1. PREVENTING MATERNAL MORTALITY AND MORBIDITY FROM OBSTETRIC HEMORRHAGE
Debra Bingham, DrPH, RN3, Kathryn Melsop, MS1, Christine H. Morton, PhD1, Connie Mitchell, MD, MPH4, Elliott K. Main, MD1,2 and Christy McCain, MPH5
In Collaboration with the Maternal, Child, and Adolescent health Division within the California Department of Public Health, the CMQCC OB Hemorrhage Task Force Members, the CMQCC OB Hemorrhage Collaborative Expert Panel
1California Maternal Quality Care Collaborative (CMQCC), Stanford University; 2California Pacific Medical Center, San Francisco, CA; 3Perinatal Consultant, Belmont, CA and formerly CMQCC ( ), 4CA Department of Public Health, Sacramento, CA; 5Public Health Institute, Oakland, CA (Presenter)
Background
OB Hemorrhage QI and Metrics Tools
Baseline Obstetric Hemorrhage Survey, California 2008
The OB Hemorrhage QI metrics were developed and refined by the CMQCC multi-hospital collaborative implementation project:
30 hospitals with ~ 110,000 births per year.
The California Pregnancy Associated Mortality Review (CA-PAMR) found that obstetric hemorrhage remains one of the leading causes of maternal death (10% of pregnancy-related deaths in ).
The rate of maternal deaths has nearly tripled from 5.6 per 100,000 in 1996 to 16.9 per 100,000 annual births in (1)
In 1997, 2.4% of all live births in California were complicated by obstetric hemorrhage. (n~11,000) (2)
Nationwide, blood transfusions increased 92% during delivery hospitalizations between (3)
METHODOLOGY
Survey participants: Labor and Delivery clinical leaders
66% response rate (n=173)
32-question online survey (Survey Monkey)
Analysis software: SAS and Atlas.ti
Sample: Total number of respondent hospitals by size relative to all California hospitals >50 births
SUMMARY OF FINDINGS
Inconsistent definitions used for hemorrhage
40% of hospitals DO NOT have any hemorrhage protocol
70% of hospitals DO NOT perform drills
Physicians DO NOT regularly participate in drills
Many hospitals DO NOT have access to alternative treatment methods, e.g. Balloons
Most hospitals DO have access to all four uterotonics
Major barriers to recognition and response to obstetric hemorrhage:
Lack of agreement on definitions
Difficulty assessing amount of blood loss
Lack of a coordinated team response both within and beyond the hospital obstetric unit
Difficulty obtaining needed personnel or supplies
What are the current self-reported obstetric hemorrhage processes, structures, and barriers in birthing facilities in California?
OB Hemorrhage Outcome Measures
A.1. Percent of women (≥20 0/7 weeks gestation) transfused with any blood product
during birth admissions
A.2. Total units of each type of blood product (PRBCs, Platelets, Plasma/FFP, Cryo)
transfused during birth admissions per total births
B. Percent of women (≥20 0/7 weeks gestation) transfused with ≥5 units PRBCs during
birth admissions
C. Rate of peripartum hysterectomies in women (≥20 0/7 weeks gestation) per 1000
births (hysterectomy performed during birth admission) stratified by risk of placenta
previa and/or placenta accreta/percreta.
OB Hemorrhage Process Measures
A. Policy and procedures updated and approved
B. Number of drills and participants
C. Chart audits of quantification of blood loss
Quantify Blood Loss by Measuring
Use graduated collection containers (Cesarean section and vaginal)
Account for other fluids (amniotic fluid, urine, irrigation)
All California Hospitals
# Live Births 2005 (n)
Hospitals that Responded to Survey
(n)
% by Row: Hospital Size
(76) 39
51%
(123) 86
70%
>3000 (62) 48
77%
Total (261)
173
66%
Goals of Quality Improvement Opportunities for OB Hemorrhage
Reduce risks of hemorrhage
Perform admission risk assessments
Reduce denial and delay
Quantify blood loss
Follow a step-by-step plan
Increase use of non-pharmacologic treatments
Improve treatments with blood products
“Too little, too late”—Resuscitation versus Treatment
“Old wine in new bottles”—“Whole blood” versus PRBCs
Enhance teamwork and communications!
Debrief - important for teams to learn what went well and how to improve
Four Major Recommendations for California Birth Facilities
Improve readiness to obstetric hemorrhage by implementing standardized general and massive protocols.
Improve recognition of obstetric hemorrhage by performing on-going objective quantification of actual blood loss during and after all births.
Improve response to obstetric hemorrhage by performing regular on-site multi-professional hemorrhage drills.
Improve reporting of obstetric hemorrhage by standardizing definitions and consistency in coding and reporting.
Visual Aids displayed in Labor & Delivery and/or Postpartum areas are guides for more accurate visual estimation (Photo Credit: Bev VanderWal, CNS)
References
Acknowledgements
This project was supported by Title V funds received from the California Department of Public Health; Maternal, Child and Adolescent Health Division.
CA Department of Public Health, Maternal, Child, and Adolescent Health Division Public Released Data available at:
2. Lu MC, Fridman M, Korst LM, et al. Variations in the incidence of postpartum hemorrhage across hospitals in California. MCH Journal. September 2005;9(3):
3. Kuklina E, Meikle, S., Jamieson, D., Whiteman, M., Barfield, W., Hillis, S., Posner, S. Severe Obstetric Morbidity in the U.S., ObGyn. 2009;113:
All resources online: