Better Health for Mothers and Babies November 13, 2018 Agenda - - PowerPoint PPT Presentation

Better Health for Mothers and Babies

November 13, 2018

Agenda

• Welcome
• Background
• Review AHA Initiative
• Quality Improvement Approaches from a health system
• Using data to drive improvement
• Maternal Mortality Review Boards
• Questions

Better Health for Mothers and Babies

Maternal Deaths largely occur outside week of birth

Caveat: Data is not complete but suggests trend

Caveat: Data is not complete but suggests trend

Partnering with AIM

https://safehealthcareforeverywoman.org/aim-program/

Improving Maternal Health

• Establish or Reaffirm Commitment
• DATA
• Regularly review internal data with interdisciplinary team and look for improvement
• pportunities.
• Access across continuum of care
• Health Disparities
• Prioritize and implement targeted strategies known to combat risk factors
• Accountability
• Review care protocols and discharge transitions
• Advance evidence based practices
• Listen to Mothers:
• Engage Mothers and work with like-minded community based organizations to improve

public education to lower risk

Initiative: Better Health for Mothers and Babies (BHMB) New website: https://www.aha.org/better-health-for-mothers-and-babies

Center for Health Innovation Field Engagement Public Policy Better Health for mothers and Babies

• Provide a forum for hospitals to engage

in sharing leading practices through webinars like this one, case studies, and podcasts, etc.

• Convene national summit of

stakeholders to share leading practices and identify collaborative actions

• Share quality improvement tools and

facilitate QI training to address improvement and disparities

• Partner with community based
• rganizations
• Urging Final Passage of S. 1112,

Maternal Health Accountability Act

STRENGTH IN NUMBERS

Preventable Causes of Maternal Death: Focus on Severe Maternal Morbidity

Maternal Mortality Review Committees (MMRCs)

2015: Maternal Mortality Review Information Application (MMRIA or “MARIA”)

• Supports MMRCs and provides resources to promote a

standard approach to case review

• Key decisions for each death reviewed:
• Was the death pregnancy-related?
• Underlying cause of death?
• What factors contributed to the death?
• Recommendations and actions to address contributing

factors?

• Anticipated impact of actions if implemented?
• Was the death preventable?

Centers for Disease Control and Prevention. Report from Maternal Mortality Review Committees: a view into their critical role. https://www.cdcfoundation.org/sites/default/files/files/MMRIAReport.pdf Accessed December 20, 2017 and MMRIA. Review to Action. http://reviewtoaction.org/implement/mmria. Accessed February 20, 2018.

Preventability

63.2%

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review

• committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.
• Report of 9 MMRCs in 2018 estimated

that 63.2% of pregnancy-related deaths were preventable

• 70% of deaths from hemorrhage

were preventable

• 63.2% of deaths from cardiac

disease were preventable

• Report of 4 MMRCs in 2017

determined that 59% of pregnancy- related deaths were preventable

Preventability

Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide

• review. Obstet Gynecol, 2005; 106(6): 1228-34.

Review of North Carolina maternal deaths: 21% of maternal deaths could have been prevented had care conformed to nationally recognized standards Preventability varies by cause of death

17% 22% 40% 42% 60% 89% 93%

Pulmonary embolism Cardiomyopathy Cardiovascular conditions Infection Preeclampsia Chronic medical conditions Hemorrhage

• What was the chance to alter outcome (good chance,

some chance, no chance, unable to determine)?

• Contributing factors and description
• Patient/family
• Provider
• Facility
• System
• Community
• Recommendations / specific feasible actions that if

implemented should have or might have altered the course of events

Standardized Decision Form for MMRCs: Preventability

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review

• committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.

