Disclosure None What You Can Do To Reduce Maternal Mortality And - - PowerPoint PPT Presentation

Elliott Main, MD

Director, California Maternal Quality Care Collaborative Stanford University Director of Implementation, National AIM Project

What You Can Do To Reduce Maternal Mortality And Morbidity

Transforming Maternity Care

Disclosure

 None Reduction of Maternal Mortality is one of the Greatest Public Health Success Stories of the Last Century

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11.1 7.7 10.0 14.6 11.8 11.7 14.0 7.4 7.3 10.9 9.7 11.6 9.2 6.2 16.9 8.9 15.1 13.1 12.1 9.9 9.9 9.8 13.3 12.7 15.5 16.9 16.6 19.3 19.9 22.0

0.0 3.0 6.0 9.0 12.0 15.0 18.0 21.0 24.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

California Rate United States Rate

Maternal Mortality Rate, California and United States; 1999-2013

Maternal Deaths per 100,000 Live Births HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007

• nly. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon

March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.

California: ~500,000 annual births, 1/8 of all US births

The rise in CA Maternal Mortality led to the creation in 2006

• f both the CA

Mortality Review Committee and the CMQCC, the action arm for improving maternity outcomes

The US has the highest Maternal Mortality rate of any high resource country and the

• nly country
• utside of

Afghanistan and Sudan where the rate is rising.

July 17, 2015

(CDC, Gates Foundation)

US Maternal Mortality Rates Have Risen Using Either Death Certificates (NCHS) Or Using MD Case Reviews by CDC PMSS

7.5 8 11.5 15 19 9 11.5 14.5 16 17

4 6 8 10 12 14 16 18 20 1987-1990 1991-1997 1998-2005 2006-2010 2011-2013

Mortality Rate (per 100,000 Live births)

MMR (NCHS Death Certificate) MMR (CDC PMSS)

cdc.gov

7

1.6%

2X

“The Last Person You’d Expect to Die in Childbirth”

The U.S. has the worst rate of maternal deaths in the developed world, and 60 percent are preventable

Why are more American women dying after childbirth?

PBS NewsHour August 18, 2017

Why are more American women dying after childbirth?

Maternal Mortality and Severe Morbidity

Underlying causes, compiled from multiple studies

Cause

Mortality

(1-2 per 10,000)

ICU Admit

(1-2 per 1,000)

Severe Morbid (1-2 per

100)

VTE and AFE 15% 5% 2% Infection 10% 5% 5% Hemorrhage 10-15% 35% 55% Preeclampsia 15% 25% 25% Cardiac Disease 25% 15% 5%

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Cause of Death North Carolina “Preventable” California “Good or strong chance to alter the outcome” United Kingdom “Substandard care that had a major contribution”

Hemorrhage 93% 70% 44% Preeclampsia 60% 60% 64% Sepsis / Infection 43% 50% 46% DVT / VTE 17% 50% 33% Cardiomyopathy 22% 29% 25% Amniotic Fluid Embolism 0% 0% 15%

Assessments of Preventability

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Provider Contributing Factors in Maternal Deaths (California)

Main EK, McClain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: Causes, characteristics and improvement opportunities. Obstet Gynecol 2015

From detailed chart reviews of maternal deaths (CA-Pregnancy Associated Mortality Review Committee; CDPH-MCAH)

• California Pregnancy Associated Mortality Reviews

– Missed triggers/risk factors: abnormal vital signs, pain, altered mental status/lack of planning for at risk patients – Underutilization of key medications and treatments—did not have a plan! – Difficulties getting physician to the bedside – “Location of care” issues involving Postpartum, ED and PACU

• University of Illinois Regional Perinatal Network
• Failure to identify high-risk status
• Incomplete or inappropriate management

Key Provider QI Opportunities: Hemorrhage and Preeclampsia

CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR): Report from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC.org) Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with

• severity. Am J Obstet Gynecol 2004; 191: 939-44.

Present in >95% of cases Present in >90% of cases

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 Most common preventable causes of

maternal mortality

 Far and away the most common causes

• f Severe Maternal Morbidity

 High rates of provider

“quality improvement opportunities”

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Obstetric Hemorrhage and Preeclampsia: Summary

Hemorrhage Toolkit >10,000 Downloads to date

Maternal Safety Bundles

• Readiness

 Every unit—prepare and educate

• Recognition & Prevention

Every patient—before event

• Response

Every Event—team approach

• Reporting/Systems Learning

Every unit—systems improvement

Available at: safehealthcareforeverywoman.org with resource links

Uniform Structure:

• “Checklist” of items and

practices for every birthing site

• Not a national protocol !!
• Facilities will modify content

based on local resources

What are they?

First Bundle: July 2015

Anesth Analg 2015;121:142–8 J Midwifery Womens Health. 2015 Jul;60(4):458-64. Obstet Gynecol. 2015 Jul;126(1):155-62 J Obstet Gynecol Neonatal Nurs. 2015 Jul;44(4):462-70.

