OB Hemorrhage Initiative 2009-2010

1. OB Hemorrhage Initiative 2009-2010 In collaboration with California Maternal Quality Care Collaborative

2. 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

3. 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.

4. In-situ Hemorrhage Drills Multidisciplinary drills were instituted in a new format utilizing adult learning principles – Pre-brief In-situ scenario Debriefing

5. 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.

6. 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.

7. 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.

8. Quantified Blood Loss 25 ml peripad 50 ml peripad 100 ml peripad A saturated 4x4 12-ply sponge = 5 ml • Other methods of quantification: • Weight • Direct Measurement 100 ml chux 250 ml chux 350 ml chux 500 ml chux Dry 25 ml 50 ml 75 ml 100 ml Visual Cue Chart – present in each delivery room in a discrete location 18x18 laps: 25 ml approx 50%; 50 ml approx 75%; 75 ml entire surface; 100 ml saturated and dripping

9. Three Methods of Quanitification Visual Estimation – with visual cues Weight - Scale Direct Measurement

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. OB Hemorrhage Kit Oxytocin – Methergine – Hemabate - Misoprostol 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.