Focus on Reducing Severe Maternal Morbidity: Review by Birthing Facility

Pregnancy complication or pre- existing medical condition Potentially life- threatening condition with predisposition to end-organ injury Survival despite experiencing an unanticipated event likely to result in death Adapted from: Witcher PM, Lindsay MK. Maternal morbidity and mortality. In: Troiano NH, Witcher PM, Baird SM (eds). High Risk and Critical Care Obstetrics, 2019; Wolters Kluwer: Philadelphia and Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-mortality-surveillance-system.htm. Accessed on 10/30/2018

0.5 -3% of pregnancies

SMM to maternal deaths: 100:1

18.0 per 100,000 live births in 2014

Continuum of Morbidity and Mortality

Severe Maternal Morbidity Review

• Purpose: identification of improvements in

processes and systems

• SMM Committee
• Presentation of abstracted review
• Identification of opportunities to improve outcomes
• Focus on systems and processes
• Refer cases to peer review as indicated
• Aggregate, trend and disseminate data
• Sanction by facility to provide peer review protection in

accordance with state’s legislation and statutes

• Root cause analysis for sentinel events

Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: Rationale and process. Obstet Gynecol, 2014; 124(2 Pt 1): 361-6.

Severe Maternal Morbidity Review

Timing of Review Multidisciplinary Review Committee Reviewable Events Review Methodology

• A peripartum event (pregnancy to first 24

hours postpartum) that requires 4 or more units RBCs

• A peripartum event that necessitates ICU

admission

• Unexpected and severe event that occurs

during pregnancy, peripartum, or postpartum

• OB providers
• Anesthesia providers
• Obstetric nurses
• Quality

improvement team

• Administration
• Consider patient

advocate

• Scribe
• Consider

partnership with regional perinatal center (small center)

• Timing of review will be determined by the

severity of the event and number of events (i.e. larger birth facility may consider regularly scheduled meetings)

• Peer review

protection (gather confidentiality statements from members)

• Past and current

medical records

• Trained abstractor
• Presentation of

primary review

• Utilize standardized

format

• Conclude

recommendations Specific resources available at: https://safehealthcareforeverywoman.org/patient-safety-tools/

Debriefing

• Care providers involved in the SMM event
• Supplements standardized SMM review by multidisciplinary

committee

Resources: Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: Rationale and process. Obstet Gynecol, 2014; 124(2 Pt 1): 361-6. https://www.cmqcc.org/resources/1533/download Type of event: _______________________ Date: ________________ Location of event: ____________________ Members of team present: _________ Systems and processes that went well Opportunities for improvement

• Human factors (such

as communication, teamwork, situational awareness, decision making)

• Systems issues (such

as availability of equipment, supplies,

• r medications; blood

products; transport issues; staffing Issue Actions to be taken Person responsible

Severe Maternal Morbidity, 1993-2014

Source: CDC. Severe maternal morbidity in the United States. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Updated on 11/27/2017. Retrieved on 2/19/2018.

• Acute MI
• Aneurysm
• Acute renal failure
• ARDS
• Cardiac arrest / v-fib
• Conversion of cardiac

rhythm

• DIC
• Eclampsia
• Heart failure / arrest

during procedure

• Puerperal cerebral

disorders

• Pulmonary edema
• Sepsis
• Shock
• SCD
• Air & thrombotic

embolism

• Blood transfusion
• Hysterectomy
• Temporary

tracheostomy

• Ventilation

SMM indicators and corresponding ICD codes during delivery hospitalization

SMM in 25 US Hospitals 2008 - 2011

Grobman WA, Bailit JL, Rice MM, et al. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol, 2014; 123(4): 804-10.

Secondary analysis of Eunice Kennedy Shriver NICHD MFMU Network cohort of women and neonates in 25 US hospitals

Obstetric Hemorrhage: Prioritization for Improving Quality of Care

Report and review:

• Post-event debriefs
• Multidisciplinary review
• Monitor outcomes
• Use data to guide

quality improvement initiatives Systematic review of deliveries that require 4 or more units RBC Target: 20-30% reduction in use of blood products

• Total number of transfusions in

deliveries > 20 weeks

• Number of massive transfusions in

deliveries > 20 weeks

http://www.jointcommission.org/sentinel_event _policy_and_procedures/

Main E. OB hemorrhage measures for hospital QI projects.

• CMQCC. Available at: https://www.cmqcc.org/resource/ob-

hem-hemorrhage-measures-hospital-qi-projects. Published 3/24/2015. Accessed 2/20/2018 Council on Patient Safety in Women’s Health Care. http://safehealthcareforeverywoman .org/wp- content/uploads/2017/11/Obstetric- Hemorrhage-Bundle.pdf. Accessed 2/20/2018.

