Jeanne

Mahoney, RN BSN
Senior Director, ACOG
Director, AIM Project

Elliott Main, MD
Medical Director, CMQCC
Implementation Director, AIM Project
 US Maternal Mortality Rates Using Death Certificates
(NCHS) or using Case Reviews by CDC PMSS
20
Mortality Rate (per 100,000 Live births)

19
18
17
16 16
15
14
14.5

12
11.5 11.5
10
9
8 8
7.5
6

4
1987-1990 1991-1997 1998-2005 2006-2010 2011-2013
MMR (NCHS Death Certificate) MMR (CDC PMSS)
The US has the
highest Maternal
Mortality rate of
any high resource
country and the
only country
outside of
Afghanistan and
Sudan where the
rate is rising.

(CDC, Gates Foundation)

July 17, 2015
 The U.S. has the worst rate of maternal deaths in the
developed world, and 60 percent are preventable

Propublica
The Last Person Youd Expect to Die
in Childbirth
Lauren Bloomstein, a neonatal nurse,
died from preeclampsia in the hospital
where she worked, and illustrates the
need for focus.

Why are more

American women
dying after childbirth?
PBS NewsHour
August 18, 2017
AIM Goals:
Reduce maternal mortality by 1,000 deaths
Reduce severe maternal morbidity by
100,000 cases

By:
Promoting safe maternal care for every US birth.
Engaging multidisciplinary partners at the national, state
and hospital levels.
Developing and implementing evidence-based maternal
safety bundles.
Utilizing data-driven quality improvement strategies.
Aligning existing safety efforts and developing/collecting
resources.
Funded through HRSA (federal) Maternal and Child Health Bureau
with a cooperative agreement
Such an effort requires
National Mobilization!
AIM Naitional Partners:
Professional Organizations Public Health Organizations
Am. Academy of Family Physicians Assoc. Maternal and Child Health
(AAFP) Programs (AMCHP)
Am. College of Nurse Midwives Assoc. of State and Territorial Health
(ACNM) Officers (ASTHO)
Am. College of Obstetricians and Maternal and Child Health
Gynecologists (ACOG) Bureau/HRSA (MCHB)
Assoc. of Womens Health, Centers for Disease Control and
Obstetric, & Neonatal Nurses Prevention (CDC)
(AWHONN)
Nurse Practitioners in Womens City MatCH
Health (NPWH)
Society for Maternal/Fetal Centers for Medicare and Medicaid
Medicine (SMFM) Innovation
Society for Obstetric Anesthesia National Healthy Start Association
and Perinatology (SOAP)
AIM Partners (cont):
Other Quality Improvement Organizations
Am. Society of Health Risk Management (ASHRM)
California Maternal Quality Care Collaborative (CMQCC)
HealthStream

Institute for Healthcare Innovation (IHI)

March of Dimes (MOD)

National Perinatal Information Center (NPIC)

Preeclampsia Foundation

Premier, Inc.
The Joint Commission (TJC)
Trinity Health Care
 Examples of AIM National
Partners Contributions
ACOG Hosts national staff and meetings, Highlighted at national
and district meetings, MD leadership for every state, national
education and lobbying efforts
AWHONN Postpartum discharge teaching; AIM highlighted
throughout Annual Meeting; monthly calls with state nursing leaders.
ACNM Birthtools web info, Leadership on Supporting Intended
Vaginal Birth bundle; AIM at annual meeting.
AMCHP Maternal mortality review web tools; AIM breakout at
annual meeting. Engage and support state MCH sections
ASTHO Engages state health officers to provide support. AIM
discussed at bi-monthly calls.
AAFP Content on bundle work groups and consultation for rural
state issues.
ABOG Maintenance of Certification credit for MDs working on AIM
SOAP Consultation on bundle implementation and disparities
SMFM M in MFM annual meeting; leadership and mentorship on
state teams. Annual sessions on OB QI and populaiton health
 AIM Works at National,
State, and Facility Levels

