1. Quantification of Blood Loss (QBL)
Margie Mueller Boyer, RNC, MS
Florida AWHONN Section OHI Representative
Annette Phelps, ARNP, MSN
FPQC Nursing Consultant

2. How were we doing? OHI Hospitals (31 FL and 4 NC):
Prior to implementation of
Phase 1 OHI initiative
58% report use of techniques to quantify blood loss
Only 26% quantify-only (never estimate)
We surveyed hospitals with our OHI recruitment questionnaire and found that a little over half were using some methods to quantify blood loss, with about a fourth of them quantifying only and never estimating.

3. % of OHI hospitals using QBL methods for Vaginal Deliveries
How are we doing now?
% of OHI hospitals using QBL methods for Vaginal Deliveries
Six months after implementation data show a progressive rise in quantification in vaginal deliveries in particular measurement by weight. 3

4. How are we doing now? Cont.
% of OHI hospitals using QBL methods for Cesarean Deliveries
Similarly, the rise in measurement by collection in Cesarean deliveries has increased. 4

5. Quantification History
EBL method used most often is visual estimation
Visual estimation is unreliable and inaccurate
Underestimated as much as 33 to 50 %
Institute most accurate methods: Quantification of Blood Loss (QBL)
Gabel et al 2012, Patel et al 2006, Bingham et al 2012
AWHONN Practice Brief:
Much research has been done on blood loss assessment. Accurate tracking of blood loss is critical in planning interventions for the patient experiencing PPH. Several experts recommend quantification of blood loss via quantification methods after every birth. AWHONN recommends QBL, also the success of the California Maternal Quality Care Collaborative results initiated in 2010 underscores the need to quantify. Visual estimation is not reliable and is inaccurate, it can lead to underestimation by as much as 33 to 50%.

6. We’ve always done it this way…
Clinical decisions of when and if resuscitative efforts should begin and to notify other team members of hemorrhage, need to be based on measures and evidence
It is a matter of patient safety!
Gabel, K. T., & Weeber, T. A. (2012)
Just because we have implemented a practice for a long time does not mean it is the best practice. We must move to evidence based approaches in order to make sound clinical decisions for intervention. It is important for the safety of our patients.

7. QBL Benefits QBL prompts the Nurse on critical actions
No longer rely on flawed, imprecise visual estimation
Timely recognition of excessive blood loss leads to initiation blood transfusions and other maternal resuscitative efforts
Overestimation can be costly--unnecessary treatments like transfusions
Underestimation can delay life saving hemorrhage interventions
Maternal morbidity and mortality is associated with delay in diagnosis and delay in interventions with PPH. QBL may result in earlier interventions and improved outcomes. NOTE discuss items listed on slide.

8. Recommendations AWHONN now recommends QBL at every birth
The process is intentional—a formal effort!
No more vague “Guesstimates”
Continues until the patient is stable and is cumulative with hand-off reporting
QBL is now recommended by AWHONN for every birth, it should be standardized and continuous until the patient is stable. Hand-off or SBAR reporting provides for continuity of care.
Denial
Delay

9. QBL is More Accurate The goal is not a “perfect, precise” number.
There may be some discrepancies from mixing with amniotic fluid, urine, irrigant, etc.
However it is more accurate to do some measurements than to rely solely on visual estimates.

10. Who should determine QBL?
It is a team effort and needs to be standardized.
Some teams designate one member as responsible to measure, orally report, and record.
We will discuss 2 methods.
We should be able to answer:
How much blood is in the suction canister (after amniotic fluid)?
How much blood is on sponges?
How much blood is on the floor/on the table?
At regular intervals and cumulatively until the patient is stable (2 to 4 hours post delivery)
CMQCC 2010
Denial
Delay
Each member of the obstetric team is vital to assuring a complete assessment, information must be accurately and clearly communicated to the team members. Nursing works with team to report QBL and help assure a standardized methodology is employed. Today we will discuss two methods in order to best determine blood loss over time. 10

11. AWHONN Practice Brief, Quantification of Blood Loss May 2014
Methods
Weigh: Blood soaked pads, chux
Direct Measure: Collect blood in graduated measurement containers and/or under buttocks drapes
Account for other fluids(amniotic fluid, irrigation)
AWHONN Practice Brief, Quantification of Blood Loss May 2014
Each hospital will determine the method to use. Quantification is the goal. Posters may be used to determine blood loss based on dry and blood soaked weights
The most objective manner is to measure blood volume collected via suction cannisters (Cesarean sections) & under buttocks drapes (vaginal births) along with weighing laps, pads,etc (1 gram = 1ml)

