Purpose for the Program
The California Pregnancy Related Maternal Mortality Review found that obstetric (OB) hemorrhage was one of the leading causes for maternal death and a major contributor to maternal morbidity. Deaths from hemorrhage consistently rank at the top of the most preventable list, with 70% to 92% of deaths judged to be preventable. However, few hospitals have created a systematic postpartum hemorrhage (PPH) protocol for early recognition and rapid response. Sharp HealthCare, while participating in a statewide initiative to transform maternity care in California, successfully executed best practices and tools for OB hemorrhage by implementing an active quality improvement processes to drive change.
MAP-IT (Mobilize, Assess, Plan, Implement, Track), a rapid cycle quality improvement method for outlining change was implemented. An initial assessment of staff knowledge revealed a critical tasks completion rate of 35%. Major opportunities for improved outcomes were evident. The learning opportunities identified included a focus on preassessment and preparation of hemorrhage risk, underestimation of blood loss, delay in administration of blood, delay in response from other team members, and delay in adequate resuscitation. Drills were designed to highlight 21 evidence-based critical tasks/elements needed to ensure the best outcome.
Implementation, Outcomes, and Evaluation
The percentage of drill task completion was used as the primary metric for improvement. An interdisciplinary group was mobilized, including advanced clinicians, blood bank personnel, laboratory leadership, and physician champions. The project goals included the following: standardize documentation and system order sets to aid in the prenatal admission and ongoing risk assessment (preassessment and preparation of hemorrhage risk identified 90% of audited cases); and develop and implement a multidisciplinary team response to every massive PPH by March 2013, with a goal of 90% completion of the identified critical tasks.
Electronic medical record (EMR) documentation was standardized to streamline ordering of admission blood work and blood products, and included home folders for transfusion order sets for easy access. Balloon tamponade policy and procedures, as well as standard order sets were implemented. Identification of patients with ethical, moral, or religious beliefs conflicting with blood/blood product administration and referral to the Bloodless Medicine program were streamlined through the EMR. Rapid response teams were modified to include additional interdisciplinary members.
Implications for Nursing Practice
By altering the outcome measures and reducing major complications of PPH, this project will serve to improve many core processes and improve a culture of safety for every patient every time.