National PH and Perinatal Collaborative: Hospitals, Providers,

Professional DPH, Hospital Assoc., Nurses, Offices
Organizations Professional Groups and Patients
Engage/coordinate Support/coordinate Create QI team
national partners hospital efforts Implement bundles
and resources Share tools, resources, Share best practices
Develop QI tools and best practices Collect structure
Support multi-state Use state data for and process metrics
data platform outcome metrics Review progress
Support inter-state Share and interpret
collaboration progress
 The Core Principle
of AIM is Sharing:

State to State
Hospital to Hospital

Best Practices
Implementation Tools
Strategies for Overcoming Barriers
 AIM Participation: July 2017
AIM Impact
Annual Births:
1,520,000+

(11+)

AIM Hospital Networks

Premier
Trinity
National Perinatal (8+)
Information Center (NPIC)
 Potential AIM Collective Impact
11 Current AIM States 1,520,000 Annual Births
+21 NEW AIM States 1,241,200 Annual Births
32 States 2,761,200 Annual Births

AIM Hospital Networks

Premier
Trinity
National Perinatal
Information Center (NPIC)
 Maternal Safety Bundles
What are they?
Checklist of items and
practices for every birthing site
Not a national protocol !!
Facilities will modify content
based on local resources
Uniform Structure:
Readiness
Every unitprepare and educate
Recognition & Prevention
Every patientbefore event
Response
Every Eventteam approach
Reporting/Systems Learning Available at:
Every unitsystems safehealthcareforeverywoman.org
improvement with resource links
 AIM Safety/Quality
Improvement Bundles
Severe
Obstetric
Safety Hemorrhage
Hypertension Just Released
in Pregnancy
Bundles Obstetric Care of
s Maternal Safe Reduction Women with Opioid
VTE of Primary Dependence
Prevention Cesarean Births

Maternal Early
Warning For Reducing
Postpartum Care
Safety Criteria Every Disparities in
Basics
Maternity Care
Tools SMM Case Mother
Review Forms Interconception
Maternal Mental
Care
Patient, Family Health
Coming Soon
and Staff Support
16

www.safehealthcareforeverywoman.org
Creating multi-disciplinary national
consensus Safety Bundles is
actually the easy part

Implementation is the hard part!

Goal: Move established guidelines into
practice with a standardized approach
localized for each facility
AIM Implementation Efforts
Support state teams
Monthly and ad hoc calls with team members
Creating the collaborative of collaboratives among
state teams
Clinical and data technical assistance
Identify and address common issues Examples:
Protocols for treating severe HTN
Shortages of critical pharmaceuticals
Supporting quantification of blood loss
Implementation (How-To) Tool Kits
E-modules
Resource platform
Safety Action Webinars
Implementation
Package

Cross-Bundle Help

Bundle Specific
Obstet Gynecol. 2015 126:155

AIM eModules
 Thank You!
Jeanne Mahoney, RN
AIM Program Director
Email: jmahoney@acog.org

Deidre McDaniel, MSW, LCSW

AIM Program Manager: MD, DC, VA, W. VA, NC, GA
(ACOG District IV)
Email: dmcdaniel@acog.org

Kisha Semenuk, MSN, RN

AIM Program Manager: OK, LA, MI, FL, IL, MS, NJ, UT, CA
(AIM Cohort I)
Email: ksemenuk@acog.org

Elliott Main, MD
AIM Implementation Director
Email: emain@stanford.edu
 Obstetric Safety 101:
Implementing the
Hemorrhage Bundle

Elliott K. Main, MD
Medical Director, CMQCC
 Objectives

1. List the key elements of AIM Obstetric Bundle

2. Recognize the sticky points within the bundle
3. Understand the implementation lessons from
other collaboratives
4. Know where to go for help and further
resources
 Maternal Mortality and Severe Morbidity
Underlying causes, compiled from multiple studies

Mortality ICU Admit Severe Morbid

Cause (1-2 per (1-2 per (1-2 per
10,000) 1,000) 100)