SMM Review: Other Priorities

• Appropriate and timely recognition of

hypertensive disorder?

• Appropriate magnesium sulfate

prophylaxis?

• Timely and appropriate recognition and

treatment of severe hypertension?

• Appropriate timing of delivery
• Appropriate management of

complications Example quality metrics

• Cases admitted to ICU due to systems

issues

• Elapsed time from onset of confirmed,

severe hypertension to initiation of antihypertensive therapy

• Total number of women with severe

features of preeclampsia who receive magnesium sulfate for seizure prophylaxis Hypertensive Disorders of Pregnancy

• Appropriate thromboprophylaxis?
• Timely diagnosis of VTE?
• Recognition of risk factors for VTE?

Venous Thromboembolism

• Timely diagnosis of sepsis or infection
• Appropriate timing and selection of

antibiotics?

• Appropriate (adequate) IVF volume
• Identification of risk factors?

Infection / Sepsis

• Appropriate and timely diagnosis and

management?

• Were risk factors recognized?
• Appropriate consultation?

Cardiac Disease / Cardiomyopathy

https://safehealthcareforeverywoman.org/ patient-safety-tools/severe-maternal- morbidity-review/

Maternal Safety Toolkits

Organization Patient Safety Toolkits

Obstetric Hemorrhage Severe Hypertension Venous Thromboembolism Maternal care . . . Opioid disorder Postpartum Care Basics Reduction in Racial/ Ethnic Disparities Safe Reduction of Primary C/S Support After Maternal Event Cardiovascular Disease Toolkit

Eliminating Elective Deliveries Before 39 Weeks Gestation Maternal Mental Health: Depression & Anxiety Patient Safety Tool: Maternal Early Warning Signs

ACOG District II Safe Motherhood Initiative    Council on Patient Safety in Women’s Healthcare          

+ AIM + AIM + AIM + AIM + AIM + AIM + AIM

CMQCC  

PEC

   

Safe Motherhood Initiative (SMI) ACOG District II

• May, 2013
• Standardized review and reporting of maternal

deaths in NY

• Standardized practices for obstetric emergencies

associated with maternal mortality and morbidity

• Education/engagement

Safety bundles

https://www.acog.org/About-ACOG/ACOG-Districts/District-II/Safe-Motherhood-Initiative. Accessed 2/20/2018

OB Hemorrhage Severe Hypertension VTE

• Maternal health initiative
• Alliance for Innovation on Maternal Health (AIM)
• September, 2014
• National data-driven maternal safety and quality

improvement initiative

• Funded through MCHB

OB Hemorrhage Maternal VTE Severe hypertension Maternal mental health-depression and anxiety Opioid use disorder Postpartum basics Prevention of retained vaginal sponge  Peripartum racial/ethnic disparities Safe in primary C/S Support after severe maternal event Maternal early warning criteria Severe maternal morbidity review Toolkits for Quality Improvement

Safety bundles Safety tools

http://safehealthcareforeverywoman.org/. Accessed 2/20/2018 Some members

AHA Member Advisory – November 6, 2018

Heart Safe Motherhood: Innovation to Improve Maternal Outcomes, Experience and Cost Wednesday, November 28, at 2 p.m. ET Meeting the Challenges to Reduce Maternal Risk: A Dialogue with Neel Shah, MD Wednesday, December 5, at 12 p.m. ET Reducing Maternal Morbidity and Mortality: The Providence Oregon Approach Thursday, December 13, at 12 p.m. ET

Upcoming Webinars

QUESTIONS?

Robyn Begley, DNP, R.N. AHA Senior Vice President and Chief Nursing Officer & CEO, American Organization of Nurse Executives rbegley@aha.org Jay Bhatt, D.O. AHA Senior Vice President and Chief Medical Officer jbhatt@aha.org Patricia (Trish) M. Witcher, MSN, RNC-OB Clinical Outcomes Manager, Northside Hospital Trish.Witcher@Northside.com