1. Obstetric Morbidity and Mortality: Why an Interprofessional Approach to Promote Patient Safety is Essential
Christina Davidson, MD
Maternal Fetal Medicine, Baylor College of Medicine
Vice Chair of Quality & Patient Safety | Department of Obstetrics and Gynecology | Baylor College of Medicine
Chief Quality Officer, Obstetrics & Gynecology | Texas Children’s Hospital
Kristin Thorp BSN, RNC-OB
Assistant Clinical Director
Labor & Delivery & Women’s Assessment Center, Texas Children’s Pavilion for Women

2. Objectives
Review most common causes of maternal mortality and morbidity in Texas
Review interprofessional statewide initiatives to reduce maternal mortality/morbidity
Texas Perinatal Quality Collaborative
Alliance for Innovation in Maternal Health (AIM)
Levels of Maternal Care
Discuss interprofessional approaches to improve patient outcomes
Maternal Early Warning System (MEWS)
Safety huddles
Interprofessional debriefs

3. SEVERE MATERNAL MORBIDITY
MATERNAL MORTALITY
Mortality is the “tip of the iceberg”, for every instance of mortality there are several instances of SMM
SEVERE MATERNAL MORBIDITY

4. MATERNAL MORTALITY AND SEVERE MORBIDITY
US maternal mortality: 21.1 deaths/100,000 live births (2014)
US rate is increasing as every other developed country decreases
Texas maternal mortality: 34 deaths/100,000 live births (2014)
79% increase in maternal mortality rate between 2010 and 2014
Black women are 3–4 times more likely to die a pregnancy-related death as compared with white women
For every 1 death there are 100 cases of severe maternal morbidity (SMM)
The United States has the highest maternal mortality rate of any high resource country—and it is the only country outside of Afghanistan and Sudan where the rate is rising.
Whereas every other developed country seems to be decreasing its MM rate, the US rate is increasing.
Most maternal deaths occur more than 42 days after delivery
Clinical Practice: AIM to Prevent Maternal Mortality and Morbidity
It’s no secret that the US has one of the highest maternal morbidity and mortality rates in the modern, industrialized world. In fact, a recent study in ACOG’s Green Journal sparked the latest national conversation (with Texas at the epicenter) about why we fail to reduce these numbers.
The reality is—improving maternal health outcomes requires strong leaders, an engaged team, and a data-driven, evidence-based approach.
To combat maternal mortality and morbidity, ACOG leads the Alliance for Innovation on Maternal Health (AIM), an open-access, collaborative program based on proven approaches to improve maternal safety in all US birth hospitals. AIM utilizes rapid-cycle and continuous quality improvement strategies in conjunction with a team-based approach to help hospitals improve their readiness and response to emergency obstetric events. As ob-gyns, we have a unique opportunity as maternity care team members to influence and lead efforts at the hospital level. Not only can we help prevent severe maternal events at childbirth, but we can also save lives.
How AIM Works
AIM provides hospitals with implementation resources to help them prepare for and respond to obstetric emergencies, which will ultimately improve overall maternal health outcomes in their state.
Focusing on the four R’s of patient safety bundles—readiness, recognition, response, and reporting—AIM provides implementation support and data collection plans for the following Patient Safety Bundles and Tools:
Obstetric Hemorrhage
Severe Hypertension in Pregnancy
Maternal Prevention of VTE
Safe Reduction of Primary Cesarean Birth
As an AIM member, you will also have access to a growing community of multidisciplinary health care providers, public health professionals, and cross-sector stakeholders that connect regularly to share their experiences and provide helpful suggestions on how to implement patient safety bundles more effectively. AIM provides ongoing technical assistance to ensure knowledge sharing across hospitals and states.
AIM also offers your hospital the ability to track your maternal safety and quality improvement efforts through the secure and centralized AIM Data Center. The AIM Data Center provides timely tracking of outcome, process, and structure data measures to ensure you are effectively reducing maternal morbidity and mortality outcomes at both the hospital and state level.
A Nurse’s First-Hand Experience with AIM
Beth McGovern, RNC-B, MSN, is a clinical practice specialist for Women's and Children's Services at Valley Hospital in Ridgewood, New Jersey. When she and her colleagues heard of the “AIM e-Learning Module on Maternal Early Warning Signs (MEWS),” they discussed the benefits of having such protocols in their labor and delivery unit. A multidisciplinary perinatal committee subgroup developed a hospital-specific MEWS protocol, then staff education and trainings were conducted. Implementation of MEWS in the labor and delivery unit at Valley Hospital was officially rolled out in March 2015.
MEWS protocols proved beneficial for labor and delivery staff at Valley Hospital and have proven effective in reducing maternal morbidity. For example, a mother who had delivered her baby the previous day began showing symptoms of severe hypertension. The notation of MEWS status signs in her EMR led to action. Immediately, the patient was treated, transferred from the postpartum floor to the labor and delivery unit, and eventually to the intensive care unit where her blood pressure was controlled. Ultimately, she was able to go home with her newborn.    
The implementation of MEWS protocols has received positive feedback from nurses and labor and delivery staff at Valley Hospital. It is user-friendly and has improved the quality of teamwork. “Nurses are seeing validity and they absolutely love it,” says McGovern. “They’re able to have women assessed for critical conditions in a timely manner, which reinforces the culture of safety within our hospital.” McGovern concludes, “Anybody can take these criteria and have it tailored to fit their institution.” Given physicians’ concerns about being called too frequently for emergencies, resulting in alarm fatigue, following MEWS protocol ensures labor and delivery staff are consistently prepared to face situations that could result in maternal mortality or morbidity. 

