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

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Postpartum Hemorrhage: Creating an Evidence-Based Safety Bundle

ERIN A. S. CLARK, MD MATERNAL-FETAL MEDICINE

Disclosures

I have no conflicts of interest to disclose.

Postpartum Hemorrhage: M&M

Leading cause of pregnancy-related severe morbidity and

mortality in both the U.S. and worldwide

The most preventable cause

Timely diagnosis Appropriate resources Evidence-based management

Postpartum Hemorrhage: U.S.

Incidence of PPH is 2-3%
Most deaths occur within 24-48 hours of delivery
Over half of these deaths are preventable
Most postpartum hemorrhages occur in women without
bvious risk factors
Highlights the need for system preparedness

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University of Utah Hospital

In 2013, our PPH rate was as high as 15%
We acknowledged our high rate but hid behind the

assumption that our patients were higher risk

Tertiary care center with a wide geographic referral region
Placenta accreta referral center
“We’re special”

University of Utah Hospital

In 2013, several national initiatives on OB

hemorrhage were underway…

Compared to other University academic medical

centers we stood out

Top-performing University Hospitals: 3-5%
Hemorrhage rates up to 5x higher

We did some serious introspection, to figure out who we really were, as an obstetric unit, and why.

University of Utah Hospital

Case review themes:
Under-recognition (diagnosed too late)
Under-treatment (didn’t treat fast enough
r aggressive enough)

Twin evils of “denial and delay”

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University of Utah Hospital

“We are University of Utah Hospital and we have a postpartum hemorrhage problem.”

How did we change?

We embarked on a postpartum

hemorrhage prevention odyssey

5 years of work and counting

Objectives

Discuss key principles of how to implement, and

sustainably adopt, an evidence-based OB hemorrhage safety bundle

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Objectives

How do you get from a bundle of evidence-based items, to a well-functioning team with a shot at improving outcomes?

What’s a safety bundle?

Set of evidence-based recommendations known to

improve outcomes

Selection of existing guidelines and

recommendations in a form that aids in implementation and consistency of practice

All major women’s health care professional organizations, including ACOG, were represented.

Readiness Recognition & Prevention Response Reporting/ Systems Learning

4 Action Domains

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No hospital will have 100% of

these elements at the start of this quality improvement process

Even when uniformly adopted,

hospitals will need to continue to maintain and optimize these elements

4 Action Domains

Standardized, comprehensive, multidisciplinary

bstetric hemorrhage programs have

demonstrated significant reductions in maternal morbidity.

Increased use of appropriate interventions Decreased ICU admissions Reduction in blood product use

1. Einerson et al., Does a postpartum hemorrhage patient safety program

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

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Where is your hospital on this path?

A. Thinking about implementing the hemorrhage

safety bundle

B. In the process of rolling out the hemorrhage safety

bundle

C. Safety bundle is established, now working on
ptimization
D. Declined to formally participate in “bundle-mania”
E. I don’t know where we are

T h i n k i n g a b

u

t i m p l e m e n t i n . . . I n t h e p r

c

e s s

f

r

l

l i n g

u

t . . . S a f e t y b u n d l e i s e s t a b l i s h e d , . . . D e c l i n e d t

f
r

m a l l y p a r t i c i . . . I d

n

’ t k n

w

w h e r e w e a r e

2% 9% 24% 1% 63%

STEP 1 – Know your baseline data

1) What’s your rate of hemorrhage? 2) How many elements of the bundle have you already adopted? 3) What’s your compliance with elements of the bundle?

Do you know your hospital PPH rate?

A. Yes
B. No

Y e s N

84%

16%

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STEP 2 – Understand what’s going wrong

Focus Groups of All Stakeholders

1) Understand the current process 2) Identify problems 3) Gain insight into roadblocks

Multidisciplinary Team of Stakeholders

Labor and Delivery staff (medical assistants, unit coordinators)
Labor and Delivery nurses
Labor and Delivery Nurse Educator
Nurse midwives and nurse practitioners
Resident physicians (Ob/Gyn, Family Practice, ED, Anesthesia)
Attending physicians (Ob/Gyn, Family Practice, Anesthesia)
Women and Newborns Service Line hospital administrators
Blood bank administrators and staff

STEP 3 – Acknowledge

Acknowledge there is a problem or that you

can do better

Buy in, from all stakeholders, is critical
“Dog and pony show”

STEP 4 – Make a specific goal & stick to it

Lower your hemorrhage rate
We aimed to lower our rate by 25%
Increase adoption of elements of the bundle
Increase compliance with specific elements

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STEP 5 – Identify tools to help you

Utah’s Every Mother Initiative

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

hospital or hospital system

STEP 7 – Consider the Electronic Medical Record

Documentation of admission and ongoing

risk stratification

Standardize documentation of PPH

prophylaxis, diagnosis and treatment

STEP 8 – Education

All stakeholder groups

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STEP 9 – Simulation and Team Training

All stakeholder groups participate
“Homework”
Practice what you’ve learned
Make sure the system you’ve created works
Video tape and review as a group

How do you expect to work together in an emergency if you’ve never practiced together as a team?

ARE YOU required to participate in simulations or team training efforts?

A. Yes
B. No
C. I don’t know

Y e s N

I

d

n

’ t k n

w

77% 1% 22%

SHOULD YOU BE required to participate in simulations or team training efforts?

A. Yes
B. No
C. I don’t know

Y e s N

I

d

n

’ t k n

w

97% 1% 3%

STEP 10 – Ongoing data analysis

1) What’s your rate of hemorrhage? 2) How many elements of the bundle have you already adopted? 3) What’s your compliance with elements of the bundle?

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Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15 Series1 15.1 13.1 13.9 11 8 7.9 15.1 13.1 13.9 11 8 7.9

University of Utah PPH Rates

PPH Perfect Care Audit

0-79% = Red 80-89% = Yellow 90-100% = Green

Perfect Care Measures

1stQtr 2014 2nd Qtr 2014 3rd Qtr 2014 4th Qtr 2014 1st Qtr 2015 2nd Qtr 2015

Risk Stratification 54% 68% 91% 93% 90% 88% Active Management 3rd Stage 85% 92% 90% 92% PPH Documentation 49% 62% 67% 78% 88% 71% Activation PPH Order Set 19% 19% 20% 46% 48% 44% OB Rapid Response 20% 20% 20% 45% 56% 32% Quantify Blood Loss 95% 87% 86% 97% 97% 100% PPH Debriefing Done 19% 18% 29% 23%

Using this approach, we’ve adopted all of the

elements of the bundle and improved our compliance

ver time
We’ve reduced our hemorrhage rates by 25% and

sustained that improvement

University of Utah Hospital Be Aware…

Once you start tracking PPH very closely, rates may

go up before they go down

Requires prolonged, sustained effort from

multidisciplinary stakeholders

Requires a strong and ongoing hospital and

institutional commitment

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It’s Not a One Trick Pony

The infrastructure that is created, the process that is

defined, can be used to implement other obstetric safety bundles and quality improvement initiatives

Good return on investment

A New Culture

It requires creating a new culture that is adept at adopting new best practices.

Obstetric Hemorrhage Bundle

It’s a map, not a guided tour!
Journey versus destination
Learning from others “in the trenches” can be helpful