MBU Nurses Prevent Postpartum Hemorrhage through Safety Protocols

MBU Nurses Prevent Postpartum Hemorrhage through Safety Protocols Presented by: Jelina Geronca MSN RNC-MNN Regem Biyo BSN RN Samantha Breton BSN RN Vonetta Elie BSN RN

Postpartum Hemorrhage (PPH) remains the leading cause of preventable maternal mortality and morbidity. Global decline of about 40% in the past decade in Maternal Mortality Rates (MMR) (UNICEF, 2017), while the U. S. is on the rise compared to other developed countries.

Purpose: The purpose of this project is to create awareness, empower nurses, and to illuminate on the early recognition, prevention, and treatment of PPH.

The Safety Protocols: Maternal Early Warning System (MEWS) Standardized Oxytocin Infusion after Delivery Quantitative Blood Loss Postpartum Risk Stratifications

Partnership and Collaboration: Council on Patient Safety in Women’s Health Care: Mission: To continually improve patient safety in Women’s Health Care through multidisciplinary collaboration that drives culture change. Vision: Safe healthcare for every woman.

Alliance for Innovation on Maternal Health Program (AIM) TEXAS is part of the Alliance!

Texas AIM: Postpartum Hemorrhage Bundle

Maternal Early Warning System (MEWS)

MEWS:

MEWS:

MEWS:

Data is based on electronic data sources using the information documented in the Epic MEWS Flowsheet for MEWS activations between 12/13/19 to 2/18/19

MEWS:

MEWS Summary: Challenges continue to happen in meeting the 15 minute window of seeing the patient, however with MEWS activation: 1. Patient’s issues are identified and verified timely 2. Escalation to the appropriate chain of command 3. Plan of care initiated 4. Nurses feel empowered and secured

Oxytocin The following were observed by the staff: 1. Inconsistencies with Oxytocin Administration by physicians and nurses 2. Increased incidence of RRT noted by staff related to PPH

RRTs by Reason FY 18 – FYTD 19

RRTs by Location FY 18 – FYTD 19

The Recommendation: AWHONN recommends oxytocin administration for management of third stage of labor for all births. Oxytocin should be administered only by intramuscular or intravenous route. Administration Options A. Oxytocin 20 units in 1 liter of NS. Initial bolus 1000 ml/hours for 30 min (=10 units) followed by maintenance rate of 125 ml/hr. over 3. 2 hours (equals remaining 10 units) B. Administer IV oxytocin by providing a bolus dose followed by a total minimum infusion time of 4 hours after birth. **For women who are at high risk for a postpartum hemorrhage or who have had cesarean births, continuation beyond 4 hours is recommended** C. Give 10 units of Oxytocin for women without IV access AWHONN Practice Brief

Revised order set for Oxytocin: 30 units in 500 ml of NS or LR solution, set the infusion pump rate to 334 ml/hour for 30 minutes (10 units in 167 ml), then reduce the rate to 95 ml/hour (remaining 20 units) over 3. 5 Effective Date: April 2019

Quantifying Blood Loss: Ø Postpartum hemorrhage is excessive bleeding after vaginal delivery or cesarean delivery Ø Greater than 500 ml of bleeding after vaginal delivery Ø Greater than 1000 ml of bleeding after cesarean delivery

Quantifying Blood Loss: Primary and Secondary Postpartum Hemorrhage Primary PPH – excessive loss within the 1 st 24 hour of birth 1. Minor PPH 500 -1000 ml of blood loss within the first 24 hrs 2. Major PPH >1000 ml of blood loss within the first 24 hrs 3. Massive PPH >2000 ml of blood loss within the first 24 hrs Secondary PPH is excessive blood loss between 24 hours of birth to 12 weeks after birth

Common Maternal Risk Factors for Maternal Hemorrhage: Over distended uterus Placenta Abruption Placenta Previa Multiple Pregnancies Gestational hypertension Prolonged Labor Infection Obesity

Common Maternal Risk Factors for Maternal Hemorrhage: General anesthesia Medications to induce labor (Oxytocin) Tear in the cervix or vaginal tissues Blood clotting disorders Hematomas Instrumental deliveries such as vacuum delivery or forceps delivery

