Department of Obstetrics and Gynecology

PPH: We don’t need NO stinkin’ blood!June 11, 2015

Background

Postpartum hemorrhage is a leading cause of maternal mortality.

Several morbidity events at St. Joseph Medical Center led to our focus on this problem.

Vaginal Delivery % Hgb Change

Feb 2012n=88

0%

5%

10%

15%

20%

25%

30%

35%

40%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87

pt

rate

of

ch

an

ge

Goal <15%

Average Hgb Change = 13.1%

25/88=28% of vaginal deliveries have higher than 15% change in Hgb. These are our target

Avg % Hgb Change vs %Hgb Change >15%Vaginal Deliveries

13.0% 12.6% 13.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1 2 3June 2010

March 2011

February 2012

Avg % Hgb Change

% Hgb Change >15%

39%

25%

28%

At SJMC, there is a higher incidence of >15% blood loss with childbirth than desirable. Ideally, with reduced EBL, there is a reduced need for intervention, need for transfusion and mortality.

•Cluster of events occurred at SJMC relating to post partum hemorrhage.•Post partum hemorrhage is one of the top two causes of pregnancy

related mortality in the U.S.•National trend towards increased incidence of postpartum hemorrhage

(Am J Obstet Gynecol, Apr 2010).•Similar trend observed in this region and at SJMC.•June 2010; 67 seq vag delivery pts chart review: 39% of pt had >15% EBL.•Mar 2011; 40 vag delivery pts reviewed: 25% of pts had >15% EBL.•Actions included: Subcommittee to champion effort.

•RN education re: management of uterine atony•Increased fundal checks with massage•Increased recovery time to 2 hrs•Provider ED administer oxytocin earlier – w/ delivery of baby not placenta•Order set updated re: timing of oxytocin admin

•Feb 2012; 88 vag delivery patients had an average EBL =13.3%; 28% of pts EBL >15%•Feb 2012; 58 c-section delivery patients had an

average EBL = 16.7%; 57% of pts EBL >15%

Laboring Vaginal Delivery Pt: not actively bleedingED OBS status Pt laboringL+D Triage LDR Pt moved to L&D roomall paper: EBL narrative different RN from triage

admitting labs drawn: Hgb if RN relief handoff may not include EBLhandoff verbal

Non documentation standard re: EBL EBL : pt notes or I&O

admission assessment

THE BOARD: updated @ time of provider check or change in status

adult admission assessment Could the board include running EBL?L&D assessment (amt vag bleeding: scant, sm, mod, large)I&O (EBL)Pt notes: narrative EBLmidlevels OB assess summary: Comments EBLpad count performed but may or may not be documentedpt placed on "THE BOARD" EBL currently not included on BOARD

vaginal delivery Pt in PACU Pt to 3Esame RN

no EBL announced or documented in delivery room same roomno Meditech documentation provider doc EBL post procedure - EBL documented on: handoff - paper, faxed (1=baby, 1=mom)2 different forms pending delivery type L&D record (scant, sm, etc) no standard for EBL includednot communicated to RN Pt notes: narrative

I&O - only #s pull update of events after handoff faxed are verbalL&D recovery assessment (no EBL)L&D recovery d/c (no EBL)If weigh pads: baby scale usedmidlevel could order Hgb1:1 RN: Pt ratio

Pt arrives on 3E Pt discharged from SJMC

post partum flow sheet: lochia= scant, small, etc 6 a.m. POC Hemacue day after delivery (6-30 hrs post delivery)does not flow to I&O OR MD can choose CBC - provider dependent

PT notes IF RBCs given: provider dependent3E RN can see running I&) for EBL IV Iron dextrin if HGB low: provider dependentheplock prob removed after 6 hrs may not need I&O except if voiding issuesvitals assessed on arrival then q2, then q8x2, then q shift? No standard for f/u Hgb/CBC prior to d/c after RBCs givenRN: pt ratio = 1:? No standard communication to pt on d/c of PPH or increased risk or f/u.

• Lots of places to record EBL

• Lots of handoffs with no EBL

• Lots of opportunities to treat

• Few opportunities to diagnosis

• Cum EBL not calculated

• to measure• Cum EBL not visible• EBL hard Protocols

unclear• Safety net too late

• More accurate and timely collection of EBL data

• Real-time cum EBL running total – highly visible

• Robust protocol with clear triggers

• Ultimately, 95% of our Vag pts will be below the 15% trigger

Machine Man Management

Why is EBL >15% for 25-40% of delivering patients?

