1. December 10, 2015 11:00 a.m. – 12:30 p.m. CT HEN 2.0 OB HARM WEBINAR UPDATES IN OB HARM PREVENTION 1

2. 2 WELCOME AND INTRODUCTIONS Natalie Erb, Program Manager, HRET | 11:00 – 11:05

3. 3 SUMMARY DISCLOSURE & ACCREDITATION STATEMENT HRET HEN 2.0 – Updates in OB Harm Prevention Webinar Online Live Webinar – December 10, 2015 The planners and faculty of the HRET HEN 2.0 Updates in OB Harm Prevention Webinar have indicated no relevant financial relationships to disclose in regard to the content of this activity. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical education through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and Health Research & Education Trust (HRET). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. ABQAURP is an approved to provide continuing education for nurses. This activity is designated for 1.50 Nursing Contact Hours through the Florida Board of Nursing, Provider # 50-94.

4. 4 WEBINAR PLATFORM QUICK REFERENCE Mute your computer audio  Download today’s slides and resources

5. Quality of video and audio (if listening through your computer) depends on your internet connection To maximize the size of any one ‘pod,’ simply press the four- way arrow icon in the top right corner 5 ADDITIONAL REMINDERS

6. 6 AGENDA 11:00-11:05 AM Welcome and Introductions Open and housekeeping information. Natalie Erb, MPH Program Manager, HRET 11:05-11:15 AM HEN Data Update Update on OB harm data and results from HEN 1.0. Review the HEN 2.0 OB harm measures: obstetrical trauma – vaginal delivery with instrument (AHRQ PSI 18); obstetrical trauma – vaginal delivery without instrument (AHRQ PSI 19); OB hemorrhage – massive blood transfusions; pre-eclampsia – ICU admissions. Julia Heitzer, MS Data Analyst, HRET 11:15-11:40 AM Updates in Obstetrical Harm: Focusing and Fine Tuning Describe the interconnectedness of obstetrical harms and how to reduce through the four “Rs”: readiness, recognition, response and reporting/learning. Kim Werkmeister, RN, BA, CPHQ Cynosure Improvement Advisor 11:40-12:00 AM Is There Ever Only ONE Root Cause? Describe ways to utilize the root-cause-analysis process to prevent future harm, including third and fourth-degree lacerations, OB hemorrhage and pre-eclampsia. Kim Werkmeister, RN, BA, CPHQ Cynosure Improvement Advisor 12:00-12:15 PM Bring It Home Review action items to reduce OB harm, and provide resources to address all forms of OB harm. Natalie Erb, MPH Program Manager, HRET 12:15-12:30 PM Q&AAll

7. Describe risk factors for obstetrical harm related to perineal trauma Discuss strategies to decrease the incidence of perineal trauma during childbirth Apply methods to review and analyze “triggers” that could indicate severe maternal morbidity Describe a methodology for prioritizing improvement efforts based on data analysis 7 OBJECTIVES FOR TODAY

8. 8 HEN DATA UPDATE Julia Heitzer, Data Analyst, HRET | 11:05 – 11:15

9. 88% of eligible birthing hospitals reported obstetrical (OB) harm data 26% reduction across all OB harm measures 766 OB Harms prevented and a cost savings of $705,000 HEN 1.0 OB HARM PROGRESS DATA SOURCE: Comprehensive Data System (11/18/14); Data covers January 2012 through November 2014. Cost reference sources listed in PEC April 2014 Formative Feedback report appendices. 1 Harms prevented calculated at hospital level and then aggregated to HEN level (hospital compared to own baseline). Harm calculated only with months that have sufficient n (85 percent of hospitals reporting at baseline). Hospitals omitting months of data were determined to be negligible at HEN level.

