Postpartum hemorrhage (PPH) accounts for 11.4% of U.S. maternal deaths and is a leading
cause of preventable pregnancy-related mortality.[1]
[2]
[3]
[4]
[5] In 2017, the American College of Obstetricians and Gynecologists called for widespread
hospital implementation of organized and systematic processes in PPH management.[6] Effective July 1, 2020, the Joint Commission will require hospitals to have evidence-based
practice elements aimed toward preventing PPH-related maternal morbidity and mortality.[7] The Alliance for Innovation on Maternal Health (AIM) Safety Bundle on PPH—adapted
from the National Partnership for Maternal Safety's obstetrics (OB) Hemorrhage Bundle—is
a tool that compiles evidence-based, peer-reviewed guidelines and contains 13 key
practice elements which are organized into a form that aids implementation and consistency
of practice. Use of an OB PPH Safety Bundle has been associated with improved PPH
management and morbidity benefit.[8]
[9]
Grady Memorial Hospital is a large publicly supported hospital in Atlanta (970 beds,
approximately 2,500 deliveries per year). Grady is staffed by faculty from two medical
schools and serves as a safety net hospital, and a regional perinatal center, accepting
high-risk patients from Georgia, Florida, and Tennessee.[10] Examination of maternal outcomes at Grady found that PPH complicated 11% of deliveries
and was responsible for 7.5% of preventable pregnancy-related deaths in a 40-year
period.[11] Safety-net hospitals play a critical role in providing care to Medicaid, uninsured,
undocumented, or otherwise vulnerable patients, yet their ability to provide sustained
high-quality care is limited by resource availability and economic challenges.[12]
[13] As a safety-net hospital providing care for high-risk parturients, we partnered
with the Georgia Perinatal Quality Collaborative to implement the AIM PPH Safety Bundle.
In this article, we present key steps with insights that might assist groups contemplating
implementation of similar initiatives in their hospitals. This was deemed exempt from
institutional review board approval by both the Emory and Morehouse Schools of Medicine.
Methods
Establishing an Obstetric Hemorrhage Task Force and Task Force Aims
The labor and delivery unit is staffed by residents and faculty from two academic
services, each with independent Chiefs of Service who report to the hospital's chief
medical officer; nursing reports to the hospital's chief nursing officer. Prior to
implementation, the three groups had been working independently to improve care processes
on the unit. The chief medical officer requested that the chiefs of obstetrics and
nursing leadership convene and assess PPH management in our hospital. A 10-member
multidisciplinary task force was formed with representation from both obstetric services,
maternal–fetal medicine, midwifery, obstetric anesthesia, labor and delivery nurses,
postpartum nurses, nurse educators, pharmacy, health information management, and quality.
The charge of the task force was to determine the incidence and severity of obstetric
hemorrhage to review the differences in hemorrhage management, to develop a program
mission, and to identify key interventions. Key deficiencies were identified through
the process, which ultimately led to the following priority goals (1) systematic identification
of all women at high risk for PPH; (2) standard and efficient recognition and management
of PPH; (3) ready access to hemorrhage management medications, instruments, and transfusion;
(4) improvement in team-based performance; and (5) a process to conduct debriefs and
detailed review of hemorrhage cases. A key driver diagram ([Fig. 1]) was adapted from AIM and organized to include the program mission, aims, and key
interventions for implementation.[14]
Fig. 1 Key driver diagram. Built on the “four Rs” from AIM, this depicts the program mission
and organization includes the program's goal (based on the obstetric hemorrhage bundle
from AIM), key drivers, and itemizes goals and intervention. Grady specific initiatives
are listed under the Intervention section. AIM, Alliance for Innovation on Maternal
Health.
Improving Identification and Delivery Preparation
The Association of Women's Health, Obstetric and Neonatal Nurses Postpartum Hemorrhage
Risk Assessment Tool (PHRAT), uses an algorithm to combine the patient responses,
clinical factors, and available chart data to systematically risk stratify all delivering
women into low-, medium-, or high-risk categories ([Fig. 2]).[15]
[16] The initial risk assessment is performed by the patient's nurse at the time of delivery
hospitalization admission and adjusted should the patient develop risk factors such
as chorioamnionitis, preeclampsia, prolonged second stage, or difficult placental
extraction.