Method Material Mother Nature

no running EBL total in meditech

not enough scales to weigh sponges in L&D nor 3E

variation of approach re: weighing sponges or not

variation on trigger and response

Timing of pitocin bolus

3E vs L&D location for for recovery not standardized

No assessment of risk on admit

Hgb @ 6 a.m. f ixed b/c phelebotomy schedule (not pt focused)

subjective EBL vs objective

communication EBL +risk

varied EBL documentation sources

no visual cue of accumulation EBL

handoffs vary: fax vs verbal + do not include EBL

Heplock pulled for vag del @ 6hrsvitals assess freq enough on 3E to assess PPH? 1st w/in hour, 2nd w/ in 2 hrs of f irst then q 4 x

no communication to pt of PPH or risk (at d/c)

no f /u lab af ter transfusion prior to d/c

Hemacue manual uploadedMon-Fri 8-4

RN need hemacue training

inconsistent comm PPH meds given no standard OBS time in L&D after PPH meds given

hand off issues: need 2 sep reportsfor Mom and Baby

no standard education on when pt is to notify RN post partum of pad changes

vaginaldelivery drape not calibrated - diff to estimate blood loss at delivery

no standard process for tx of PPH including triggers

pph cart x 2

Assessment and documentation of risk

addtl fundal massage education - how to and trigger of when

define high risk and tx

green = completedred = yet to be donewhite = in progress

add misoprostol to pph cart

hemacue after 6 hrs rather than CBC if <8.5 Lisa/Karen/Robin 2/20/2013implement revision of post op order sheet re:Hemacue timing Lisa 2/21/2013Implement: standardize pad+ice pack selection PP and L&D Karen/Andrea/Angela/Kelly 2/25/2013Implement: PPH cart outside of high risk pt rooms- process changeMary Beth/Kelly 2/14/2013Implement: additional pph cart Mary Beth/Kelly 3/1/2013Develop massive transfusion protocol Committee 2/28/2013Implement: Intro intervention algorithm at quarterly staff meeting Dr. Rossiter 3/13/2013Implement PPH intervention algorithm for excessive bleeding Dr. Rossiter 3/18/2013Implement 3E/3W w/ consistent vocera use Karen 4/1/2013handoff: EBL total to print on handoff Hand off Committee - Kelly lead 2/28/2013handoff: update format for summary information - update MeditechHand off Committee - Kelly lead 2/28/2013handoff meds given for PPH communicated to 3E Hand off Committee - Kelly lead 2/28/2013handoff report utilized by 3E Hand off Committee - Kelly lead 2/28/2013audit process Kelly/Karen 3/15/2013

Hemacue automate upload- capital request Rossiter/Grace/Jamison/Ancona/Maureen Paul ??????

Methodology

Walk the process

What we had to fix

1. Many places to record EBL

2. Handoffs without EBL included

3. Many opportunities to treat

4. Few opportunities to diagnose

Highlights of implementation

Interventions Standardized:

Timing of postpartum oxytocin Timing of postpartum hemoglobin

Assembled PPH carts Developed intervention algorithm Developed massive transfusion protocol

Highlights of implementation

Quantification of blood loss Purchased scales for every room in L&D and

postpartum floor

Purchased graduated drapes for vaginal deliveries

Educated MDs and CNMs to announce EBL at both c/s and vaginal deliveries

Educated nurses to teach patients re: need to weigh all peri-pads for the 1st 24 hours

Highlights of implementation

Communication Added blood loss entry to I’s +O’s in EMR

Added EBL to communication tool for nursing handoff from L&D to postpartum

California Maternal Quality Care Collaborative Hemorrhage Task Force 2009

Obstetric Hemorrhage Care Summary: Table Chart

Assessments Medications / Procedures Blood Bank

Stage 0: Every woman in labor/giving birth

Assess every woman for risk factors for hemorrhage Ongoing quantitative evaluation of blood loss on every birth

Active Management 3rd Stage Pitocin IV infusion or 10u IM Fundal Massage- vigorous, 15 seconds minimum

All patients: T&S High Risk: T&C 2 U and 2nd IV line for:

-suspected abruption -placenta previa/acreta T&C 2 U

-platelets < 80 -hematocrit < 25

Stage 1: Blood loss >750 ml vaginal or >1250 ml Cesarean, or VS changes (by >15% or H.R. >110, BP <85/45 O2 Sat < 95%)

Activate OB Hemorrhage Protocol And Checklist Notify charge nurse and Anesthesia VS, O2 Sat, q 5 min. Calculate cumulative blood loss q 5- 15 min. Weigh bloody materials Careful inspection with good exposure of vaginal walls, cervix, placenta.

IV access: at least 18 gauge Empty bladder: straight cath or place foley with urimeter Increase IVF (LR) and Pitocin and repeat fundal massage Methergine 0.2 IM: If hypertensive Move on to 2nd level uterotonic drug (see below) Bring Hemorrhage Cart to room.

