Project Leaders: Janel Zion, Patient Care Supervisor, Patti Bradley, - PowerPoint PPT Presentation

• Understand basic elements of the California Maternal Care Quality Collaborative (CMQCC ) and AWHONN recommendations related to improving PP hemorrhage outcomes • Identify ways to design, implement and evaluate an interprofessional hospital project to improve PP hemorrhage outcomes • Review staff educational strategies to help assure effective evidenced based project implementation

Project Leaders: Janel Zion, Patient Care Supervisor, Patti Bradley, Maternal • Child Services Manager, Carol Heflin, Nurse Educator OB and Anesthesia Physicians: Dr. Sarah Newman and Dr. Robert Taylor • Pharmacist: Hieu Tran • Labor RN’s: Karin Gerberding, Denise Rosser, Christy Sybrat • Postpartum RN’s: Beth Diebold, Dana Shoe, Jennifer Reed, Jennifer • Gronniger Labor and Postpartum Technicians: Sheila Carpenter, Joy Butler, Peggy • Rothrock Administration: Michele Malone, Director of Women’s Services • Consultant: Dr. Sally Ellis Fletcher, Clinical Nurse Researcher •

California Maternal Care Quality Collaborative (CMQCC): Improving Health Care Response to Obstetric Hemorrhage Association of Women’s Health and Neonatal Nurses: Postpartum Hemorrhage Project

Postpartum Hemorrhage (PPH) affects 1-3% • of pregnancies in the first 24 hours after birth PPH is a leading cause of pregnancy-related • mortality in developed countries Deaths due to PPH have declined but serious • morbidities have remained constant and include massive transfusions, secondary surgical procedures, ICU admissions and fertility loss

1998-1999 compared to 2008-2009: • 75% increase in severe maternal morbidity • 184% increase in the number of women who received a blood transfusion during a hospital birth admission (AWHONN postpartum hemorrhage project)

Recognition of Risk Factors for PPH, that will lead to • heightened surveillance of postpartum bleeding Standardized approach to accurate estimation of • blood loss to guide intervention (typically underestimated by clinicians) The use of clinical evaluation and assessment that • indicate or alerts for PPH Standardized protocols for rapid intervention and • treatment of PPH to reduce morbidity from massive hemorrhage

Mortality and Morbidity from PPH is preventable!

1). Blood loss > 500 ml or hemodynamic instability is a trigger for heightened surveillance and/or aggressive treatment should bleeding continue 2). Blood loss of 1000 ml should be used for quality monitoring, and internally report all EBLs of 500 ml for adherence to established protocols 3). Birthing centers maintain protocols for: quantification of blood loss management of women with EBL >500 ml notification of physician and administration of Methergine 0.2 mg IM and fundal massage Establish clinical triggers for intervention: heart rate >110 blood pressure <85/45 O2 saturation <95%

I know! Let’s do a Performance Improvement Project based on our most immediate need!

Legitimizes the project across disciplines • Assures a specific focus and agreement on goals • Helps obtain leadership support and resources • Assures measures of success are identified early • Helps project stay organized and on timeline • Helps troubleshoot problems and identify next steps • Everyone is accountable and shares in the outcomes •

Three PP hemorrhage events in October 2013 were the • catalyst for a performance improvement project Charge RN discussed need to improve response process • and response time to PPH events PPH emergency supplies were kept in different locations on • our two floors, and could get moved by well meaning staff. Supply par levels were hard to consistently maintain. • Varying degrees of staff and physician knowledge related to • type, location and use of supplies and medications during PPH events.

Enhanced Emergency Intervention for Post Partum Hemorrhage 1. Plan: (goal statements) A) 100% of emergency supplies for post partum hemorrhage will be readily available 100% of the time and nursing staff and physicians will be aware of the location, types and use of supplies and medications. B) Reduce the number of blood transfusions needed by PPH patients and reduce the number of units transfused per event, using prior six months of data for PPH events as baseline date. (Prior six months there were 599 births, 15 PPH events, utilizing average of 4.06 units of blood per patients, equaling 2.5% of patients with PPH.)

