“It is a Bloody Good Job!” Utilizing OB Hemorrhage Drills and Standardized Electronic Order Sets to Champion Excellence and Collaboration During Postpartum Hemorrhage

Purpose for the program: The California Pregnancy Related Maternal Mortality Review found that OB hemorrhage was one of the leading causes for maternal death and a major contributor to maternal morbidity. Deaths from hemorrhage consistently rank at the top of the most preventable list: with 70-92% of deaths being judged as preventable. However, few hospitals have created a systematic postpartum hemorrhage (PPH) protocol for early recognition and rapid response. Sharp Health care, while participating in a statewide initiative to transform maternity care in California,  successfully implement best practices and tools for obstetric hemorrhage by implementing an active quality improvement processes to drive change.

Proposed change: MAP-IT (Mobilize, Assess, Plan, Implement, Track), a rapid cycle Quality Improvement method for outlining change was implemented. Initial assessment of staff knowledge reveled critical tasks completion of 35 percent. Major opportunities for improved outcomes were evident. Learning opportunities identified included a focus on the pre-assessment and preparation of hemorrhage risk, underestimation of blood loss, delay in administration of blood, delay in response from other team members, delay in adequate resuscitation. Drills were designed to highlight 21 evidence based critical tasks/elements needed to assure best outcome.

Implementation, outcomes and evaluation: Percentage of drill task completion was utilized as the primary metric for improvement.  An interdisciplinary group was mobilized, including advanced clinicians, blood bank personnel, and laboratory leadership and physician champions. Project goals included: 1) Standardize documentation and system order-sets to aid in the prenatal admission and ongoing risk assessment. 2) Pre -assessment and preparation of hemorrhage risk identified 90% of audited cases 3) Develop and implement a multidisciplinary team response to every massive PPH by March, 2013, with a goal of 90%completion of identified critical tasks.Electronic medical record (EMR) documentation was standardized to streamline ordering of admission blood work and blood products and included home folders for transfusion order-sets for easy access. Balloon tamponade policy and procedures, as well as standard order sets were implemented.  Identification of patients with ethical, moral or religious beliefs conflicting with blood/blood product administration and referral to the Bloodless Medicine program were streamlined through the EMR. Rapid response teams were modified to include additional interdisciplinary members.

Implications for nursing practice:  To affect outcome measures of reducing major complications of PPH, this project will serve to improve many core processes, and improve a culture of safety for every patient every time!

Keywords: Hemorrhage, postpartum Hemorrhage, blood, transfusion