Hemorrhage is one of the leading causes of morbidity and mortality in pregnancy, delivery and in the immediate post-partum period. Prior to the changes from ICD-9-CM to ICD-10-CM, the severe maternal morbidity (SMM) rate in Delaware increased by 37 percent from 114 per 10,000 delivery hospitalizations to 157 per 10,0000 delivery hospitalization[1] Consistent with national estimates,[2] blood transfusions (a procedure where a delivering mother is given blood due to excessive bleeding around delivery – hemorrhage) was the largest contributor to SMM. The Delaware Perinatal Quality Collaborative, through a grant (CDC-RFA-DP17-1702) from the Centers of Disease Control and Prevention (CDC) to the Delaware Division of Public Health, has been working on decreasing maternal and infant morbidity and mortality by working specifically on decreasing the incidence of obstetrical hemorrhage by providing education to health care professionals regarding faster recognition and response. OB hemorrhage has been identified as a complication of deliveries for which the consequences may be mitigated if recognized and treated sooner. The DPQC has spent the last two years, addressing the response to obstetrical hemorrhages with the goal of preventing or decreasing the severity of OBH in Delaware and as such contributing to reductions in severe maternal morbidity (SMM).
The most important offense is a good defense. The DPQC has supported hospitals in the creation and training of staff in the implementation of OB hemorrhage carts. These carts are portable so that they can be wheeled to the patient’s bedside, operating room or wherever a patient may be when a crisis is anticipated. The carts contain supplies necessary to act quickly to contain, treat and “stay ahead” of the hemorrhage whenever possible. Not all hemorrhages are preventable, but when early signs are recognized, health care workers can respond swiftly before the hemorrhage becomes severe. If they do become severe, the hemorrhage carts are stocked with the appropriate supplies to stabilize or manage the hemorrhage long enough to get the patient to the operating room or the ICU.
Just having the hemorrhage carts isn’t enough. Early in 2019, the DPQC sponsored a state wide educational initiative of a “Train the Trainer” event, hosted by Christiana Care. Each birthing facility in Delaware, including the birth Center, sent representatives from the bedside, including physicians, midwives and nurses, to learn about emergency management of hemorrhage and other life-threatening complications of pregnancy and delivery. By having the training in the VEST center at CCHS, all participants were able to learn in both a lecture environment and then go into the high-tech simulation lab and put their skills into action. The interesting part of this training was that not only did the participants learn from the instructors, but they learned from each other, as each facility has different procedures in how to handle crisis situations. Smaller hospitals have different staff members play different roles in responding to the bedside and larger hospitals have more staff that respond, necessitating clear role delineations. The simulation training consisted of learning and operating within the roles of “Team Stepp”, where each respondent has a clearly defined job while working as a member of a multidisciplinary team. The goal of the “Train the Trainer” state-wide training, was for attendees to go back to their home facility and begin OB emergency response drills on their units utilizing what they learned and implementing the OB hemorrhage carts.
The DPQC has 10 “Key Elements” that they are working on concerning the OB Hemorrhage project. They are:
- OB Hemorrhage Carts
- Ob Risk Assessments, at the time of admission and 2 hours post-partum
- OB emergency alert announcements
- Train the Trainer simulation-based learning
- Create/Improve Massive Transfusion protocols
- Accurate calculation of blood loss
- Debriefings
- Improving communication when patient changes hands (hand-offs)
- Consistent data collection
- OBH champions in each hospital
Since the implementation of the OB hemorrhage project, many of these key elements have been achieved or are being developed currently. Our tireless OB hemorrhage champions at each birthing facility work hand-in-hand with the DPQC and the multidisciplinary staff at their facility helping Delaware decrease the incidence and severity of OB hemorrhage, while protecting mothers and babies born in our state.
[1] Hussaini, SK. Severe Maternal Morbidity: Delaware, 2010-2014. Data Brief. Delaware Health and Social Services, Division of Public Health. Published August 2017.
[2] Centers for Disease Control and Prevention. Severe Maternal Morbidity. Available at https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html