Signs and Symptoms of PPH: Tachycardia Dizziness Weakness Palpitations Sweating Restlessness or pallor

Main Causes of PPH: Tone: the uterus fails to contract properly due to uterine atony or distended bladder (accounts for 70% PPH) Trauma: Such as lacerations of the cervix, vagina, uterus Tissue: Retained placenta or blood clots Thrombin: Coagulopathy such as Thrombocytopenia or Von Willebrand’s disease

Quantifying Blood Loss vs Estimated Blood Loss: QBL is the cumulative measured blood loss 1. Takes time 2. Lower error rates than estimated blood loss EBL is visual estimation 1. Quick and easy 2. Not 100% accurate and it has a higher error rate

QBL Tools: Dry weight cards that will BE placed on scales! 1 gram = 1 ml This tool will be utilized until the QBL calculator is built in EPIC

QBL: Blood soaked items must be weighed! Weigh, don’t delay!

PPH Risk Assessment & Stratification AQI 10 – PFW Team

Obstetrical Hemorrhage Risk Assessment and Stratification OB Hemorrhage Safety Bundle Element: Recognition & Prevention The Risk Assessment & Stratification tool ü Helps to identify, and predict, those patients at risk for obstetrical hemorrhage ü Early identification of risk factors provides time for advanced planning and prevent potentially adverse outcomes (morbidity/mortality) ü Provides interventions, prioritization and evidenced based recommendations for mitigating risks of potential/future obstetrical hemorrhage

Obstetrical Risk Assessment & Stratification Adhere patient label Perform initial risk assessment when the patient is admitted for delivery L&D Main OR (scheduled cesareans) WSU will initiate the assessment for scheduled cesarean cases only Assess risk, circle risk level accordingly (Paper form) H: high; M: medium; L: low The form (paper) will travel with the patient (chart) and incorporated into i. PASS report At discharge, the form should be scanned into the medical record We will evaluate workflow/ form utilization 4 -6 weeks after go live; Once final, we will submit the form for EPIC development

Post Delivery Management • These interventions are recommendations • It is at the providers discretion to initiate orders according to his/her assessment • Currently, EPIC order entry will require provider revision • Near future: revise order sets to reflect post delivery management recommendations

Implementation and Update MEWS implemented - June 2018 Oxytocin standardization - April 2019 Maternal Level of Care Designation (Level 4) – Designation announced June 2019 PPH Risk Stratification and QBL – August 2019 (Pilot complete) Critical Care Conference, featuring Obstetrics – October 2019

Special Thanks: Aderonke Igbekele BSN- RN

References: Association of Women’s Health, Obstetric and Neonatal Nurses. AWHONN postpartum hemorrhage project. 2014. Available at: http: //www. pphproject. org. Retrieved March 17, 2017 AWHONN (2014). Guidelines for Oxytocin Administration after Birth: AWHONN Practice Brief Number 2: The Journal of Obstetrics and Gynecologic and Neonatal Nursing, (44), 161 -163; 2015. DOI: 10. 1111/1552 -6909. 12528 Bingham D, Melsop K, Main E. CMQCC Obstetric hemorrhage hospital level implementation guide. Stanford, CA: California Maternal Quality Care Collaborative; 2010. Lyndon A, Lagrew D, Shields L, Melsop K, Bingham B, Main E. (Eds). Improving health care response to obstetric hemorrhage. Stanford, CA: California Maternal Quality Care Collaborative; 2010. Mishkin, L. (2019, January 23) NJ first lady launches new campaign to help reduce maternal deaths. Retrieved from https: //www. njtvonline. org/news/video/nj-first-lady-launches-new-campaign-to-help-reduce-maternal-deaths/ Nina Martin, P. & Montagne, R. (2017, May 12). U. S. has the worst rate of maternal deaths in the developed world. NPR. Retrieved from https: //www. npr. org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed -world. Unicef (2017). Maternal Mortality. Retrieved from https: //data. unicef. org/topic/maternal-health/maternal-mortality. World Health Organization. (2018, February 16). Maternal Mortality. Retrieved from https: //www. who. int/news-room/fact -sheets/detail/maternal-mortality.