T&C 2 Units PRBCs (if not already done)

Stage 2: Continued bleeding (>100 ml in 30 min) with total blood loss under 1500 ml OB back to bedside (if not already there) Alert Anesthesia, assemble necessary personnel. VS and cumulative blood loss q 5-10 minutes Weigh bloody materials Complete evaluation of vaginal Walls, cervix, placenta and uterine cavity. Send additional labs, including DIC panel If on 3E/W, move to L&D Evaluate for special cases -Uterine Inversion -Amniotic Fluid Embolism

2nd Level Uterotonic Drugs: Hemabate 250 mcg IM or Misoprostol 800-1000 mcg PR 2nd IV Access (at least 18 gauge) Bimanual Massage Place foley with urimeter Vaginal Birth (typical order) Move to OR Repair any tears D&C: r/o retained placenta Place intrauterine balloon Selective Embolization (Interventional Radiology) SCD’s Cesarean Birth (still intra-op) Inspect broad ligament, posterior uterus and retained placenta B-Lynch Suture Place intrauterine balloon

Transfuse per clinical signs – do not wait for lab values Use blood warmer for transfusion Consider thawing 2 FFP (takes 35+ min) use if transfusing >2 units PRBCs Determine availability of additional RBCs and other Coag products

Stage 3: Total blood loss over 1500 ml, or >2 units PRBCs given or VS unstable or suspicion of DIC

Mobilize Team as needed (OBERT) -Consider advanced GYN surgeon -Dedicated Anesthesia assistant -OR staff -Adult Intensivist Repeat labs including ABG’s Consider Central Line Social Worker / family support

Activate Massive Hemorrhage Protocol Laparotomy: -B-Lynch Suture -Uterine Artery Ligation -Hysterectomy Patient support -Fluid warmer -Upper body warming device

Notify Blood Bank of OB Hemorrhage Transfuse Aggressively Massive Hemorrhage Pack Unresponsive Coagulopathy: After 10 units PRBCs and full coagulation factor replacement: may consider rFactor VIIa

Source: California Maternal Quality Care Collaborative Hemorrhage Task Force 2009

University of Maryland St. Joseph Medical Center

7601 Osler Drive • Towson, MD 21204-7582 Draft 2/1/13

Q1

2011

Q2

2011

Q3

2011

Q4

2011

Q1

2012

Q2

2012

Q3

2012

Q4

2012

Q1

2013

Q2

2013

Q3

2013

Q4

2013

Q1

2014

Q2

2014

Q3

2014

Q4

2014

Q1

2015

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

4.1%

2.8%2.6%

3.3%

2.7%2.9%

1.8%1.8%2.1%

2.8%

1.7%

2.3%2.4%

1.8%1.9%

1.6%

0.6%

% of delivering pts receiving blood productsby quarter

CY 2011- Q1 2015

2012 Avg = 2.3%

2011 Avg = 3.2%

2013 Avg = 2.2% 2014 Avg = 1.9%

Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 Q4 14 Q1 150

10

20

30

40

50

60

9

1410 11 11 11

139

4

40

55

31 3229 29

42

15

7

#OB pts receiving RBC per quarter# RBC received per quarter

2013 - Q1 2015

# pts transfused

# units given

2013: transfusing 1+ pts per week. Now: transfusing 1 per month.

Assuming $500 per RBC unit not given, from Jan 2014 to April 2015: estimated $45,500 saved.

Current state: sustainment

Education of providers:Transfuse to symptomatic patients Transfuse single unit at a time

Chart review: 100% of delivering patients receiving blood products

Feedback to all providers and staff

Lessons learned

• ClinicalChange in perspective

“We measure everything else, why not blood?”

Change in process results in fewer surprises

Lessons learned

• TeamworkMultidisciplinary approach including the day to day

staff

Involvement in creating the solution engenders enthusiasm and buy in

Standardized approach and walking the process is profoundly valuable

• Kelly Archer, RN L&D

• David Brinker, MD Blood Bank Advisory Chair

• Mary Beth Campbell, RN L&D

• Alice Cootauco, MD MFM• Phi Duong, Blood Bank

• Tracey Duke, MD OB/GYN

• Lisa Everhart, RN Clinical Educator

• Maria Giachini, RN L&D

• Robin Harper, RN Postpartum

• Diane Interrante, RN Quality

• Nikki Koklanaris, MD MFM• Mary Knauer, CNM • Laurie Mathis, RN

Postpartum

• Maureen Paul, Laboratory

• Charlie Rizzuto, MD Anesthesiology

• Nancy Stec, Blood Bank

• Karen Tomcho, RN Postpartum

• Judy Rossiter, MD Chief OB/GYN

The PPH initiative team: it takes a village!