Fig. 2 Postpartum Hemorrhage Risk Assessment Tool. Reprinted with permission from Association
of Women's Health, Obstetric and Neonatal Nurses.
The patient's risk classification is communicated three ways (Supplement)[1]: In the electronic medical record (EMR), with a green, yellow, or red circle corresponding
to her hemorrhage risk level[2]; color coded hearts placed on the door of every laboring woman[3]; verbally among providers during twice daily team huddles, which includes members
from the obstetric, anesthesia, and nursing teams.
The patient's risk stratification guides delivery preparation and blood availability.
The electronic record of all admitted patients is reviewed to confirm the patient's
type and screen. Low-risk patients have a “clot to hold, blood” order placed, which
instructs the nurse to draw blood and send the specimen to the blood bank, but no
additional testing is performed. This allows for availability of crossmatched blood
within 1 hour. Medium-risk patients have a “type and screen” order, which instructs
the blood bank to perform ABO group-Rh type-antibody screen and to have blood available
within 15 minutes. High-risk patients (as well as antibody-positive patients) have
an ABO group-Rh type-antibody screen-crossmatch order with immediate availability
of blood. High-risk patients also have the obstetric hemorrhage cart placed outside
their room at delivery. These orders are performed through the EMR via the “intrapartum
and immediate postpartum admission” order set, which prompts the provider to risk
stratification patient and appropriately select options to order additional IV placement,
adjusted vital sign frequency monitoring, type and screen, crossmatch for blood, tranexamic
acid, and postpartum uterotonic agents.
Improving Recognition and Response
Quantitative Blood Loss
The most common method of measuring blood loss during the third stage of labor is
visual estimation of blood loss (EBL) by the birth attendant. Quantitative blood loss
(QBL) has been proposed to be more accurate than EBL for the management of obstetric
hemorrhage and has a higher sensitivity in diagnosing PPH.[17]
[18]
[19]
[20]
[21]
[22] For vaginal deliveries, we used commercially available underbuttock drapes with
a funneled, metered plastic bag to collect blood and amniotic fluid expelled during
delivery. The volume of amniotic fluid was measured prior to placental delivery and
subtracted from the total volume in the bag. Similarly, the volume of amniotic fluid
was measured and subtracted from the total volume in the suction cannister during
cesarean deliveries.
Weighed sponges also contributed to blood loss quantification. The sponges are weighed
on the neonatal scales available in each room as follows: the sponges have a premeasured
dry weight which is subtracted from the wet weight. That difference is converted in
1:1 g to milliliters, which is added to the measured blood loss volume. If blood was
collected on other materials (i.e., postpartum pads or sheets), the difference between
the dry and wet weight would use to calculate QBL. The dry weight ratios for commonly
saturated objects were kept on hemorrhage carts and laminated copies affixed to badges
(Supplement).
Obstetric Simulations and Performance Feedback
All physician and nursing providers were required to complete online educational modules
on hemorrhage management. Obstetric simulations reinforced team-approach to care.
Examples of simulation exercises include QBL, using the OB hemorrhage cart, OB hemorrhage
stage approach to intervention based on the OB hemorrhage protocol, and management
of disseminated intravascular coagulation, and cardiopulmonary arrest. Over an 18-month
time period, a total of fourteen 30-minute simulation exercises were conducted on
PPH management, capturing approximately 85% of the labor and delivery workforce.
Standardization of the Management of Postpartum Hemorrhage
Hemorrhage Protocol
A revised hemorrhage protocol was implemented in close coordination with transfusion
medicine, pharmacy, anesthesia, maternal fetal medicine, and obstetrics, following
the California Maternal Quality Care Collaborative Obstetric Staged hemorrhage care
guidelines checklist.[23]
[24] We worked with our health information system and transfusion medicine to streamline
electronic activation of the Massive Transfusion Protocol (MTP) by creating an order-sets
that includes 6UPRBC-6U FFP, followed by 6UPRBC-6U FFP-1 pack platelets, alternating
every 30 minutes until resolution, with cryoprecipitate ordered based on laboratory
values.
