POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means...
Transcript of POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means...
![Page 1: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/1.jpg)
POSTPARTUM HEMORRHAGE
Implementing Your Bundle
Brett D. Einerson, MD MPH
University of Utah, Maternal-Fetal Medicine
![Page 2: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/2.jpg)
No disclosures
![Page 3: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/3.jpg)
U.S. Maternal Mortality
U.S. Maternal mortality is:
OB Hemorrhage is:
• Increasingly Common
• A leading killer of moms
OB hemorrhage deathsare largely preventable.
MacDorman. U.S. Maternal Mortality Trends. Obstet Gynecol 2016.
![Page 4: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/4.jpg)
One state bucked the trend
United States California
1. Statewide mortality review2. Maternal Quality Care Collaborative (CMQCC)3. Hemorrhage and Preeclampsia Bundles
MacDorman. U.S. Maternal Mortality Trends. Obstet Gynecol 2016.
![Page 5: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/5.jpg)
http://pphproject.org/
![Page 6: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/6.jpg)
Why adopt OB “bundles”?
• Peer pressure.
• Performance measures matter.
• Patient care.Enhanced response.Improved outcomes.
Main. Consensus Bundle on Obstetric Hemorrhage. Obstet Gynecol 2015.
![Page 7: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/7.jpg)
Pathway to poor outcomes
A.k.a “Anatomy of failed systems”
Adapted from talk by Laurence Shields, MD (SMFM Quality Safety Chairman, Feb 2016)Image: http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html
OB Hemorrhage
Symptoms/signs unrecognized
Assumptions of safety
Delayed Diagnosis
Delayed Treatment
Keep trying failed treatment
SERIOUS MORBIDITY
NEAR MISS (ICU ADMIT)
MATERNAL DEATH
![Page 8: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/8.jpg)
Stronger Swiss with Bundles
A.k.a “Anatomy of a successful system”
OB Hemorrhage
READINESS (systems)
RECOGNITION & PREVENTION
RESPONSE
REPORTING & LEARNING
SERIOUS MORBIDITY
NEAR MISS (ICU ADMIT)
MATERNAL DEATH
Adapted from talk by Laurence Shields, MD (SMFM Quality Safety Chairman, Feb 2016)Image: http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html
![Page 9: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/9.jpg)
POSTPARTUM HEMORRHAGE
KEY ELEMENTS
OF A BUNDLE
![Page 10: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/10.jpg)
• Risk Assessment
• AMTSL
Four ”R”s
RECOGNITION & PREVENTION
• Blood bank
• Hemorrhage cart
• Simulation / Team Drills
READINESS
• Checklist
• Rapid response team
RESPONSE
• Culture of debriefing
• Multidisciplinary review
• Measure outcomes/process
REPORTING & LEARNING
![Page 11: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/11.jpg)
Every Patient
![Page 12: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/12.jpg)
Risk Assessment
Intrapartum(& Postpartum)
Identify risk “on the fly”
L&D Admission
Identifyrisk factors
Prenatal
Identify extraordinary risk
Transfer to higher level
of care
Transfusionpreparedness
(e.g. T&S)
Transfusion preparedness,
mobilize resources
![Page 13: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/13.jpg)
Risk Assessment: Admission
Moderate Risk[ ] Prior uterine surgery or CS[ ] Multiple gestation[ ] >4 prior births[ ] Prior OB hemorrhage[ ] Large myomas[ ] EFW >4000 g[ ] Obesity (BMI >40)[ ] Hematocrit <30%
High Risk[ ] Previa[ ] Accreta / percreta[ ] Platelet count <70K[ ] Active bleeding[ ] Known coagulopathy[ ] >2 medium risk factors
Transfusion preparedness1. Alert / huddle / SBAR
2. T&S?, crossmatch? Hold clot?
![Page 14: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/14.jpg)
Risk Assessment: Intrapartum
Moderate Risk[ ] Chorio[ ] Prolonged oxytocin >24hr[ ] Prolonged 2nd stage[ ] Magnesium sulfate
High Risk[ ] Active bleeding[ ] >2 medium risk factors
Transfusion preparedness1. Alert / huddle / SBAR
2. T&S?, crossmatch? Hold clot?
***Key: Make reassessment systematic***
Every shift change?
