Postpartum Hemorrhage: Creating an Evidence-Based I have no - PowerPoint PPT Presentation

6/8/2018 Disclosures Postpartum Hemorrhage: Creating an Evidence-Based ◦I have no conflicts of interest to disclose. Safety Bundle ERIN A. S. CLARK, MD MATERNAL-FETAL MEDICINE Postpartum Hemorrhage: M&M Postpartum Hemorrhage: U.S. ◦Incidence of PPH is 2-3% ◦ Leading cause of pregnancy-related severe morbidity and mortality in both the U.S. and worldwide ◦Most deaths occur within 24-48 hours of delivery ◦ Over half of these deaths are preventable ◦ The most preventable cause  Timely diagnosis ◦ Most postpartum hemorrhages occur in women without obvious risk factors  Appropriate resources  Evidence-based management ◦Highlights the need for system preparedness 1

6/8/2018 University of Utah Hospital University of Utah Hospital ◦In 2013, several national initiatives on OB ◦In 2013, our PPH rate was as high as 15% hemorrhage were underway… ◦We acknowledged our high rate but hid behind the ◦Compared to other University academic medical assumption that our patients were higher risk centers we stood out ◦Tertiary care center with a wide geographic referral region ◦Top-performing University Hospitals: 3-5% ◦Placenta accreta referral center ◦Hemorrhage rates up to 5x higher ◦“We’re special” University of Utah Hospital We did some serious introspection, to figure out who we really were, ◦Case review themes: as an obstetric unit, and why. ◦Under-recognition (diagnosed too late) ◦Under-treatment (didn’t treat fast enough or aggressive enough) Twin evils of “denial and delay” 2

6/8/2018 University of Utah Hospital “We are University of Utah Hospital and we have a postpartum hemorrhage problem.” How did we change? Objectives o Discuss key principles of how to implement, and ◦ We embarked on a postpartum sustainably adopt, an evidence-based OB hemorrhage prevention odyssey hemorrhage safety bundle ◦ 5 years of work and counting 3

6/8/2018 Objectives What’s a safety bundle? How do you get from o Set of evidence-based recommendations known to a bundle of evidence-based items, improve outcomes to a well-functioning team with a shot o Selection of existing guidelines and at improving outcomes? recommendations in a form that aids in implementation and consistency of practice 4 Action Domains  Readiness All major women’s health care  Recognition & professional organizations, including ACOG, were Prevention represented.  Response  Reporting/ Systems Learning 4

6/8/2018 Standardized, comprehensive, multidisciplinary 4 Action Domains obstetric hemorrhage programs have demonstrated significant • No hospital will have 100% of reductions in maternal morbidity. these elements at the start of this quality improvement process  Increased use of appropriate interventions • Even when uniformly adopted,  Decreased ICU admissions  Reduction in blood product use hospitals will need to continue to maintain and optimize these 1. Einerson et al., Does a postpartum hemorrhage patient safety program elements result in sustained changes in management and outcomes? AJOG 2015 2. Shields et al., Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. AJOG 2015. 3. Main et al., National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage. Obstet & Gynecol 2015. Obstetric Hemorrhage Bundle Hands you the tools that work So that you can implement process change 5

6/8/2018 Where is your hospital on this path? A. Thinking about implementing the hemorrhage 63% safety bundle B. In the process of rolling out the hemorrhage safety bundle 24% C. Safety bundle is established, now working on optimization 9% 2% 1% D. Declined to formally participate in “bundle-mania” E. I don’t know where we are e . r . . . . . . a n . . . . . i d , i e t t c w n u e i t e o h r s a e m g i p r n l e e b y l l i a l h p l t l w m o s a r e m w i f t o s r o u i o s e f n o s k b e d l o a t t c n n ’ g o u d n r b e o p n d i y k e i l I n h e t c i e h t f D T n a I S STEP 1 – Know your baseline data Do you know your hospital PPH rate? 84% A. Yes 1) What’s your rate of hemorrhage? B. No 2) How many elements of the bundle have you already adopted? 16% 3) What’s your compliance with elements of the bundle? s o e Y N 6