A protocol focused on stage approach to interventions was developed ([Fig. 3]). For example, Stage 0 management—which is defined as prevention—includes QBL, early
administration of tranexamic acid or uterotonic agents if ongoing blood loss, and
oxytocin administration using the Rule of 3 Algorithm after cesarean delivery or as
a 10-unit bolus after vaginal delivery.[6]
[25]
[26] The hemorrhage cart should be called for if there is concern for Stage 1 hemorrhage,
as well as continued administration of uterotonic agents and fluid resuscitation;
additional nursing or physician help should be mobilized.[27] Stage 2 involves notification of an attending obstetrician, charge nurse, and OB
anesthesia; possible mobilization to the operating room if not already there; and
blood transfusion while the back up team is mobilized, MTP is activated, and the patient
definitively brought to the operating room for all Stage 3 hemorrhages. Additionally,
a time-keeper and recorder is identified, and the OB Narrator used to document interventions.
These patients are admitted either to obstetric intermediate care unit on labor and
delivery or the intensive care unit following resolution.
Fig. 3 Obstetrics Hemorrhage Protocol. Pictorial depiction of the protocol with a staged
approach to intervention. ICU, intensive care unit; IVF, intravenous fluid such as
plasma-lyte, lacted ringer, or normal saline; LDR, labor and delivery room; OR, operating
room.
Defining Team Members, Roles, and Responsibilities
We defined the hemorrhage response team to include the delivering attending physician,
the resident physician, the patient's primary nurse, the charge nurse, and anesthesia.
For Stage 3 hemorrhage, we created a tiered back-up system which included a second
obstetric attending physician and additional nurse. The on-call maternal fetal medicine
attending, advanced gynecologic surgeon, urology, and trauma services were involved
when needed.
Obstetric Hemorrhage Cart
As a key component of our initiative, OB hemorrhage carts were designed with input
from pharmacy, obstetric, and nursing providers. The purpose of the hemorrhage cart
was to have readily available checklists, uterotonic medications, and other supplies
required to manage refractory hemorrhage. A total of five hemorrhage carts were developed:
three of which are stationed on labor and delivery, one in the operating room suite,
and one in the postpartum unit. The hemorrhage protocol is affixed to the top of the
cart, as well as the names, dose, and route of administration for uterotonic medications
and tranexamic acid[28]; all contain uterotonic medications, surgical instruments, kits for laboratory draws,
and materials for fluid administration (Supplement).
Postpartum Hemorrhage Order-Set
The OB narrator (Supplement) is a tool to document hemorrhage management and a checklist,
ensuring appropriate management of hemorrhage in real time. It can therefore be used
for team debriefs, case reviews, and process improvement. The paper form is under
pilot, with the ultimate goal is an electronic version that can also function as an
order set, which would include MTP activation.
Team Debriefs
We created a formal process to conduct debriefs and detailed review of PPH cases.
Team Debriefs occur after management of any patient with PPH, immediately following
patient stabilization. Stage 3 hemorrhage review involves chart investigation and
presentation at Mortality and Morbidity conference, which provides for department
wide review and process improvement. These cases are also brought to the Perinatal
Quality Committee, allowing for multidisciplinary input. The purpose of these reviews
is to provide a protected forum for process evaluation, root cause analysis, and systems
improvement.
Monitoring and Evaluation
For each intervention detailed, the task force developed a plan for stepwise implementation
and monitored integration. Safety bundle implementation was iterative, requiring multiple
Plan-Do-Study-Act (PDSA) cycles, continuous nurse training, and completion rate reports.
Interventions were introduced during twice daily team huddles and formal didactic
conferences for nurses, midwives, and physicians. Target metrics were developed, collected,
and displayed on a team progress board on the unit. Consultants were hired to perform
external quarterly review of the program.