5. What is Severe maternal morbidity?
Acute myocardial infarction
Acute renal failure
Adult respiratory distress syndrome
Amniotic fluid embolism
Aneurysm
Cardiac arrest/ventricular fibrillation
Disseminated intravascular coagulation
Eclampsia
Heart failure/arrest during procedure or surgery
Puerperal cerebrovascular disorders
Acute Heart Failure/Pulmonary edema
Severe anesthesia complications
Sepsis
Shock
Sickle cell disease with crisis
Thrombotic embolism
Blood transfusion
Conversion of cardiac rhythm
Hysterectomy
Temporary tracheostomy
Ventilation
SMM can be thought of as unintended outcomes of the process of L&D that result in significant short-term or long-term consequences to a woman’s health.

8. A Maternal Mortality and Morbidity Task Force was put together in TX and their report’s key findings were:
-African American women are at greatest risk for maternal deaths
-African American women account for just 11.4 percent of all births in Texas during but account for 28.8 percent of all maternal deaths
-The leading causes were cardiac events, overdoses by prescription drugs, and hypertensive disorders
Black women were much more likely to experience SMM during a pregnancy related hospitalization compared to women of other races and ethnicities. Further, the risk of mortality at discharge from a pregnancy-related hospital stay was almost twice as high for Black women as it was for women in all other race/ethnic groups. (ref=Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report)

9. Top Causes of Maternal Death: During Pregnancy & Within 7 Days Postpartum
Slides from Dr. Lisa Hollier

11. CALIFORNIA PREGNANCY-ASSOCIATED MORTALITY REVIEW
Chance to alter outcome among major causes of pregnancy-related death (n=205*), California, 2002–2005. *The California Pregnancy-Associated Mortality Review Committee was unable to determine preventability in one cardiovascular disease death and one eclampsia death. †Significantly more likely to have good-to-strong chance than cardiovascular disease deaths and amniotic fluid embolism deaths. ‡Significantly less likely to have good-to-strong chance than all causes.Main. Pregnancy-Related Mortality in California. Obstet Gy
Overall, 41% of pregnancy-related deaths had
a good-to-strong chance of preventability, and nearly
90% had at least “some” chance; however, the leading
causes showed considerable variation (Fig. 3).
Hemorrhage and preeclampsia were significantly
more likely than cardiovascular disease and amniotic
fluid embolism deaths to have had a good-to-strong
chance of preventability, estimated at 70% and 60%,
respectively.necol 2015.
Main E, et al. Obstet Gynecol 2015;125:938–47

12. In case review, the evaluators felt that delayed response to clinical warning signs was the most commonly preventable etiology in maternal mortalities
Main et al. Pregnancy-related mortality in California. Obstet Gynecol 2015

13. Our Successes
California’s maternal mortality rate declined more than 55% from 2006 – 2013, saving 9.6 lives per 100,000
120,000 early births were prevented from 2009 – 2014, with an increase of 8% of births making it to full term
Maternal morbidity was reduced by 20.8% between 2014 – 2016 among the 126 hospitals participating in our projects to reduce maternal hemorrhage and preeclampsia

14. Interprofessional Statewide Initiatives to Reduce Maternal Mortality/Morbidity

16. AIM MATERNAL SAFETY BUNDLE COMPONENTS: THE “4 R’S”
Readiness – every unit
Is your team ready for an emergency?
Recognition – every patient
How does your team recognize patients at risk or experiencing deterioration?
Response – every emergency
What is your team’s response to an emergency?
Reporting – every unit
How does your team improve and learn?

17. MEWs is a framework for the Readiness and Recognition portions of both the hemorrhage and HTN bundles from AIM

18. “The goal of regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reduce maternal morbidity and mortality in the US.”