10. Vaginal Delivery with Instrument HEN 2.0 REQUIRED OB HARM MEASURES

11. Vaginal delivery Without Instrument HEN 2.0 REQUIRED OB HARM MEASURES

12. Obstetrical Hemorrhage – Massive Blood Transfusions HEN 2.0 REQUIRED OB HARM MEASURES

13. Pre-Eclampsia – ICU Admissions HEN 2.0 REQUIRED OB HARM MEASURES

14. 14 Kim Werkmeister, Improvement Advisor, Cynosure Health | 11:15 – 11:40 UPDATES IN OBSTETRICAL HARM: FOCUSING AAND FINE TUNING

15. FROM 30,000 FEET

16. SCOPE OF THE PROBLEM Source: http://www.cdc.gov/reproductivehealth/ MaternalInfantHealth/PMSS.html

17. 17 HOW IS IT ALL CONNECTED? 3 rd and 4 th Degree Lacs C-Sections FTR EED Hemorrhage Preeclampsia OB VTE

18. 18 HOW IS IT ALL CONNECTED? 3 rd and 4 th Degree Lacs C-Sections FTR EED Hemorrhage Preeclampsia OB VTE

19. Readiness Recognition Response Reporting / Learning THE FOUR “R’S”

20. UPDATES TO OB HARM CARE BUNDLES

21. www.SafeHealthcareforeverywoman.org Council on Patient Safety in Women’s Health Care NATIONAL IMPROVEMENT EFFORTS

22. Readiness: Hemorrhage cart with procedural instructions (balloons, compression stiches) Rapid access to hemorrhage medications (kit or equivalent) Establish a response team: multiple partnerships // unit education, drills, debriefs n Establish MTP and 0- neg/uncrossmatched transfusion protocols Recognition: Assessment of hemorrhage risk (prenatal, on admission, ongoing in labor & PP) Measurement of CUMMULATIVE blood loss Active Management of 3rd Stage (oxytocin after birth) REDUCTION OF HARM FROM PPH

23. Response: Unit-standard, stage-based OB hemorrhage emergency management plan with checklist support program for patients, families and staff Reporting / Systems Learning: Establish a culture of huddles for high-risk patients and post-event debriefings Review all stage 3 hemorrhages for systems issues Monitor outcome and process metrics in perinatal QI committee REDUCTION OF HARM FROM PPH

24. What are we measuring? What has changed? REDUCTION OF HARM FROM PPH

25. REDUCTION OF HARM FROM SEVERE PREECLAMSPISA

26. PREECLAMPSIA EARLY RECOGNITION TOOL

27. CLINICAL SIGNS TO WATCH FOR:

28. Does your hospital have a process for decreasing 3 rd and 4 th degree lacerations? a)No - we don’t have a process and we don’t collect data b)No specified process, but we do collect data c)Yes – we have a specified process POLLING QUESTION

29. What does the evidence tell us? 3 RD AND 4 TH DEGREE LACERATIONS

30. 1° laceration extends into the perineal skin and may include the vaginal mucosa 2° laceration extends into the perineal body and does not involve the anal sphincter / 2° laceration with capsular involvement extends into the perineal body and partially involves the anal sphincter (Frequently described as a partial 3° laceration) 3° laceration extends completely through the anal sphincter 4° laceration extends through the rectal mucosa DEFINITIONS

31. Parity Length of second stage Previous anal sphincter laceration Neonatal birth weight OP presentation Shoulder dystocia Mode of delivery Episiotomy RISK FACTORS

32. April 2006 Routine use of episiotomies not recommended Restricted use of episiotomy decreases the likelihood of perineal lacerations. Avoiding episiotomy may be the best way to minimize the risk of extending damage to the perineum There is a place for episiotomy for maternal or fetal indications – fetal distress or “expediting difficult deliveries” ACOG PRACTICE BULLETIN #71

33. Forceps with episiotomy associated with 10x increase in anal sphincter laceration compared to vacuum w/out episiotomy Vacuum w/ episiotomy associated with 7x increase in anal sphincter laceration compared to vacuum w/out episiotomy Robinson, et al. Episiotomy, operative vaginal delivery, and significant perineal trauma in nulliparous women. Am J Obstetric Gynecology 1999;181;1180-1184. EPISIOTOMY WITH OPERATIVE DELIVERY

34. 3 RD AND 4 TH DEGREE LACERATION PREVENTION

35. (a)“Labor down” for at least 1 hour or until the urge to push is felt (but no longer than 2 hours); (b)use of warm packs to the perineum applied every 30 minutes during the second stage of labor; (c)change position every 15 to 20 minutes to help facilitate fetal descent and rotation; (d)foot position should rest on the bed or in foot rests instead of being held by the nurse or support person (avoidance of McRobert position except for the shoulder dystocia maneuver); and (e)avoidance of manual perineal stretching during the second stage of labor. “SAVE THE PERINEUM” – AWHONN PROTOCOL