VTE and AFE 15% 5% 2%

Infection 10% 5% 5%

Hemorrhage 10-15% 35% 55%

Preeclampsia 15% 25% 25%

Cardiac Disease 25% 15% 5%

23
 Maternal Mortality Rate,
California and United States; 1999-2013

California: ~500,000 annual births, 1/8 of all US births

24.0
California Rate 22.0
21.0
Maternal Deaths per 100,000 Live Births

19.3
United States Rate 16.9
18.0 16.6 19.9
15.5 16.9
15.1
14.6
15.0 13.1 14.0
12.7
10.9 11.6
12.0 10.0 13.3
9.9 9.9 12.1
11.8 11.7 9.2
11.1
9.0 9.8 9.7 7.4
8.9 7.3
6.0 7.7
6.2

3.0 HP 2020 Objective 11.4 Deaths per 100,000 Live Births

0.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for
California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data
and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007
only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon
March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March,
2015.
 Obstetric Hemorrhage and
Preeclampsia: Overview
n Most common preventable causes of
maternal mortality (70-90%)
n Far and away the most common causes of
Severe Maternal Morbidity (80%)
n High rates of provider quality improvement
opportunities (90%)
Obstet Gynecol. 2015 Jul;126(1):155-62
First Bundle:
July 2015

J Obstet Gynecol Neonatal Nurs.

2015 Jul;44(4):462-70.

Anesth Analg 2015;121:1428

26
J Midwifery Womens Health. 2015 Jul;60(4):458-64.
OB HEM
Bundle
Approved by Council
on Patient Safety and
posted on website.

Publication:
July 2015

Can be downloaded from

website with resource
links

Creating a
bundle is the
easy part

safehealthcareforeverywoman.org 27
Every
unit
OB Hemorrhage - Readiness
q Hemorrhage cart with supplies, checklist,
instruction cards and posters
q Immediate access to hemorrhage medications
q Establish a response team who to call when
help is needed
q Establish massive and emergency release
transfusion protocol/policies
q Unit education on processes, unit-based drills
(with debriefs)
 Just in Time Education

Put into the hands of doctors, midwives and nurses

key information at the moment of its use (Cart)
Response Education
Management Plan with checklist (reminders)
Uterotonic Medication Guide: pros and cons
How To Do: Steps to place an intrauterine balloon
How To Do: B-Lynch Suture
Blood Product Information
 Intrauterine Balloon Should be
First Step after Failure of Medical Therapy

n High success rate not different

than other approaches
n Low-tech, fast, inexpensive,
easy to utilize on any L&D Unit
----BUT NEED SOME PRACTICE
n Least morbidity of any next step
n Can be used as Tamponade Test to temporize,
determine needs and mobilize other resources

Doumouchtsis SK, et al Obstet Gynecol Surv 2007; 62: 540-7.

30 Dabelea V, Schultze PM, McDuffie RS Am J Perinatol 2007; 24: 359-64
 Tips for Cook Balloon
n Place a balloon early
n Needs several clinicians (MD/RN):
Uterine evaluation (filling), holding the balloon, instilling
fluidGood to practiceMD Skills Day!
n More fluid, not less
How much to fill? (150-500ml is a big range). Can
estimate the uterine volume bimanually --usually 250-
300ml is sufficient unless the uterus is very floppy
others recommend Ultrasound
n Vaginal packing is often useful, but
There can be hour-glassing of the balloon thru the
cervix into the vagina (esp. if more than 1-2cm dilated)
Remember to tie the kerlex to the tubing.
 B-Lynch Suture
n Every Obstetrician should know how to do
this (Recommend diagrams in each OR)
n Quick (<2 minutes) and easy!
n Ideal at time of Cesarean birth for atony
n Can be combined with an intrauterine
balloon for Sandwich technique
n BUT needs some practice