6/8/2018 STEP 2 – Understand what’s going wrong Multidisciplinary Team of Stakeholders ◦ Labor and Delivery staff (medical assistants, unit coordinators) ◦ Focus Groups of All Stakeholders ◦ Labor and Delivery nurses ◦ Labor and Delivery Nurse Educator 1) Understand the current process ◦ Nurse midwives and nurse practitioners 2) Identify problems ◦ Resident physicians (Ob/Gyn, Family Practice, ED, Anesthesia) 3) Gain insight into roadblocks ◦ Attending physicians (Ob/Gyn, Family Practice, Anesthesia) ◦ Women and Newborns Service Line hospital administrators ◦ Blood bank administrators and staff STEP 3 – Acknowledge STEP 4 – Make a specific goal & stick to it ◦Acknowledge there is a problem or that you ◦Lower your hemorrhage rate can do better ◦ We aimed to lower our rate by 25% ◦Buy in, from all stakeholders, is critical ◦Increase adoption of elements of the bundle ◦“Dog and pony show” ◦Increase compliance with specific elements 7

6/8/2018 STEP 5 – Identify tools to help you STEP 6 – Develop or Adopt Guidelines ◦ Risk stratification ◦ Algorithm for care based on risk ◦ Prevention, diagnosis and management of PPH ◦ Address the unique environment of your Utah’s Every Mother Initiative hospital or hospital system STEP 7 – Consider the Electronic Medical Record STEP 8 – Education ◦ Documentation of admission and ongoing ◦All stakeholder groups risk stratification ◦ Standardize documentation of PPH prophylaxis, diagnosis and treatment 8

6/8/2018 ARE YOU required to participate in STEP 9 – Simulation and Team Training simulations or team training efforts? 77% A. Yes ◦All stakeholder groups participate ◦ “Homework” B. No ◦Practice what you’ve learned ◦Make sure the system you’ve created works C. I don’t know 22% ◦Video tape and review as a group 1% How do you expect to work together in an emergency if you’ve never practiced s o w e N Y o n k t together as a team? ’ n o d I SHOULD YOU BE required to participate in simulations or team training efforts? STEP 10 – Ongoing data analysis 97% A. Yes 1) What’s your rate of hemorrhage? B. No 2) How many elements of the bundle have you C. I don’t know already adopted? 3) What’s your compliance with elements of the 3% 1% bundle? s o w e N Y o n k t ’ n o d I 9

6/8/2018 University of Utah PPH Rates PPH Perfect Care Audit 0-79% = Red 80-89% = Yellow 90-100% = Green Perfect Care Measures 1 st Qtr 2014 2 nd Qtr 2014 3 rd Qtr 2014 4 th Qtr 2014 1st Qtr 2015 2nd Qtr 2015 15.1 13.9 13.1 Risk Stratification 54% 68% 91% 93% 90% 88% 11 Active Management 3 rd Stage 85% 92% 90% 92% 8 7.9 PPH Documentation 49% 62% 67% 78% 88% 71% Activation PPH Order Set 19% 19% 20% 46% 48% 44% Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15 OB Rapid Response 20% 20% 20% 45% 56% 32% Series1 15.1 13.1 13.9 11 8 7.9 Quantify Blood Loss 95% 87% 86% 97% 97% 100% PPH Debriefing Done 19% 18% 29% 23% University of Utah Hospital Be Aware… o Using this approach, we’ve adopted all of the o Once you start tracking PPH very closely, rates may elements of the bundle and improved our compliance go up before they go down over time o Requires prolonged, sustained effort from o We’ve reduced our hemorrhage rates by 25% and multidisciplinary stakeholders sustained that improvement o Requires a strong and ongoing hospital and institutional commitment 10

6/8/2018 It’s Not a One Trick Pony A New Culture o The infrastructure that is created, the process that is defined, can be used to implement other obstetric It requires creating a safety bundles and quality improvement initiatives new culture that is adept at adopting o Good return on investment new best practices. Obstetric Hemorrhage Bundle o It’s a map, not a guided tour! o Journey versus destination o Learning from others “in the trenches” can be helpful 11