National Partnership for Maternal Safety Patient Safety Bundles
National Partnership for Maternal Safety: Patient Safety Bundles Elliott Main, MD Stanford University California Maternal Quality Care Collaborative
Maternal Deaths per 100, 000 Live Births Maternal Mortality Rate, California and United States; 1999 -2010 HP 2020 Objective – 11. 4 Deaths per 100, 000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999 -2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A 34, O 00 -O 95, O 98 -O 99) for 1999 -2010. United States data and HP 2020 Objective were calculated using the same methods. U. S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008 -2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http: //wonder. cdc. gov/ucd-icd 10. html on Apr 17, 2013 8: 00: 39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013. 2
Maternal Mortality and Severe Morbidity Approximate distributions, compiled from multiple studies Cause Mortality (1 -2 per 10, 000) ICU Admit Severe Morbid (1 -2 per 1, 000) 100) VTE and AFE 15% 5% 2% Infection 10% 5% 5% Hemorrhage 15% 30% 45% Preeclampsia 15% 30% Cardiac Disease 25% 20% 10%
Dominance of Provider QI Opportunities: Hemorrhage and Preeclampsia • California Pregnancy Associated Mortality Reviews – Missed triggers/risk factors: abnormal vital signs, pain, altered mental status/lack of planning for at risk patients – Underutilization of key and treatments Present inmedications >95% of cases – Difficulties getting physician to the bedside – “Location of care” issues involving Postpartum, ED and PACU • University of Illinois Regional Perinatal Network - Failure to identify high-risk status - Incomplete. Present or inappropriate management in >90% of cases CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR): Report from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC. org) Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with severity. Am J Obstet Gynecol 2004; 191: 939 -44.
Federal (MCH-B, CDC, CMS/CMMI) Obstetricians (ACOG/SMFM/ ACOOG) Family Practice (AAFP) OB Anesthesia (SOAP) Midwives (ACNM) Maternal Safety Blood Banks (AABC) Hospitals (AHA, VHA) Perinatal Quality Collaboratives (many) Nurses (AWHONN) State (AMCHP, ASTHO, MCH) Nurse Practitioners (NPWH) Birthing Centers (AABC) Direct Providers Safety, Credentials (TJC) 5
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4 Domains: OB Hemorrhage Patient Safety Bundle • Improve readiness to hemorrhage by identifying standardized protocols (general and massive) • Improve recognition of OB hemorrhage by performing on-going objective quantification of actual blood loss • Improve response to hemorrhage by utilizing unitstandard, stage-based, obstetric hemorrhage emergency management plans with checklists • Improve reporting/systems learning of OB hemorrhage by performing regular on-site multiprofessional hemorrhage drills
Obstetric Hemorrhage Key Elements Readiness - Every Unit 1. 2. 3. 4. 5. Hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches Immediate access to hemorrhage medications (kit or equivalent) Establish a response team - who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched) Unit education on protocols, unit-based drills (with post-drill debriefs)
Obstetric Hemorrhage Key Elements Recognition - Every Patient 5. Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times) 6. Measurement of cumulative blood loss (formal, as quantitative as possible) 7. Active management of the 3 rd stage of labor (routine use of oxytocin)
Obstetric Hemorrhage Key Elements Response - Every Hemorrhage 9. Unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists 10. Support program for patients, families, and staff for all significant hemorrhages
Obstetric Hemorrhage Key Elements Reporting/Systems Learning - Every Unit 11. Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities 12. Multidisciplinary review of serious hemorrhages for systems issues 13. Monitor outcomes and process metrics in perinatal quality improvement (QI) committee
4 Keys • Have a “Safety Bundle” • “Standard Work”—Check list for putting the bundle into action • Practice (drills) • Feedback and tweaking (debriefs and formal case reviews
Key OB Hemorrhage QI Toolkits: Full of Resources www. CMQCC. org www. pphproject. org v 2. 0 available soon www. safehealthcareforeverywoman. org
Large-Scale Implementation How do we reach EVERY hospital in the CA? ü Engage every Professional organization üState-level groups ü Engage every Hospital organization ü The Joint Commission ü CMMI: Hospital Engagement Networks ü State Agencies ü State Maternal Quality Collaborative ü Different models of QI (mentoring)
Things to Remember • The development of a multidisciplinary taskforce with physician and nursing champions from OB, anesthesia, and blood bank is critical for success • Don’t reinvent the wheel – use available resources to help develop and implement your hospital’s individualized response plan • Simulation is a great way to educate, practice new behaviors and test your infrastructure – make time for it • Debriefings are critical for continuous quality improvement and effective debriefing is a skill that needs to be taught and practiced
Maternal Deaths per 100, 000 Live Births Maternal Mortality Rate, California and United States; 1999 -2010 HP 2020 Objective – 11. 4 Deaths per 100, 000 Live Births SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999 -2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A 34, O 00 -O 95, O 98 -O 99) for 1999 -2010. United States data and HP 2020 Objective were calculated using the same methods. U. S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008 -2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http: //wonder. cdc. gov/ucd-icd 10. html on Apr 17, 2013 8: 00: 39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013. 16
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