The most reliable metric we developed was PHRAT completion rate, which was generated
using the EMR. We collected process metrics (case reviews rates, proportion of providers/nurses
educated, PHRAT, and QBL completion rates) and outcome metrics (PPH rates) initially
were collected and available data kept on a team progress board on the unit. When
targets were not achieved, case review involving chart investigation and discussion
with the delivery team was conducted. Individual and group feedback was provided by
physician and nursing leadership, and multidisciplinary buy-in and was critical to
improving nonadherence and achieving targets. For example, PHRAT completion rates
([Fig. 4])—measured as the proportion of delivering women with a risk assessment completed
prior to delivery—improved once we addressed different workflows for patients transferred
to labor and delivery from other hospital units, identified a nurse educator to lead
nursing teaching and utilization, and provided continuous verbal and visual feedback
on performance. Protocols were changed often, sometimes daily, to improve use.
Fig. 4 Risk assessment tool compliance rates. This is an example of how compliance rates
improve and the need for iterative approach to integration. The rates were reported
weekly and then monthly, and posted on the team communication board on labor and delivery.
In-depth reviews, including review of the patient's medical record, admission note,
and discussion with the admitting nurse, was performed for all patients missing assessments.
As we developed EMR capability for surveillance, we developed a rudimentary monitoring
and evaluation system involving an OB safety board. The goal was to capture rates
of Stage 3 hemorrhage, ICU admission, blood transfusion greater than 4 units; the
MRN for any patient with these outcomes was added to a poster board. The “safety board”
was placed in a Health Insurance Portability and Accountability Act-compliant office,
accessible only to physicians, midwives, and nurses on the unit and the location where
team huddles occur. EMR reports involve using International Classification of Diseases-10
and procedure codes to track outcomes, remains an ongoing area of improvement.[29]
Discussion
This paper describes key components for the implementation of a standardized protocol
for improved surveillance and management of obstetric hemorrhage ([Table 1]). The process was iterative process, requiring multidisciplinary, high-level, hospital
administrative engagement, as well as physician and nursing co-champions for clinical
integration. Critical components toward successful integration include culture change
to one geared toward patient safety, weekly meetings during which implementation processes
were reviewed, and nursing involvement who provided behavioral motivation, educational
support, and advocated for enhanced communication between all members of the team.
Continuous education, feedback, and intensive audit is critical.
Table 1
Prerequisites to effective implementation of postpartum hemorrhage bundle
|
Clearly define the burden of hemorrhage and align proposed change to institutional
goals
|
|
Develop a strategy for open communication and involve key stakeholders
|
|
Provide effective training and iterative implementation of initiatives
|
|
Develop infrastructure support
|
|
Monitor and evaluate process measures and health outcomes
|
Regarding actual implementation, the order in which to implement the initiatives is
critically important. After the task force was convened, the first initiative was
to create the obstetric narrator to standardize hemorrhage management. It became clear
that this would be insufficient to standardize and improve our management and instead
we focused our attention on effecting a proactive approach to hemorrhage management
rather than reactive.
Based on our experience with this multicomponent implementation, the following sequence
for implementation is recommended:
-
Standardize a hemorrhage protocol
-
Define a hemorrhage response team and ensure ongoing education on hemorrhage management
for all providers on the unit
-
Routinize use of Postpartum Hemorrhage Risk Assessment Tool and establish an easy
method to communicate risk status to team members (i.e., Red Hearts)
-
Employ QBL for all deliveries
-
Develop and utilize hemorrhage carts
-
Streamline protocol adherence with an obstetric narrator
Systems for case review and monitoring and evaluation (i.e., simulation, chart review
and debrief, OB Safety board) should also be implemented in parallel.
A major limitation of the process is that a system for monitoring and evaluation was
not established prior to the start of the safety bundle implementation. Further, we
did not formalize a process to assess unintended consequences from the program. For
example, the risk assessment tool stratifies 49% of our patients as high risk for
PPH, yet only 7–9% of deliveries are complicated by PPH. It is unclear how the burden
of excess preparation has affected transfusion services or services at our institutions.
From the outset, it is important to develop process and outcome metrics to track progress;
not only for process improvement, but also for positive reinforcement.
National organizations have called for the implementation of an obstetric hemorrhage
bundle in all maternity hospitals, which is now a standard for accreditation required
by the Joint Commission.[7] It is our goal that this paper may provide anticipatory guidance for other organizations
beginning to implement an obstetric hemorrhage bundle, and that others may learn from
our experience.
