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Obstetric hemorrhage is a leading cause of maternal mortality, accounting for nearly one-quarter of all maternal deaths worldwide. Hemorrhage can also be associated with severe morbidity, such as organ failure or septic shock, in many cases necessitating prolonged hospitalizations. This condition also calls for a significant examination of equity issues, because while there is no evidence that any ethnic or racial group is more physiologically predisposed to it, Black women suffer from disproportionately high rates of hemorrhage-related mortality and morbidity.
More than six years ago, leaders at Atrium Health were determined to tackle this problem. Atrium Health is a large system in the southeast United States where more than 37,000 births occur annually. At the end of 2013, the Atrium team embarked on a quality improvement project to reduce hemorrhage-related morbidity. The project was motivated in part by understanding that mortality and morbidity from hemorrhage are highly preventable. “It’s very important that we have prompt recognition and treatment,” said Amy Bell, Assistant Vice President, Performance Improvement. “Minutes count and lives can change forever when things are not properly identified and treated.”
In November 2013, in collaboration with the Florida Perinatal Quality Collaborative (FPQC), they began work. Fortunately, they had not had any recent maternal deaths, but some hemorrhages had resulted in unplanned hysterectomies, a complication of hemorrhage that can be prevented if the condition is identified and treated properly in a timely manner. As a result, their primary goal was to decrease the unplanned peripartum hysterectomy rate. To begin, they identified two pilot facilities: Carolinas Medical Center & Atrium Health Pineville.
The pilot sites developed an Obstetric Hemorrhage Protocol, by undertaking the following steps:
- Reviewing all postpartum hemorrhage cases;
- Researching best practices;
- Creating an OB Hemorrhage Toolkit;
- Educating teammates and providers on new best practices;
- Determining facility-specific resources available and reevaluating continually for improvement opportunities.
One essential part of the project was to ensure they were consistently quantifying blood loss (QBL) and accurately tracking the number of hemorrhages. Quantification of blood loss is done by measuring blood and/or weighing used supplies to provide a more accurate assessment of blood loss instead of estimating blood loss based on a visual assessment. Once they improved their compliance with QBL, they realized they “had way more hemorrhages than we thought,” said Bell. “If you have not implemented a hemorrhage protocol, when you do, you will see an increase in your hemorrhage rate.”
In addition to timely recognition of the condition, it was key to ensure that providers had the necessary supplies at hand for treatment. “To be efficient, we wanted to bring supplies closer to point of use,” said Debbie Pasquarello, Quality Nurse. They obtained a red hemorrhage cart, which contains lab supplies and blood transfusion materials, as well as a secure cooler to transport blood products. They also developed a protocol for massive transfusion.
Another essential component was provider education, including hands-on simulation.
Atrium was able to buy a high-fidelity mannequin, and to provide skills and drills at both pilot facilities. They also needed to educate staff on why the work was necessary. The protocol was sometimes viewed by staff as “one more thing to do.” To drive home its importance, Bell said, “we reviewed detrimental effects to mom, baby, and family” that hemorrhage can have.
Results from implementation at the pilot sites included reduction of unplanned peripartum hysterectomies, reduction in the number of women transfused with any blood product, reduction of massive transfusion (greater than/equal to 4 units), and reduction of maternal ICU admissions as a result of hemorrhage. After highly promising results at the pilot sites, the next step was to spread the initiative to the entire system. The spread plan, led by system-level OB leadership, was to create interdisciplinary teams and develop protocols at every facility, educate physicians and nurses, and purchase carts and other needed supplies. Another important part of the spread plan was to offer simulation training to providers to enable them to practice different scenarios. Data reporting was also key.
Throughout this process, Atrium was using the Model for Improvement, including plan-do-study-act (PDSA) cycles, to test and enhance implementation of the new elements of the process. For example, a risk assessment tool was developed and added into the protocol. “That’s not something you do once and solve it,” said Bell. “We are still using the PDSA cycle.”
After the systemwide implementation, the results were remarkable. Unplanned peripartum hemorrhage-related hysterectomies fell from 0.08 percent in 2013 to 0.05 percent in 2018. For quantification of blood loss, the rate rose from 26.7 percent in 2014 to 91.3 percent in 2019. To put these numbers into more concrete terms: “When you look at the decrease,” said Bell, “it equates to 12 women in a year who may have had a hysterectomy but didn’t.”
Now, Atrium is working on sustaining the improvements, through ongoing collaboration with physician and nursing leaders across all facilities. All new nursing school graduates who are working in OB areas receive simulation training. There are also pop-up drills throughout the year, and if necessary, providers may receive one-on-one training. Atrium has also enlisted patient advisors to provide a patient perspective, and they held collaborative work sessions with the lab to develop their massive transfusion protocol.
From the initiative, leaders learned several key lessons including the importance of physician and nurse champions to support the new processes and provide education within the units and the teams. It’s also crucial to have unit-specific OB hemorrhage committees to review trends, identify gaps, and implement continuous improvement projects. And it’s critical to have a standardized OB hemorrhage toolkit, including cart and medication kits.
Initially, physicians and nurses sometimes found it hard to believe that so much blood loss was occurring. “We needed to show them the value of quantification,” said Bell. “We’ve made a lot of great strides. It’s not even a question anymore. But it took a lot of reinforcement.”
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