12. Recommendations
Weigh wet materials (with known dry weight); may be done by gathering a group of pads and weighing them all together
TIP: A practical way of measuring blood in laps is to weigh them in groups of 5.
Calculate the gram weight and convert to milliliters.
One gram = One milliliter
AWHONN Practice Brief, Quantification of Blood Loss May 2014
The California collaborative and AWHONN have made several recommendations based on their experience. Our interviews with California hospitals who ranged in number of deliveries from 350 to 5,000 per year indicated that once a quantification method was selected and consistently applied, it became an institutional practice that was not a burden, and that made a difference in responding early and often preventing a hemorrhage from increasing to higher stages.
Jennifer McNulty MD and Amy Scott MSN

13. FPQC QBL Calculation Poster
FPQC has developed this poster and it is available on our website, it include a place to insert your hospital’s dry weights.
Created by Tricia Walton, RNC,BSN, Hedy Edmund, RNC,BSN and the FPQC
Available upon Request from the FPQC

14. Recommendations cont.
Use calibrated under-buttock drapes (at vaginal birth, note the volume of amniotic fluid, urine and stool after birth but before the placenta)
Measure what can be suctioned at CS (less irrigation +AF)
Read slide…..

15. Direct Measure Under Buttocks Drapes 275 mL
Quantifying blood loss by measuring is the most accurate method—this slide illustrates the under buttocks drape.
 Use graduated collection containers (C/S and vaginal deliveries)
Account for other fluids (amniotic fluid, urine, irrigation
Document amount at delivery of infant and then ongoing post delivery until patient is hemodynamically stable=2 to 4 hours
275 mL

16. Cesarean Sections
Hospitals need to adapt quantification measures to their situation, for example: A 2 step process using 2 canisters with documentation of irrigation and amniotic fluid as appropriate is recommended by some hospitals, a notation of the amount of fluid in the canister at delivery of the baby may also be made and one canister used. Read slide.
Shared by Jennifer McNulty MD and Amy Scott MSN and available in the OHI Toolbox

17. AWHONN’s tips for: Where Do We Begin?
Start by teaching the process that is common for most cases.
Begin with vaginal births then scheduled cesareans.
Be willing to modify and tweak the process to meet the particular logistics of your facility.
Have team meeting to determine how to manage e.g., the STAT cesarean.
Some ideas for developing your plan may include: read slide
Other places may find that beginning with the C-section births is best for them because they are already using collection canisters and accounting for sponges, laps, and irrigation.

18. Vaginal Births: Keep it Simple
For Vaginal Births, begin right after the infant’s birth:
• Note amniotic fluid, urine, etc. in the under-buttocks bag prior to birth. (Applicable if SROM occurs close to birth or amnioinfusion performed.)
• RN looks at the bag as soon as OB/CNM has completed the delivery to communicate the amount of blood in the calibrated drape as QBL.
AWHONN Practice Brief, Quantification of Blood Loss May 2014
These are recommended steps in quantification for vaginal deliveries.
Additional AWHONN reference:

19. Quantification Tips from AWHONN
Assess amount of fluid in the under buttocks drape prior to delivery of placenta - mark drape or state amount
Begin QBL immediately after the infant’s birth PRIOR to delivery of the placenta.
Record the amount of fluid collected
Most of the fluid collected prior to birth of the placenta is amniotic fluid, urine, and feces. If irrigation is used, deduct the amount of irrigation from the total fluid that was collected.
Subtract the pre-placenta fluid volume from the post-placenta fluid.   Most of the fluid collected after delivery of placenta is blood.
Continue QBL 2-4 hrs postpartum
These tips are adapted from AWHONN—read slide.

20. FPQC OHI Toolkit and Materials for QBL
Resources
FPQC OHI Toolkit and Materials for QBL
FPQC has posted a number of resources on the website that can be accessed at this url.