![Page 15: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/15.jpg)
Universal AMTSL
Active management of the 3rd Stage of Labor (AMTSL)
***Key: Every patient, every delivery***
1. Uterotonic within 1 min.2. Controlled cord traction3. Fundal massage after
delivery of placenta
![Page 16: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/16.jpg)
![Page 17: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/17.jpg)
![Page 18: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/18.jpg)
Every Unit(yes, that means postpartum too)
![Page 19: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/19.jpg)
Blood Bank
***Key: Access to transfusion in a hurry*** (even without a crossmatch)
1. Massive Transfusion Protocol (MTP)(should be written & multidisciplinary)(should include RBC, coagulation factors, platelets)
2. Emergency Release Transfusion Protocol (ERT)(minimum 4 units O-neg / uncrossed RBCs)
Details available from resources at the end of this presentation
![Page 20: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/20.jpg)
[Surprising] Barriers to Transfusion
• How do I activate the MTP?
• What phone number do I call?
• Who is delivering the blood? When?
• Where is blood bank? Where do I send the RN/MD?
• How do I effectively communicate urgency of need?
![Page 21: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/21.jpg)
Hemorrhage Cart / OR Kits
***Key: Easy access, universal awareness******Key: Know when to go to the operating room***
Hemorrhage Cart Components1. Hemorrhage checklist!2. Uterotonics 3. Intrauterine balloon4. Supplies for phlebotomy, fluids, transfusion5. Fridge?6. Instructions, doses, contraindications, contact #s
Don’t forget to design a “OR PPH Action Kit”
![Page 22: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/22.jpg)
Every hemorrhage(yes, that means every hemorrhage)
(and yes, that means postpartum too)
![Page 23: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/23.jpg)
Rapid Response Team
***Key: You need an extra hand***
The first step is always… mobilize additional help.
Know who is doing what.Pre-define RN and MD roles.
Use the checklist!
Frequent Timeouts (make up acronym… ELBOW?)Etiology, Labs, Blood bank, Other help, What’s Next
Practice (simulation, team training)
![Page 24: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/24.jpg)
Checklist
***Key: update, define roles, mobilize, act, think***
![Page 25: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/25.jpg)
Checklist
Don’t forget…
…to debrief (with staff, with patient/family)
…and to document
![Page 26: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/26.jpg)
Every unit / hospital
![Page 27: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/27.jpg)
Reporting & Systems Learning
• Establish a culture of huddles for high risk patients
• Establish post-event debriefs
• Conduct multidisciplinary review of serous hemorrhages with an intent to learn, not blame
• Track outcomes & process metrics
![Page 28: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/28.jpg)
Safe Motherhood Initiative
AWHONN
Safe Health Care
CMQCC
http://www.acog.org/About-ACOG/ACOG-Districts/District-II/SMI-OB-Hemorrhage
http://pphproject.org/index.asp
http://www.safehealthcareforeverywoman.org/
https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit
Resources for your bundle
![Page 29: POSTPARTUM HEMORRHAGE - physicians.utah.edu · Pathway to poor outcomes ... (and yes, that means postpartum too) Rapid Response Team ***Key: You need an extra hand*** The first step](https://reader030.fdocuments.in/reader030/viewer/2022040310/5d1f826988c993364d8d0092/html5/thumbnails/29.jpg)
Utah Department of Health: Every Mother Initiative
Erin A.S. Clark, MD
Amy Sullivan, MD
Janet A. Fisher, MS, RNC
Laurie Baksh, MPH
Brett D. Einerson, MD
Resources for your bundle