32
 B-Lynch Compression Suture
Belt and Suspenders

33
 Patient Level Readiness

Women with Placenta Accreta or Percreta

Women with inherited coagulation disorders
Jehovahs Witness
Informed Consent and Decline checklists,
Pregnancy planning guide
Iron Sucrose and Ferric Carboxymaltose
Protocols
 Every OB Hemorrhage
patient
Recognition & Prevention
Assessment (and communication) of hemorrhage risk:
prenatal, admission, 2nd Stage onset (opportunity for a
huddle to develop a full 2nd stage plan), and prior to
transfer to Postpartum unit. Integrate with general
assessment and planning.
Measurement of cumulative blood loss: formal, as
quantitative as possible; practical tips given for a variety
of techniques. NO MORE GLANCE AND GUESS
Active management of 3rd stage of labor: oxytocin is the
key component and should not interfere with delayed
cord clamping
California Partnership for Maternal Safety
 How to Quantify Blood Loss
Dont get stuck arguing about weighing every pad
and every clot (some folks have mastered this!)
Stick with the principles: Intentional and
Cumulative
Under-buttock drapes and suction canisters
Train to look and estimate pads and clots
Keep running EBL (cumulative), especially for
recovery/PP
Cumulative Blood Loss is a key component to the
plan
California Partnership for Maternal Safety
 Toolkit resource: Example
Risk Assessment

Some units have found it easier, cost-effective and time saving to Type and
Screen everyone (cross match the highest risk as above).

California Partnership for Maternal Safety

 Every
hemorrhage
OB Hemorrhage
Response
q Obstetric hemorrhage emergency
management plan
Unit-standard,
Includes Evaluation steps
Stage-based (dependent on QBL)
With checklists
q Support program for patients, families, and
staff for all significant hemorrhages
California Partnership for Maternal Safety 38
 Stage-Based Approach to PPH
Stage O All Births
>500 mL VD or >1000 mL CD
Stage 1
Brisk bleeding, large gush, large clots,
boggy uterus
Continued bleeding, VS instability or
Stage 2 symptomatic (mental status can be telling)
AND <1500 mL cumulative blood loss
Cumulative QBL> 1500 mL with bleeding
Stage 3 2 units PRBCs given
Coagulopathy suspected
 Example
Hemorrhage
Emergency
Response Plan

Tools are adapted

for each hospital's
resources

www.CMQCC.org
 CMQCC OB Hemorrhage
Care Guidelines

Can be posted on L&D or Placed

41 on the Charge Nurses Clipboard
California Partnership for Maternal Safety 42
Intervention Delay that increased risk for
severe hemorrhage

Oxytocin administration >10 minutes

Obstetrician present or >10 minutes
notified

Anesthesiologist present or >10 minutes

notified

Manual examination of the >20 minutes

uterine cavity

Driessen M et al., Obstet Gynecol 2011; 117:21-31

Importance of Protocols and Checklists creating
standardized approaches esp. for Emergencies

44
Importance of Protocols and Checklists creating
standardized approaches esp. for Emergencies

Importance of Drills and Debriefs 45

 Transfusion Criteria:
Are OB Patients Different?

n Small Blood Volume, less n Increased Blood Volume,

vascular tone
n Tolerate blood loss poorly,
with VS changes very
quickly
more vascular tone
n Tolerate blood loss well,
with VS changes masked
n to a point, then the floor
falls out
 Is OB Hemorrhage like other
Hemorrhages?
n What is a key difference for OB hemorrhage
compared to bleeding from:
Explosives or Auto accidents or GSW or
Ruptured Aortic Aneurisms?
n Placenta, placental implantation site,
(thromboplastin rich) and hemostatic
changes of pregnancy
n Much more likely to develop DIC featuring
low Fibrinogen and low Platelets
 Deciding to Transfuse:
Combination Logic
n EBL >1500?
EBL and even QBL are not perfect
n Vital Signs suggesting hypovolemia?
How much crystaloid is on board, is it barely
maintaining the BP? Good to a point
n Is the bleeding under control or continuing?
Any chance for concealed hemorrhage
Massive Transfusion vs Massive Confusion?