21. Available at www.pphproject.org
Resources
AWHONN has a number of open resources on their website at the URL shown here.
Available at

22. Frequently Encountered Clinical Issues and Responses (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
Providers believe that their patients are unique; thus, the research does not apply to their specific group of patients.
Many physicians and nurses have only performed EBL. They are not familiar with how to QBL.
Distribute key peer-reviewed literature related to the measurement of blood loss to every nurse and physician.
The lack of experience indicates that there is a need for more education tactics with QBL details.
There are always questions and concerns when change is implemented. These issues and recommendations are based on AWHONN and CMQCC experiences and closely track what we have seen in FPQC sites. See slides.
Issue: Providers believe that their patients are unique; thus, the research does not apply to their specific group of patients. Response: Distribute key peer-reviewed literature related to the measurement of blood loss to every nurse and physician.
Issue: Many physicians and nurses have only performed EBL. They are not familiar with how to QBL. Response: The lack of experience indicates that there is a need for more education tactics with QBL details.
Issue: The providers are concerned, on the basis of their training and experience, that if they begin quantifying blood loss they will have higher blood loss levels which might reflect negatively on their practices. P putting their reputations in jeopardy. Response: Track the number of births quantified and their relationship to early recognition of PPH. Report facts and QBL trends to the physicians and nurses.
Issue: “QBL is only needed for cases where a hemorrhage is identified.” Response: Measurement of cumulative blood loss is the goal. Often it is too late when we recognize that the woman has lost too much blood. Perform regular quantification in non- emergency situations to prepare the team for the actual PPH event.
Issue: “QBL is not exact and therefore it is not worth doing.” Response: The goal is not a “perfect, precise” number. There may be some discrepancies from mixing with amniotic fluid, urine, irrigant, etc. and this can be measured to some degree. It is more accurate to do some measurements than to rely solely on visual estimates.
Issue: “There was fluid already in the canister, just estimating, we forgot it and so it’s just an estimate.” Response: Since irrigation is usually done after the major bleeding is controlled, it may be best to connect to another canister BEFORE irrigating to capture this fluid separately. With continued use, documenting the measures at birth and then ongoing becomes routine practice and there is less forgetting to document.
Issue: “With QBL, it is now my responsibility to get it right.” “I used to be in charge and still want the responsibility.” Response: Shared responsibility and accountability is critical to quality patient outcomes. A shared team awareness is needed. It is no one person’s responsibility. It is a TEAM responsibility.
Issue: “QBL takes a lot of time doesn’t it?” Response: Teams that do QBL report that it becomes routine and takes very little additional time. Have QBL nurse and physician experts showcase doability of QBL and describe how they successfully performed QBL.
Issue: “It’s going to slow down OR room turnover.” Response: Have scales and dry item lists readily available in every OR. Develop quick methods for totaling/calculating in EMR. Think of the time that will be saved by avoiding a hemorrhage event. 
 Just my editorial comment.

23. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
The providers are concerned, on the basis of their training and experience, that if they begin quantifying blood loss they will have higher blood loss levels which might reflect negatively on their practices putting their reputations in jeopardy.
Track the number of births quantified and their relationship to early recognition of PPH. Report facts and QBL trends to the physicians and nurses.

24. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
“QBL is only needed for cases where a hemorrhage is identified.”
Measurement of cumulative blood loss is the goal. Often it is too late when we recognize that the woman has lost too much blood. Perform regular quantification in non- emergency situations to prepare the team for the actual PPH event.

25. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
“QBL is not exact and therefore it is not worth doing.”
The goal is not a “perfect, precise” number. There may be some discrepancies from mixing with amniotic fluid, urine, irrigation, etc. and this can be measured to some degree. It is more accurate to do some measurements than to rely solely on visual estimates.

26. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
“There was fluid already in the canister, just estimating, we forgot it and so it’s just an estimate.”
Since irrigation is usually done after the major bleeding is controlled, it may be best to connect to another canister BEFORE irrigating to capture this fluid separately. With continued use, documenting the measures at birth and then ongoing becomes routine practice and there is less forgetting to document.

27. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
“With QBL, it is now my responsibility to get it right.” “I used to be in charge and still want the responsibility.”
Shared responsibility and accountability is critical to quality patient outcomes. A shared team awareness is needed. It is no one person’s responsibility. It is a TEAM responsibility.

28. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
“QBL takes a lot of time.”
Teams that do QBL report that it becomes routine and takes very little additional time. Have QBL nurse and physician experts showcase doability of QBL and describe how they successfully performed QBL.

29. Issues and Responses cont
Issues and Responses cont. (adapted from Bingham & Main 2012 and AWHONN 2014)
Issue
AWHONN Response
“It’s going to slow down OR room turnover.”
Have scales and dry item lists readily available in every OR. Develop quick methods for totaling/calculating in EMR. Think of the time that will be saved by avoiding a hemorrhage event. 