19. Maternal Levels of Care
All levels required to have written guidelines or protocols for conditions that place pregnant/postpartum patient at risk for morbidity and/or mortality, including promoting prevention, early identification, early diagnosis, therapy, stabilization, and transfer. The guidelines or protocols must address a minimum of:
Massive hemorrhage and transfusion
Obstetrical hemorrhage
Hypertensive disorders in pregnancy
Sepsis and/or systemic infection
Venous thromboembolism
Shoulder dystocia
Behavioral health disorders

20. Interprofessional Approaches to Improve Patient Outcomes

21. Maternal Early Warning Systems
System of escalation based on maternal vital signs
Developed to facilitate timely recognition, diagnosis, and treatment for women developing critical illness
Results in bedside evaluation and communication between physician and nurse

22. Different processes exist for maternal early warning systems
Examples include a trigger system versus a point system
Further examples include simply an escalation to get the provider at bedside faster, versus protocolized responses based on the combination of clinical factors and vital signs.
Hospitals may choose to protocolize or pre-specify a sequence of actions/orders based on the MEWS, or simply utilize MEWS for prompt provider assessment.

23. Abnormal Parameter Maternal Early Warning
Create multidisciplinary task force with physician and nurse champions to outline MEWS criteria
Identify trigger(s) that will warrant response
Validate abnormal vital signs
A single abnormal vital sign can reflect measurement artifact
MEWS trigger should prompt immediate action
Create multidisciplinary task force with physician and nurse champions to outline MEWS criteria
Identify trigger(s) that will warrant response
MEWS trigger should prompt immediate action
The key elements to the successful implementation of MEWS are:
Early Warning Criteria
Prompt reporting
Bedside evaluation
It is important to identify what system works best for your patients and what triggers will identify your more common causes of morbidity
Abnormal parameter = prompt reporting to clinician

24. Effective Escalation Policy
Who to notify
How to notify them
When to expect a response
How to escalate to get desired response

25. Effective Escalation Policy
Patient
Obstetric provider
Hospitalist
Maternal Fetal Medicine
Emergency Medicine Provider
Rapid Response Team
Family Medicine Provider
Nurse Midwife
Bedside Nurse
Critical Care Medicine Provider
Anesthesia Provider
Resident or Fellow
Each organization may have different implementation plan according to hospital resources, availability of MEWS responders
Simplicity is key to success:
Identify one responder role
Identify consistent method of contact
If MEWS responder unavailable, establish backup responder
SBAR, closed-loop communication for MEWS notification
Identify one responder role so variance is minimal and nurse can contact responder quickly
How to notify: Mobile communication devices, Automated paging systems, hospital emergency response system
If MEWS responder unavailable, establish backup responder to minimize delay in notifying a clinician
Situation–Background–Assessment–Recommendation (SBAR)

26. MEWS at TCH Pavilion for Women
MEWS Trigger Criteria
Systolic BP < 90 or > 160
Diastolic BP > 110
Heart Rate < 50 or > 120
Respiratory Rate < 10 or > 30
O2 Sat % on RA < 95
Oliguria < 35 mL/hr for ≥ 2 hrs
Maternal agitation, confusion or unresponsiveness
Patient with preeclampsia reporting a non-remitting headache or shortness of breath
Within 5 minutes of identifying MEWS trigger, using SBAR communication, RN notifies designated provider:
L&D PGY 3 via MEWS Voalte Role for all units excluding WAC
WAC hospitalist via WAC MEWS Voalte Role for WAC
If no answer from designated provider within 5 minutes, call another resident, Ob attending, or WAC Hospitalist
Abnormal MEWS criteria vital sign (in red box) obtained by PCA or RN
PCA immediately notifies RN
Vital sign repeated and verified by RN
Designated provider will:
Assume patient care responsibility until issue is resolved or patient is handed off to another provider
Report findings to patient’s OB attending
Discuss plan of care and additional orders with RN
Differential diagnosis
Planned frequency of monitoring & re-evaluation
Diagnostic or therapeutic interventions (e.g., labs, imaging)
Designated provider will evaluate patient at the bedside within 15 minutes of notification

27. MEWS Key Points
Delays in diagnosis contribute to a large portion of preventable maternal deaths and severe maternal morbidity
Key components to Maternal Early Warning Systems
Early Warning Criteria (Recognition)
Bedside evaluation (Response)
Prompt reporting (Reporting/Systems Learning)
Local implementation
Identify triggers and debrief
Outline who to notify, how to notify them
Institute back-up systems/chain of command to ensure timely evaluation

28. Interprofessional Safety Huddles
Regularly scheduled huddles attended by Nurses and Physicians
Discussion can include:
Patient overview
“Watcher” patients, concerns
MEWS calls
Throughput issues
Staffing concerns
Discharge barriers

29. Debriefs after Adverse Events
Cases resulting in severe maternal morbidity and/or unexpected outcomes undergo debrief around time of event:
Transfusion >4 units PRBCs or initiation of massive transfusion protocol (MTP)
Shoulder dystocia
Stat cesarean
Maternal or neonatl code
Neonatal total body cooling
Eclamptic seizure
Unanticipated peripartum hysterectomy
Debrief participants include all staff and providers involved in patient's care
Purpose: identify improvement opportunities related to policies, processes, knowledge or systems in a non-punitive environment
Goal: uncover areas that, if addressed, could improve care or prevent adverse outcomes for future patients in a similar situation; highlight best practices
Identify list of events that should be routinely debriefed in your organization

31. Thank You!