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Am J Perinatol 2021; 38(12): 1281-1288
DOI: 10.1055/s-0040-1712452
Original Article

The Postpartum Hemorrhage Patient Safety Bundle Implementation at a Single Institution: Successes, Failures, and Lessons Learned

Christina M. Duzyj
1   Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
2   Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
,
Carla Boyle
3   Robert Wood Johnson University Hospital, New Brunswick, New Jersey
,
Kathleen Mahoney
4   School of Nursing, New Jersey City University, Jersey City, New Jersey
,
Anna Rose Johnson
2   Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
,
Grace Ogot
3   Robert Wood Johnson University Hospital, New Brunswick, New Jersey
,
Charletta Ayers
2   Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Abstract

Objective In 2015, a multidisciplinary consensus bundle of recommendations for the anticipation and management of postpartum hemorrhage was published. Our goal was to evaluate the successes and failures of our institutional bundle implementation process.

Study Design An interdisciplinary committee was created to facilitate bundle implementation. All components of the bundle were addressed with cross-disciplinary teaching between stakeholders on the obstetrics units. Tools were built in the electronic medical record to facilitate bundle components of risk stratification, quantitative blood loss calculation, and stage-based hemorrhage management. Bundle components were individually evaluated for acceptability and sustainability. Overall rates of hemorrhage and transfusion from the periods 1 year before and after bundle implementation were also evaluated.

Results Readiness bundle components were successfully implemented, although simulation drills demonstrated limited sustainability. Recognition components were mixed: risk stratification was successfully and sustainably implemented while quantitative blood loss met resistance and was ultimately discontinued as it did not clinically perform superiorly to estimated blood loss. Among response and reporting elements, patient level support and team debriefing were noted as particular deficiencies in our program.

Conclusion The postpartum hemorrhage patient safety bundle provided concrete individual elements, which overall improved the success of a stratified program implementation. Multiple deficiencies in acceptability and sustainability were uncovered during our process, particularly concerns about quantitative blood loss implementation and team communication skills.

Key Points

  • Supply readiness and protocol development were “quick wins.”

  • Culture change elements included recognition, response, and communication.

  • Dedicated champions and electronic medical record tools improved sustainability.

  • Poor acceptability and lack of improved outcomes led to element failure.

Keywords

postpartum hemorrhage - patient safety - safety bundle - electronic medical record - estimated blood loss - quantitative blood loss


Publication History

Received: 27 February 2020

Accepted: 15 April 2020

Article published online:
26 May 2020

© 2020. Thieme. All rights reserved.

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