality Improvement

Dana Downing, B.S., MBA-H,

CPHQ

Vice President of Quality Program

Development

National quality measures

Quality outcome transparency

Electronic clinical quality measures

MBQIP grant lead

MOAHQ

Jessica Rowden, R.N., BSN, MHA

Clinical Quality Improvement

Manager

Clinical quality SME

Data management and analytics

HEN/AHRQ grant projects

TeamSTEPPS

Host of WUW|LNL

MOAHQ

Cheryl Eads

Executive Assistant of Quality Improvement

Provides support to the SQI team

Coordinates webinars, conference calls and

meetings

Distributes correspondence and

communication

Assists in maintaining reports

Lporth@mhanet.com 573/893-3700x1305

Awilliams@mhanet.com 573/893-3700x1326

Ddowning@mhanet.com 573/893-3700x1314

Jrowden@mhanet.com 573/893-3700x1391

Ceads@mhanet.com 573/893-3700x1382

Clinical quality SME

Oversight of Quality Improvement

Grant management

Collaborative management

Patient & Family Engagement

MOAHQ

MHA Government Relations

Sharon Burnett, R.N., BSN, MBA-HCA

Vice President of Regulatory

and Clinical Affairs

Hospital Licensure and Regulation

Medicare Certification and Regulation

Professional Licensure

Accreditation

Legislative Clinical Affairs Advocacy

OB and Women’s

Health Constituency Group

MONL

James R. Mikes, ScD, MPH

Vice President of Rural Advocacy

and Regulation

CAH Network

Rural Hospital Council

Post-Acute Care Hospitals Group

FLEX Grant

Federal and Sate licensure, regulation and certification for post-acute, RHCs,

CAHs

Peggy Taylor

Executive Assistant of

Clinical and Regulatory Affairs

Provides support to the regulatory and advocacy team

Coordinates webinars, conference calls and meetings

Distributes correspondence and communication

Assists in maintaining reports

sburnett@mhanet.com 573/893-3700x1304

jmikes@mhanet.com 573/893-3700x1393

ptaylor@mhanet.com 573/893-3700x1370