Code H Obstetrical Hemorrhage, Development of a Team Approach

Purpose for the program:

New York State Department of Health issued a health advisory in 2009 stating the following:

• Maternal mortality rate is higher than the national average, and hemorrhage the leading cause of mortality.
• Providers can prevent maternal deaths by improving recognition and response to hemorrhage.
• Blood loss is frequently underestimated.
• The causes of death are multi-factorial, and prevention requires a multidisciplinary response.
• Hospitals with rapid and coordinated responses to extreme blood loss can limit morbidity and improve survival.

Proposed change:

Although we had implemented interventions to reduce the risk of morbidity and mortality secondary to maternal hemorrhage, we needed to further develop a multidisciplinary team response, and identify system factors that result in delay in recognition and treatment.

Implementation, outcomes and evaluation:

Implementation:

Step 1- We performed a needs assessment and posed the following questions:

• How to improve estimating blood loss?
• Who will be on the team?
• Guidelines to follow in responses to hemorrhage?
• Who will need to be educated?

Step 2- How do we improve estimation of blood loss? Literature search reveals improving visual estimation and a weight based conversion method. We also quantified the average amount of laps used in a cesarean section.

Step 3- Collaborate with Anesthesia, Blood Bank, MFM, and GYN/Oncology to develop guidelines for team response, hemorrhage resource guide and emergency equipment cart.

Step 4- Eliminate barriers to rapid blood access and laboratory testing.

Step 5- Facilitate communication with hemorrhage team.

Step 6- Education and implementation of what we named CODE H, a multidisciplinary coordinated response to maternal hemorrhage.

Outcomes:

Simulation Lab:

106 Nurses, Physicians and Nursing Assistants participated. Specific measured quantities of simulated blood were displayed on perpads, 4x4's, floor spills, clots in bedpan, to determine the accuracy of estimating blood loss in the clinical setting Staff members estimated loss and recorded their findings. Individual results were compared to actual quantities of simulated blood. Only 1/3 in range.

Clinical Setting:

• Direct observation during 23 cesarean deliveries to determine average lap pad usage in order to establish a trigger point identifying hemorrhage. 25 saturated laps determined as trigger to alert surgeons of greater than average blood loss.
• Development of a task force with representatives from Anesthesia, Blood Bank, and Maternal Fetal Medicine
• Code H Team implemented

Evaluation:

The Code H team has enhanced a cohesive team approach to a complicated obstetrical crisis.

Implications for nursing practice:

Improved communication, better defined roles and nursing care more patient focused.

Keywords: hemorrhage team; maternal hemorrhage; estimating blood loss