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OB Hemorrhage - Readiness

 Hemorrhage cart with supplies, checklist, instruction cards and posters  Immediate access to hemorrhage medications  Establish a response team – who to call when help is needed  Establish massive and emergency release transfusion protocol/policies  Unit education on processes, unit-based drills (with debriefs)

Every unit

“Just in Time” Education

• Put into the hands of doctors, midwives and nurses

key information… at the moment of its use (Cart)

• Response Education
• Management Plan with checklist (reminders)
• Uterotonic Medication Guide: pros and cons
• How To Do: Steps to place an intrauterine balloon
• How To Do: B-Lynch Suture
• Blood Product Information

Patient Level Readiness

• Women with Placenta Accreta or Percreta
• Women with inherited coagulation disorders
• Jehovah’s Witness
• Informed Consent and Decline checklists,
• Pregnancy planning guide
• Iron Sucrose and Ferric Carboxymaltose

Protocols

Tools are adapted for each hospital's resources www.CMQCC.org

Example Hemorrhage Emergency Response Plan

23

CMQCC OB Hemorrhage Care Guidelines Can be posted on L&D or Placed

• n the Charge Nurse’s Clipboard

Driessen M et al., Obstet Gynecol 2011; 117:21-31

Intervention Delay that increased risk for severe hemorrhage Oxytocin administration >10 minutes Obstetrician present or notified >10 minutes Anesthesiologist present or notified >10 minutes Manual examination of the uterine cavity >20 minutes

Deciding to Transfuse: “Combination Logic”

 EBL >1500?

 EBL and even QBL are not perfect

 Vital Signs suggesting hypovolemia?

 How much crystaloid is on board, is it barely

maintaining the BP? Good to a point…

 Is the bleeding under control or continuing?

 Any chance for concealed hemorrhage?

 RCT of 20,000 women with PPH in both low and high

resource countries, dose was 1gm IV (may repeat x1)

 Maternal death was reduced by 30% among women

treated within 3 hours of bleeding

 Hysterectomy was not reduced (many cases were already

at that stage at time of randomization)

Lancet 2017;389:2105-16 (on line April 26)

CMQCC TXA Recommendations for PPH

 TXA is not for prophylaxis or initial treatment  Consider use after higher dose oxytocin/ methergine have

been tried and before additional drugs/procedures (after CMQCC Stage 1)

 Respect the dose: 1 gm IV, may repeat in 30min x1  Safety issues:  Task overload—need to ensure that basic PPH tasks

are attended to

 Potential for serious drug error, vial can be confused

with bupivicaine; intrathecal TXA injection is serious

 Higher doses of TXA are associated with renal toxicity See summary document on TXA Recommendations at www.CMQCC.org

Be Wary of Concealed Hemorrhage

 Intra-abdominal bleeding Post Cesarean  Posterior Uterine Rupture  Extension of Cervical or Vaginal Side-wall

Laceration

Extra, objective eyes are critical!

How Judge Hatchett’s Son Is Coping After His Wife’s Childbirth Death (Healthy woman with complications resulting in death during “routine” repeat Cesarean) 8/3/2017 8/21/2017 (Healthy woman with major complications during “routine” repeat Cesarean: “Near Miss” now with PTSD) Not just placenta accreta…

30 31

www.safehealthcareforeverywoman.org

Practical advice for establishing Patient Family and Staff support

• n your unit:

Patient Safety Bundle for Hypertension

Focus points

 Use standard language and

definitions for preeclampsia (e.g. with severe features)

 Standardize the measurement

• f blood pressure!

 Use ACOG protocols for

treatment of severe range BP within 60 min

 Standard protocols for the use

• f MagSO4

 Early Postpartum follow-up

CA-PAMR Final Cause of Death Among Preeclampsia Cases, 2002-2004 (n=25)

Final Cause of Death Number

%

Rate/100,000 Stroke Hemorrhagic Thrombotic 16 14 2 64.0% (87.5%) (12.5%) 1.0 Hepatic (liver) Failure 4 16.0% .25 Cardiac Failure 2 8.0% Hemorrhage/DIC 1 4.0% Multi-organ failure 1 4.0% ARDS 1 4.0%

Measure Pregnancy Baseline (mm Hg) Pre-stroke (mm Hg) Mean systolic BP 110.9 + 10.7 (n=25) 175.4 + 9.7 (n=24) Systolic BP range 90-136 159-198 Systolic BP % > 160 95.8 (n=27/28) Mean diastolic BP 67.4 + 6.5 (n=25) 98.0 + 9.0 (n=24) Diastolic BP range 58-80 81-113 Diastolic BP % > 110 12.5 (n=3) Diastolic BP 5 > 105 20.8 (n=5)

Preventing Stroke from Preeclampsia

Blood Pressure Comparisons: Baseline and Pre-stroke

Adapted from Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia and Eclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, OG 2005;105-246.

Controlling blood pressure is the key intervention to prevent deaths due to stroke in women with preeclampsia.

“Treat the Damn Blood Pressure!”

Over the last decade, the UK has focused QI efforts on aggressive treatment of both systolic and diastolic blood pressure and has demonstrated a reduction in deaths.

