1. Elliott Main, MD Stanford University California Maternal Quality Care Collaborative

2. Maternal Mortality Rate, California and United States; 1999-2010 SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013. HP 2020 Objective – 11.4 Deaths per 100,000 Live Births Maternal Deaths per 100,000 Live Births 2

3. Maternal Mortality and Severe Morbidity Approximate distributions, compiled from multiple studies Cause Mortality (1-2 per 10,000) ICU Admit (1-2 per 1,000) Severe Morbid ( 1-2 per 100) VTE and AFE15%5%2% Infection10%5% Hemorrhage15%30%45% Preeclampsia15%30% Cardiac Disease25%20%10%

4. California Pregnancy Associated Mortality Reviews –Missed triggers/risk factors: abnormal vital signs, pain, altered mental status/lack of planning for at risk patients –Underutilization of key medications and treatments –Difficulties getting physician to the bedside –“Location of care” issues involving Postpartum, ED and PACU University of Illinois Regional Perinatal Network -Failure to identify high-risk status -Incomplete or inappropriate management Dominance of Provider QI Opportunities: Hemorrhage and Preeclampsia CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR): Report from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC.org) Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with severity. Am J Obstet Gynecol 2004; 191: 939-44. Present in >95% of cases Present in >90% of cases

5. Maternal Safety Obstetricians (ACOG/SMFM/ ACOOG) Nurses (AWHONN) Family Practice (AAFP) Midwives (ACNM) Hospitals (AHA, VHA) OB Anesthesia (SOAP) Birthing Centers (AABC) Safety, Credentials (TJC) Blood Banks (AABC) Perinatal Quality Collaboratives (many) Federal (MCH-B, CDC, CMS/CMMI) State (AMCHP, ASTHO, MCH) Direct Providers Nurse Practitioners (NPWH) 5

6. 123(5):973-977, May 2014

7. 4 Domains: OB Hemorrhage Patient Safety Bundle Improve readiness to hemorrhage by identifying standardized protocols (general and massive) Improve recognition of OB hemorrhage by performing on-going objective quantification of actual blood loss Improve response to hemorrhage by utilizing unit- standard, stage-based, obstetric hemorrhage emergency management plans with checklists Improve reporting/systems learning of OB hemorrhage by performing regular on-site multi- professional hemorrhage drills

8. Obstetric Hemorrhage Key Elements Readiness - Every Unit 1.Hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches 2.Immediate access to hemorrhage medications (kit or equivalent) 3.Establish a response team - who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services 4.Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched) 5.Unit education on protocols, unit-based drills (with post-drill debriefs)

9. Obstetric Hemorrhage Key Elements Recognition - Every Patient 5.Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times) 6.Measurement of cumulative blood loss (formal, as quantitative as possible) 7.Active management of the 3rd stage of labor (routine use of oxytocin)

10. Obstetric Hemorrhage Key Elements Response - Every Hemorrhage 9.Unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists 10.Support program for patients, families, and staff for all significant hemorrhages

11. Obstetric Hemorrhage Key Elements Reporting/Systems Learning - Every Unit 11.Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities 12.Multidisciplinary review of serious hemorrhages for systems issues 13.Monitor outcomes and process metrics in perinatal quality improvement (QI) committee

12. 4 Keys Have a “Safety Bundle” “Standard Work”—Check list for putting the bundle into action Practice (drills) Feedback and tweaking (debriefs and formal case reviews

13. Key OB Hemorrhage QI Toolkits: Full of Resources www.CMQCC.orgwww.pphproject.org v2.0 available soon www.safehealthcareforeverywoman.org

14. Large-Scale Implementation How do we reach EVERY hospital in the CA? Engage every Professional organization State-level groups Engage every Hospital organization The Joint Commission CMMI: Hospital Engagement Networks State Agencies State Maternal Quality Collaborative Different models of QI (mentoring)

15. Things to Remember The development of a multidisciplinary taskforce with physician and nursing champions from OB, anesthesia, and blood bank is critical for success Don’t reinvent the wheel – use available resources to help develop and implement your hospital’s individualized response plan Simulation is a great way to educate, practice new behaviors and test your infrastructure – make time for it Debriefings are critical for continuous quality improvement and effective debriefing is a skill that needs to be taught and practiced

16. Maternal Mortality Rate, California and United States; 1999-2010 SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013. HP 2020 Objective – 11.4 Deaths per 100,000 Live Births Maternal Deaths per 100,000 Live Births 16