n Some are calling out for MTP to get blood quick

Need to have the ability to get 2 units in a a hurry
MTP is really for large losses when you need coag
factors at same time
n Exact components of the MTP package appear
less important
RBC:FFP ratio of 1:1 or 2:1 may not matter or even it
contains Platelets immediately
One MTP for the entire hospital
Likely only will use 1-2 times per thousand deliveries

n Bigger issue is small/rural hospitals

CMQCC TXA Recommendations for PPH
n TXA is not for prophylaxis or initial treatment
n Consider use after higher dose oxytocin/
methergine have been tried and before additional
drugs/procedures (after CMQCC Stage 1)
n Respect the dose: 1 gm IV may repeat in 30min x1
n Safety issues:
Task overloadneed to ensure that basic PPH tasks
are attended to
Potential for serious drug error, vial can be confused
with bupivicaine; intrathecal TXA injection is serious
Higher doses of TXA are associated with renal toxicity
 Be Wary of
Concealed Hemorrhage

n Intra-abdominal bleeding Post Cesarean

n Posterior Uterine Rupture
n Extension of Cervical or Vaginal Side-wall
Laceration

Extra, objective eyes are critical!

Practical
advice for
establishing
Patient
Family and
Staff support
on your unit:

Link on ACOG
home page, or:
www.safehealthcareforeverywoman.org
52
Every
unit
OB Hemorrhage
Reporting/Systems Learning
q Establish a culture of huddles for high risk
patients and post-event debriefs to identify
successes and opportunities
q Multidisciplinary review of significant
hemorrhages for systems issues
q Monitor outcomes and process metrics in
perinatal quality improvement committee
q Celebrate Great Team Responses!!
California Partnership for Maternal Safety 53
 How to Avoid the Twin Traps

n Better quantify blood lossits about

communications
n Have a PLAN! Call for Help!
n Dont ignore abnormal vital signs (or be fully
reassured by normal ones)
n Have rapid access to at least two units of blood
n Practice (drills) and learn from events
 First
Steps:
Prioritize-
pick Top 4

1. Early wins
2. Biggest
impacts
3. Not all can be
done quickly

Bundle elements
may need to be
adapted to fit
your resources
Localize
 Creating a Team For All Seasons

n OB Hemorrhage is the prototypic OB

emergency
n Many of the system changes are directly
applicable to other obstetric emergencies
n Active engagement of Anesthesiologists
n Creating the team and systems to
implement hemorrhage project makes other
OB QI projects easier and more successful
 Maternal Mortality Rate,
California and United States; 1999-2013

California: ~500,000 annual births, 1/8 of all US births

24.0
California Rate 22.0
21.0
Maternal Deaths per 100,000 Live Births

19.3
United States Rate 16.9
18.0 16.6 19.9
15.5 16.9
15.1
14.6
15.0 13.1 14.0
12.7
10.9 11.6
12.0 10.0 13.3
9.9 9.9 12.1
11.8 11.7 9.2
11.1
9.0 9.8 9.7 7.4
8.9 7.3
6.0 7.7
6.2

3.0 HP 2020 Objective 11.4 Deaths per 100,000 Live Births

0.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for
California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data
and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007
only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon
March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March,
2015.
 Maternal Mortality Rate,
California and United States; 1999-2013

24.0
California Rate 22.0
21.0
Maternal Deaths per 100,000 Live Births

19.3
United States Rate 16.9
18.0 16.6 19.9
15.5 16.9
15.1
14.6
15.0 13.1 14.0
12.7
10.9 11.6
12.0 10.0 13.3
9.9 9.9 12.1
11.8 11.7 9.2
11.1
9.0 9.8 9.7 7.4
8.9 7.3
6.0 7.7
6.2

3.0 HP 2020 Objective 11.4 Deaths per 100,000 Live Births

0.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2013. Maternal mortality for
California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data
and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007
only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at http://wonder.cdc.govon
March 11, 2015. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, March,
2015.
Improving Maternity Outcomes
Through Collaboration
Implementation
Package

Cross-Bundle Help

Bundle Specific
Obstet Gynecol. 2015 126:155

AIM eModules
 Hemorrhage
Toolkits
265pp

25pp 60pp