36. THE IMPORTANCE OF MEASUREMENT Reduction in one kind of harm sometimes leads to an increase in other harm

37. 37 IS THER EVER REALLY ONE ROOT CAUSE? UTILIZING THE ROOT CAUSE ANALYSIS PROCESS TO PREVENT FUTURE HARM Kim Werkmeister, Improvement Advisor, Cynosure| 11:40 – 12:00

38. ROOT CAUSE ANALYSIS: A PATIENT SAFETY TOOL

39. RCA PROCESS

40. ROOT CAUSE ANALYSIS: A PATIENT SAFETY TOOL

41. ROOT CAUSE ANALYSIS: CAN WE IMPROVE IT?

43. IMPROVEMENT IN OB ROOT CAUSE ANALYSIS

44. Are you studying data related to blood use for OB patients? A.Yes, we have a process to review all cases when OB patients receive 4 or more units of blood B.Blood utilization is studied hospital-wide, and OB patients are identified in that review, but only to determine appropriateness of transfusions C.No, but are thinking about it D.It is reviewed incidentally during the peer review process POLLING QUESTION

45. Data are meaningful when you understand the weaknesses in the measures WHAT ARE WE ACTUALLY STUDYING?

46. Blood usage and ICU admits for obstetrical patients – outcome measures that don’t actually tell the whole story Meant as triggers, not used to determine actual level of harm Means more scrutiny is required to determine if case meets criteria for severe maternal morbidity WHAT ARE WE ACTUALLY STUDYING?

47. SEVERE MATERNAL MORBIDITY REVIEW Resources located at Safe Healthcare for Every Woman www.SafeHealthcareforEvery Woman.org

48. Standardized process for reviewing potential severe maternal morbidity events Meets the requirements for a RCA from TJC Findings over time should be studied to determine trends – smaller hospitals can partner with other hospitals to share regional trends SEVERE MATERNAL MORBIDITY REVIEW

49. 49 BRING IT HOME Natalie Erb, Program Manager, HRET| 12:00 – 12:15

50. What are you going to do by next Tuesday?  Support efforts to establish an interdisciplinary second stage of labor standard of practice  Work with a unit-based team to examine the current state of obstetrical harm prevention efforts What are you going to do in the next month?  Share obstetrical harm data (outcome and process measures) with the providers and the leadership  Work with a unit-based team to hardwire processes 50 PHYSICIAN LEADER ACTION ITEMS

51. What are you going to do by next Tuesday?  Choose a process to audit, i.e., length of time of second stage of labor, ICU days or massive transfusion protocol alerts.  Enlist frontline nurses to help audit What are you going to do in the next month?  Use audit data to guide PDSA efforts  Engage a physician leader and executive sponsor 51 UNIT-BASED TEAM ACTION ITEMS

52. What are you going to do by next Tuesday?  Round on front line staff to engage in a conversation about obstetrical harm prevention successes and challenges What are you going to do in the next month?  Ensure obstetrical harm data is regularly reported to providers and the leadership  Support unit based teams in removing barriers to obstetrical harm prevention 52 HOSPITAL LEADERS ACTION ITEMS

53. What are you going to do by next Tuesday?  Develop a plan to involve patients and families in obstetrical harm prevention efforts What are you going to do in the next month?  Recruit a patient family advisor who has experienced obstetrical harm or severe maternal morbidity to act as an advisor in obstetrical harm prevention programming. 53 PFE LEADS ACTION ITEMS

54. Launch the evaluation link in the bottom right hand corner of your screen. 54 CONTINUING EDUCATION CREDITS

55. Follow link that opens when webinar ends You will see your event’s survey listed; click “Login to Register” “Register” for the survey; then “Add to Cart” and “View Cart/Checkout” Follow instructions until you get to the survey; then complete and hit “Submit” If viewing as a group, each viewer will need to submit separately through the CE link 55 INSTRUCTIONS TO RECEIVE CEUS

56. Find more information on our website: www.hret-hen.orgwww.hret-hen.org Questions/Comments: hen@aha.orghen@aha.org 56 THANK YOU!