ACOG Protocol for Labetalol Treatment

LABETALOL:

Threshold Blood Pressure: Systolic 160 OR Diastolic 105-110 Target Blood Pressure: 140-150 - 90-100

Adapted from ACOG Commi ee Opinion #514; (1) MFM, Cri cal Care, Anesthesia, Internal Medicine; (2) Raheem I, Saaid R, Omar S, Tan

• P. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a

randomised trial. BJOG. 2012;119:78-85.

Switch TO:

If No IV Access: Give Oral Labetalol 200 mg Check BP in 30 minutes; if above threshold, labetalol 200 mg dose

Seek Consulta on(1)

(Maternal-Fetal Medicine, Cri cal Care, Anesthesia, Internal Medicine)

If No IV access: Give PO Nifedipine 10 mg Check BP in 30 minutes; if above threshold, repeat PO nifedipine 10 mg(2)

OR

PDSA Cycle

 Identify Barriers (Why meds not given?)  Local Teams brainstorm and implement

solutions (QI Tactics)

 Data monitoring to gauge progress

Bingham D, Main EK. Effective implementation strategies and tactics for leading change on maternity units. J Perinat Neonatal Nurs. 2010 Jan-Mar;24(1):32-42.

Barrier Analysis

Timing for Treatment of Gravidas with sBP≥160 or dBP≥110

Sample hospital from CMQCC Preeclampsia Collaborative 2013

Patient Education Materials

This and many other patient education materials in English and Spanish can be ordered from www.preeclampsia.org/ market-place

70

11.1 7.7 10.0 14.6 11.8 11.7 14.0 7.4 7.3 10.9 9.7 11.6 9.2 6.2 16.9 8.9 15.1 13.1 12.1 9.9 9.9 9.8 13.3 12.7 15.5 16.9 16.6 19.3 19.9 22.0

0.0 3.0 6.0 9.0 12.0 15.0 18.0 21.0 24.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

California Rate United States Rate

Maternal Mortality Rate, California and United States; 1999-2013

Maternal Deaths per 100,000 Live Births HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007

• nly. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon

March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.

California: ~500,000 annual births, 1/8 of all US births

California Approach to Reduce Maternal Mortality and SMM CMQCC (Professional Orgs.) CA Hospital Association (HQI) CA Medicaid Program CA Dept. of Public Health Partner with Everyone! California Approach to Reduce Maternal Mortality and SMM

• Hemorrhage Taskforce (2009)
• Hemorrhage QI Toolkit (2010)
• Multi-hospital QI Collaborative(s) (2010-11)

Test the “tools” and implementation strategies

• State-wide Implementation (2013-2014)
• Preeclampsia Taskforce (2012)
• Preeclampsia QI Toolkit (2013)
• Multi-hospital QI Collaborative (2013-2014)
• Cardiovascular Detailed Case Analysis (2013)
• Cardiovascular QI Toolkit (2017)

11.1 7.7 10.0 14.6 11.8 11.7 14.0 7.4 7.3 10.9 9.7 11.6 9.2 6.2 16.9 8.9 15.1 13.1 12.1 9.9 9.9 9.8 13.3 12.7 15.5 16.9 16.6 19.3 19.9 22.0

0.0 3.0 6.0 9.0 12.0 15.0 18.0 21.0 24.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year

California Rate United States Rate

Maternal Mortality Rate, California and United States; 1999-2013

Maternal Deaths per 100,000 Live Births HP 2020 Objective – 11.4 Deaths per 100,000 Live Births

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007

• nly. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon

March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March, 2015.

Reduction in Severe Maternal Morbidity (HEM)

Jeanne Mahoney, RN BSN

Senior Director, ACOG Director, AIM Project

Elliott Main, MD

Medical Director, CMQCC Implementation Director, AIM Project

AIM GOAL

Eliminate Preventable Maternal Mortality and Severe Morbidity in Every U.S. Birth Center

AIM STRATEGIES

• BROAD PARTNERSHIP
• TOOLS & TA
• IMPLEMENTATION TRAINING
• REAL TIME DATA
• BUILD ON EXISTING INITIATIVES
• INCREMENTAL BUNDLE ADOPTION

Obstetric Hemorrhage Severe Hypertension in Pregnancy Maternal VTE Prevention Safe Reduction

• f Primary

Cesarean Births Patient, Family and Staff Support Maternal Early Warning Criteria SMM Case Review Forms

Safety Bundles s

AIM Safety/Quality Improvement Bundles

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www.safehealthcareforeverywoman.org

Safety Tools

Obstetric Care of Women with Opioid Dependence Reducing Disparities in Maternity Care Postpartum Care Basics Interconception Care Coming Soon

For Every Mother

Just Released

Maternal Mental Health (11+) (8+)

AIM Participation: July 2017

AIM Impact Annual Births: 1,520,000+

AIM Hospital Networks

Premier Trinity National Perinatal Information Center (NPIC)

Potential AIM Collective Impact

11 Current AIM States 1,520,000 Annual Births +21 ‘NEW’ AIM States 1,241,200 Annual Births 32 States 2,761,200 Annual Births AIM Hospital Networks

Premier Trinity National Perinatal Information Center (NPIC)

Improving Maternity Outcomes Through Collaboration