2. Do:(review benchmarks and standards of care) A) Standard of care is for emergency supplies to be standardized and readily available to responders to use for life saving interventions, and for responders to be familiar with the type, location and use of all emergency supplies needed for an event. (Like crash carts for Code Blue scenarios) B) National Data Base of Nursing Quality Indicators RN Satisfaction survey measure “Nurses have the supplies necessary to do their jobs.”

3. Study: • Evidenced based practices / best practice recommendations to achieve our goals – AWHONN Postpartum Hemorrhage Project was initially used to launch project • Literature review and resources are in your handouts – CMQCC was discovered during literature review and was essential to the development of the project

4. Act: NKCH Maternal-Child unit is composted of 2 floors, one for L&D, one for postpartum. It was decided a cart for each floor would be needed.

• Identified Action Steps • Assigned responsibilities • Established a timeline for the project and each task • Considered resources (available and needed) • Identified potential barriers • Developed a communication plan with the team and all units • Set Milestone Measures to stay on track

It was identified that emergent PPH supplies were in • various locations on 2 separate maternity floors It was difficult to arrive at a consensus on necessary • items for postpartum hemorrhage carts There was variability in levels of skill and knowledge • about certain supplies and medications needed for the cart As we assembled carts and approved the supply and • medication list, the supplies would have taken three carts! We had to agree on what to pare down. The QMQCC Guidelines helped with this.

• Our pharmacy required separating meds into refrigerated and unrefrigerated: Some medications are available in the PPH cart; IV solutions, Cytotec, and Pitcocin. Other medications are in a “PPH kit” in the Pyxis refrigerator; Methergine and Hemabate • The project took longer to Go Live than anticipated (April 1 vs. January 1), but we had strong support from leadership to adjust the timeline and obtain resources we needed.

• Supply list and medications in our carts are listed in the CMQCC Guidelines, with a few minor changes specific to our hospital. • These PPH carts are maintained per Crash Cart policy: Must be locked, checked, logged and re- stocked in the same manner. Pharmacy maintains PPH medication kits in Pyxis refrigerators • Initial and ongoing education and competencies are critical to success. • Ongoing monitoring and evaluation are required, and we will be auditing % of PPH events requiring blood transfusions and average number of units per patient.

One PPH event since Go Live, that has used the cart, and a debriefing was conducted. Comments from staff included: Saved time, steps and stress • Bakri drawer was AWESOME! • We love it! • Easy and fast, everything at our fingertips • Working to hardwire the cart check and re-stock • process, we are not yet at 100%. Will look at trended transfusion measures •

• Learning strategies involved active learning principles consistent with adult learning styles. • Learning activities were designed to contribute to the objective of integrating evidence based care for the woman experiencing a postpartum hemorrhage. Goals: 1. Create a climate of mutual trust and clarify mutual expectations. 2. Create a cooperative learning environment .

Staff had uncertainty related to: 1. What they were able to do in a PP emergency 2. Locating necessary equipment, medications, etc. Education design focused on assessing: 1. Individual learning styles 2. Motivation 3. Relative past experiences 4. Level of engagement 5. Willingness to apply the learning.

Ongoing email communications • Education on Bakri balloon insertion and rapid installation • provided by Cook Medical for nurses and physicians. • Presentations at staff meeting of PPH cart. • “Scavenger Hunt” in the cart • Videos and quizzes • Mock PPH drill scenarios began with staff • Go Live scheduled after 95% of nursing staff completed education. • Postpartum Hemorrhage Order set provided framework for prompt initiation of appropriate clinical management. • Examples are in your handouts

• Accurate assessment of EBL, is one of the most important elements of the CMQCC project. That was accomplished using: – ACOG article on postpartum hemorrhage and required competency quiz – CMQCC determined that visual assessment of EBL is notoriously under rated; Poster presentation and reference sheet designed by nurses for use in clinical area for accurate weight and measurement of EBL