AIM SAFETY BUNDLESOBSTETRICAL HEMORRHAGE

Tersh McCracken, MD, FACOG

MOMS ECHO

October 27, 2020

Photo courtesy of David Lagrew, MD and used with permission

Obstetric Hemorrhage Safety Bundle

Readiness Recognition Response Reporting /

Systems Learning

North Carolina: Mortality Mostly PreventableCause of Death (n=108) % of All Deaths % PreventableCardiomyopathy 21% 22%

Hemorrhage 14 93PIH 10 60CVA 9 0Chronic condition 9 89AFE 7 0Infection 7 43Pulmonary embolism 6 17

Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet. Gynecol. Dec 2005;106(6):1228-1234.

CA-PAMR Pregnancy-Related Deaths, Chance to Alter Outcome by Grouped Cause of Death; 2002-2004 (N=143)

Key 2008 CMQCC Hemorrhage Task Force Survey Findings

40% of hospitals did not have a hemorrhage protocol

Inconsistent definitions of hemorrhage were used among responding hospitals

70% of hospitals were not performing drillsMDs were not regularly participating in drills in hospitals that were doing them

Most had access to all 4 uterotonics Many hospital reported they did not have access to

alternative treatment methods, e.g., Balloons Note: 173 hospitals responded to the first baseline survey. The response rate is 66.3% based on 173/261 hospitals (2008) with annual delivery volume > 50 births.

READINESS – EVERY UNIT

• 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)

DRILL AND REHEARSE

RECOGNITION & PREVENTION-

EVERY PATIENT

Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times)

Measurement of cumulative blood loss (formal, as quantitative as possible)

Active management of the 3rd stage of labor (department-wide protocol)

Admission Risk Assessment & TestingLow

(Clot only)Medium

(Type and Screen)High

(Type & Crossmatch)No previous uterine incision

Prior cesarean birth(s) or uterine surgery

Placenta previa, low lying placenta

Singleton pregnancy Multiple gestation Suspected placenta accreta, percreta, increta

≤4 previous vaginal births

>4 previous vaginal births

Hematocrit <30 ANDother risk factors

No known bleeding disorder

Chorioamnionitis Platelets <100,000

No history of PPH History of previous PPH

Active bleeding (greater than show) on admit

Large uterine fibroids Known coagulopathy *Pre-transfusion testing strategy should be standardized to facility conditions depending

on blood bank resources, speed of testing, and availability of blood products.*

QBL VS EBL

RESPONSE - EVERY HEMORRHAGE

Unit-standard, stage-based, obstetric

hemorrhage emergency management plan with

checklists

Support program for patients, families, and staff for all significant

hemorrhages

MEDICAL MANAGEMENT

BAKRI BALLOON

• Intrauterine Compression Balloon

R EPORTING/SYSTEMS LEARN ING

EVERY UN IT

• Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities

• Multidisciplinary review of serious hemorrhages for systems issues

• Monitor outcomes and process metrics in perinatal quality improvement (QI) committee

1. Identification of cases

2. Information collection, review by multidisciplinary

committee

3. Cause of Death, Contributing Factors and Quality Improvement (QI) Opportunities identified

4. Strategies to improve care and

reduce morbidity and mortality

5. Implementation and Evaluation of QI strategies and

tools

Toolkits• Hemorrhage • Preeclampsia• CVD

CA-PAMR Quality Improvement Review Cycle

OB Hemorrhage: We Can Do Better

Most maternal mortalities and near misses due to hemorrhage are preventable

1/3 of patients will have no risk factors prior to labor Must be prepared for every patient QBL every delivery so can respond early

Requires reliance not on individuals but on team approach

Creating a “Team For All Seasons”

OB Hemorrhage is the prototypic OB emergency Many of the system changes are directly applicable to

other obstetric emergencies Creating the team and systems to implement hemorrhage

project makes other OB QI projects easier and more successful