30. Testimonial
AWHONN recommends measuring blood loss for every woman who gives births in order to reduce denial that leads to delays in women receiving lifesaving treatments.  Measuring blood loss makes a un-reliable subjective process much more reliable.
Debra Bingham, DrPH, RN,
AWHONN Vice President of Nursing Research, Education, and Practice
Physicians and nurses have made statements related to their QBL experiences.

31. Why do Quantification of Blood Loss in Obstetrics?
Testimonial
Why do Quantification of Blood Loss in Obstetrics?
When I was practicing in Ohio, a quality improvement project was initiated for reduction of obstetric hemorrhage.  I was skeptical about some of the components and somewhat taken aback to having anesthesiologists or nurses telling me what the blood loss amount was. I had been estimating blood loss for years without any problems and did not see the value for the added time and attention that it would take.  That is, until the consistent measurements indicated that estimation was not as safe for my patients as measured quantification.
Over time, I learned from the literature that estimations were often as much as 50% inaccurate, usually underestimating the true loss.  I have heard from nurses, that on day 2 the hematocrit is sometimes low and the patient symptomatic when estimations are used and quantifications ignored.  This has made a believer out of me and now, I consistently want to have quantified measurement of blood loss for vaginal and Caesarean deliveries.  Quantification is not a perfect measurement but is more accurate than guessing, and with the new tools offered to make the measures more accurate, it is getting better and better.
Many of our national organizations are strongly encouraging us to use the most accurate quantifications we can.  Recent recommendations have come from working groups comprised of ACOG, CDC, SMFM, and AWHONN, as well as, multiple state perinatal collaboratives that quantitative measures are safer for patients. I think we need to have a culture change in the delivery suite.  We have the evidence that early recognition of significant blood loss and early intervention is safer for our patients. 
We need to get over the old thinking that we are not good at our jobs if there is blood loss and move to the evidence based model that says we are best at our work if we recognize and respond appropriately.
Judette Louis, MD, MPH Assistant Professor, Department of Obstetrics and Gynecology Morsani College of Medicine FPQC Clinical Advisor

32. Testimonial
When it comes to obstetric hemorrhage, denial and delay in recognition can equal maternal death. The uterus can bleed cc/minute and within 5 minutes of unrecognized hemorrhage a patient can suffer loss of an entire blood volume along with valuable clotting factors. Signs of hypotension are often masked in healthy patients due to increases in cardiac output and vasoconstriction. Quantification of blood loss in the operating room and labor and delivery room is vital to providing early intervention in recognition and treatment of obstetric hemorrhage. As medical providers, we need to join together in accurately measuring blood loss as part of the multidisciplinary approach to obstetric hemorrhage. By putting the ego aside and letting go of estimates, we can move towards evidenced based quantification of blood loss to help providers overcome the denial and delay in treatment of maternal hemorrhage.
Jean Miles, MD Chief of Obstetric Anesthesia Memorial Healthcare System Patient Safety Committee for the Society of Obstetric Anesthesia and Perinatology

33. Testimonial
When implementing any new initiative among nursing staff it is essential to understand the “why” behind the purpose of implementing the new process/procedure. QBL allows us to have a more accurate clinical picture of blood loss so we can proactively manage our patients rather than reactively manage their symptoms after they are already occurring. Even the most experienced clinicians can have a difference of opinion when it comes to subjective assessment. QBL is the closest we can come to objectively assessing the blood loss post-delivery so we can improve clinical outcomes for our patients.
Marie Sakowski, MSN, RNC
Nurse Manager, Perinatal, Labor and Delivery
Women’s Health Pavilion
Florida Hospital Tampa

34. Summary
For EVERY birth, begin QBL immediately after the infant’s delivery and continue ongoing QBL measurement until bleeding is stable.
Cumulative measurement of blood loss is key to early recognition of excessive blood loss for timely initiation of life saving interventions.
QBL for all births reduces the incidence of denial of significant blood loss and delayed recognition and initiation of treatment.
Adapted from AWHONN.
This slide summarizes recommendations and is adapted from AWHONN.

35. QBL Exercise
Let’s go over some samples together! 1st sample- 50 ml peripad. 2nd sample 100ml chux. 3rd example- non calibrated drape with 500 ml. I will be quizzing audience.

36. Questions?