OB Hemorrhage Initiative2009-2010

In collaboration with

California Maternal Quality Care Collaborative

Education

• Multiple educational sessions with nursing and ancillary support staff

• Didactic component• Hands on

– QBL pretest and posttest– Management of Bakri balloon

• Similar presentation to MDs– Sponsored by Perinatologist

Staff Education

Nursing staff attended a 45 minute in-service on CMQCC hemorrhage to include the introduction of Quantitative

Blood Loss. Several stations of simulated blood loss were

included for nurse evaluation with pre and post test. Also, introduction to the use and care of the patient with a

Bakri Balloon was provided.

Nursing staff attended a 45 minute in-service on CMQCC hemorrhage to include the introduction of Quantitative

Blood Loss. Several stations of simulated blood loss were

included for nurse evaluation with pre and post test. Also, introduction to the use and care of the patient with a

Bakri Balloon was provided.

In-situ Hemorrhage Drills

Multidisciplinary drills were instituted in a new format utilizing adult learning principles

–Pre-brief

In-situ scenarioDebriefing

Multidisciplinary drills were instituted in a new format utilizing adult learning principles

–Pre-brief

In-situ scenarioDebriefing

Survey Monkey to MDs

A survey link was emailed to each physician with obstetric care privileges regarding visual

estimation of blood loss. Results were varied – supported other research which states

underestimation with larger amounts; as well as overestimation with smaller amounts.

A survey link was emailed to each physician with obstetric care privileges regarding visual

estimation of blood loss. Results were varied – supported other research which states

underestimation with larger amounts; as well as overestimation with smaller amounts.

Staff and MD education

Evening education and dinner provided to medical caregivers with didactic and hands on instruction related to CMQCC OB Hemorrhage

initiative as well as Quantitative Blood Loss in-service. Results of “Survey Monkey” were discussed.

Collaborative effort between Perinatal medicine and

nursing.

Evening education and dinner provided to medical caregivers with didactic and hands on instruction related to CMQCC OB Hemorrhage

initiative as well as Quantitative Blood Loss in-service. Results of “Survey Monkey” were discussed.

Collaborative effort between Perinatal medicine and

nursing.

Quantification of Blood Loss

• Ongoing assessment through recovery period

• Better assessment methods–Visual cues (posters)–Multidisciplinary blood loss

education

Postpartum blood loss is categorized with each patient and this information is a component of the nurse handover report through all transfers of care.

100 ml peripad

250 ml chux

350 ml chux 500 ml chux

18x18 laps: 25 ml approx 50%; 50 ml approx 75%; 75 ml entire surface; 100 ml saturated and dripping

25 ml 50 ml 75 ml 100 ml

A saturated 4x4 12-ply sponge = 5 ml

50 ml peripad25 ml peripad

100 ml chux

Dry

Other methods of quantification:•Weight•Direct Measurement

Visual Cue Chart – present in each delivery room in a discrete

location

Three Methods of Quanitification

Visual Estimation – with visual cues

Weight - Scale

Direct Measurement

Hemorrhage Debriefing

Debriefing tool is used to report hemorrhage and

comment on events. Issues such as communication,

equipment availability, ease of access to meds etc are

addressed. Process improvement is a key

component of findings from the debriefing tool.

Debriefing tool is used to report hemorrhage and

comment on events. Issues such as communication,

equipment availability, ease of access to meds etc are

addressed. Process improvement is a key

component of findings from the debriefing tool.

Documentation

The OB Hemorrhage report form is used as a recording tool during a hemorrhage situation that serves to record events, meds, and procedures. It is similar to a “code sheet” – when signed by the physician it serves as an order sheet for events and interventions.

Documentation

Introduced “QBL” into postpartum recovery documentation. A quantitative amount is entered at each pad or chux change to decrease the incidence of denial or delay.

Introduced “QBL” into postpartum recovery documentation. A quantitative amount is entered at each pad or chux change to decrease the incidence of denial or delay.

Risk Assessment

Results of risk assessment will affect patient care planning

Women are assessed and assigned a Hemorrhage risk status on admission and is an ongoing assessment during labor. The level of risk identified correlates with level of lab tests needed.

Women are assessed and assigned a Hemorrhage risk status on admission and is an ongoing assessment during labor. The level of risk identified correlates with level of lab tests needed.

OB Hemorrhage Cart

We created a central location for identified equipment and supplies needed for the management of an OB hemorrhage. We have used drills and real events to

improve content and function of this cart.

We created a central location for identified equipment and supplies needed for the management of an OB hemorrhage. We have used drills and real events to

improve content and function of this cart.

OB Hemorrhage KitOB Hemorrhage Kit

Medications commonly needed for treatment of OB hemorrhage are contained in a “Hemorrhage Kit” in the Pyxis. This has been an improvement process in itself. Through drills and real events, this has evolved and is still evolving to provide convenient and timely distribution of these medications.

Medications commonly needed for treatment of OB hemorrhage are contained in a “Hemorrhage Kit” in the Pyxis. This has been an improvement process in itself. Through drills and real events, this has evolved and is still evolving to provide convenient and timely distribution of these medications.

Oxytocin – Methergine – Hemabate - Misoprostol