Introduction Planning and Implementation

Every hospital caring for obstetric patients should incorporate a

postpartum hemorrhage bundle into hospital policy.

Quantification of blood loss at all deliveries.

Simulations of postpartum hemorrhage should be conducted

quarterly using an interdisciplinary approach.

A hemorrhage cart be readily available and stocked with all

necessary supplies.

Nursing education done with all shifts targeting difficult tasks.

Participation of physician champions from OB and anesthesia

teams in California Maternal Quality Care Collaborative

(CMQCC).

.

Implementation of Postpartum Hemorrhage Bundle Touro University School of Nursing

Amy Ciraulo, MSN, RN

Overview

Evaluation of Bundle with

Simulation

Met Not met

Properly assess hemorrhage risk 3 0

Requests hemorrhage cart 3 0 Proper set up of warmer for rapid blood replacement

2 1

Quantifies blood loss 3 0 Debrief completed 3 0

Results

Ishikawa Diagram

The target population for this project was the nursing staff of a 9-bed labor and

delivery unit. During simulation drills of postpartum hemorrhage, all

components of the bundle were met except for one. The component that was

not met was during the night shift simulation and was the proper use of the

“Ranger” fluid warmer for blood product administration.

During the development, implementation, and evaluation of this bundle

discoveries were made that lead to improved workflow, communication, and

processes. Additional equipment was purchased including a hemorrhage cart,

scale, and simulator.

Education to staff at meetings and at daily shift huddles was conducted to

ensure consistency of information.

Preset orders were changed for all admissions to labor and delivery to allow

for proper assessment and intervention based on risk factors and blood typing

requirements of blood bank.

Risk assessments were incorporated into the electronic medical record and

instructed to be done on all patients at admission and at handoff.

Gantt Chart

References

Recommendations

Berg, C. J., Callaghan, W. M., Syverson, C., & Henderson, Z. (2010).

Pregnancy-related mortality in the United States, 1998-2005.

American College of Obstetricians and Gynecologists, 116, 1302-

1309. Retrieved from

http://www.cdph.ca.gov/data/statistics/Documents/MO-CAPAMR-

PregnancyRelatedMortality-Berg2010-1998-2005.pdf

California Department of Public Health. Maternity mortality rates are

increasing. (2010). Retrieved from

www.cdph.ca.gov/data/statistics/Pages/CaliforniaPregnancy-

AssociatedMortalityReview.aspx

Bingham, D., Lyndon, A., & Lagrew, D. (2011, September/October).

A State-Wide Obstetric Hemorrhage Quality Improvement Initiative.

The American Journal of Maternal/Child Nursing, 36(5), 297-304.

http://dx.doi.org/10.1097/NMC.0b013e318227c75f

Contact and Acknowledgements

Amy Ciraulo, MSN, RN ciraulo887@gmail.com

I wish to acknowledge the nurses, physicians, and management

of the NorthBay Labor and Delivery unit for their support.

Ann Stoltz, PHD, RN, CNL Touro University California, School of

Nursing Director

According to California Department of Public Health (CDPH, 2010).

The rate of maternal deaths in the United States has nearly

doubled from 1996 to 2006.

The state health department contracted with the California

Maternal Quality Care Collaborative (CMQCC) to examine deaths

related to pregnancy.

Bingham, Lyndon, and Lagrew (2011) stated, “Beyond identifying

who died, the causes of death, and where and when deaths

occurred, experts on the mortality review panel determine the

degree to which each death may have been preventable. They

also provide their best judgment of contributing factors and quality

improvement opportunities or lessons to be learned from each

death” (p. 298).

Together with the root cause analysis and the consensus that

obstetric hemorrhage had the highest probability of being

prevented a safety bundle for obstetric hemorrhage was developed

and implemented and evaluated.

The desired outcome was for nursing staff to identify patients at risk

for postpartum hemorrhage, recognize the level of hemorrhage

earlier, intervene quickly, and report postpartum hemorrhages with

a subsequent debrief of the incident. The intervention employed

was the development and implementation of a safety bundle for

obstetric hemorrhage.

“As health care quality improvement and patient safety efforts

intensify, understanding the social and health care contexts

surrounding women who die as a result of pregnancy is critical to

instituting the systemic changes needed to decrease pregnancy-

related mortality.” (Berg, Callaghan, Syverson, & Henderson, 2010,

p. 1308).

Statement of the Problem

Implementing a safety bundle for postpartum hemorrhage

takes collaboration of multiple disciplines throughout the

hospital.

Stakeholders included nurses, physicians, OB techs,

administrators, laboratory, simulation lab, central supply, and

blood bank.

Overall the success of this bundle is credited to the hospital

and the staff’s willingness to learn and make positive changes

based on evidence to ensue the safest care for their patients.

Bundle Components

Readiness

Recognition

Response

Reporting

Hemorrhage Cart

Simulation Drills

Risk Assessment

Quantification of Blood Loss

Blood Product

Replacement

Debriefing