OB Harm Initiative Webinar July 9, 2014

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Sharon Burnett Vice President of Clinical and Regulatory Affairs Missouri Hospital Association

Webinar Objectives

Provide an update on regulations and legislation applicable to OBs Provide an overview of lessons learned at the OB Harm regional

workshops Feature successes and lessons learned—including barriers and

strategies to overcome them—from the efforts of early adopters Provide information on upcoming events and deadlines

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Homestretch of Reducing EEDs

Hospital reported data for 2014 EED rate is .07%! If you haven’t gone far enough to reduce EEDs,

http://health.usf.edu/publichealth/chiles/fpqc/eed Early Elective Delivery No Payment Rule Final published July 15,

effective Sept. 1 STR Codes and Diagnosis and MO HealthNet Draft Bulletin

http://web.mhanet.com/mha-constituency-groups

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Other Regulatory and Legislative Updates

CCHD – Screening required by law 1/1/2014. Reporting voluntary now using DHSS form until reporting rules written. DHSS plans to collect data via HL7 interface in the future. http://health.mo.gov/living/families/genetics/birthdefects/cchd.php

Donor Milk Payment - Requires the MO HealthNet to reimburse hospitals for donor human milk provided to critically ill infants under three months of age in the neonatal intensive care unit. (SB 680, SB 754) Signed by Governor

Umbilical Cord Blood Bank - Beginning July 1, 2015, DHSS to transport collected, donated umbilical cord blood samples from approved collection sites to a nonprofit umbilical cord blood bank located in St. Louis City. (SB 716, 567 and 754) Delivered to Governor

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Other Regulatory and Legislative Updates

HB 2010 authorizes additional state funding to expand the newborn testing courier service to additional sites and Saturday pickup. Vetoed by Governor

Not enacted HB 1898, SB 716 to create Perinatal Advisory Council to define neonatal and maternal care regions and levels

Not enacted HB 1807 to require hospitals to designate responsible person and tract collection and transport of newborn blood samples

Missouri Task Force on Prematurity and Infant Mortality Report. http://media.wix.com/ugd/79d087_21e483ed0539428c8a35c2d627a759a5.pdf. Interim workgroup established

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Pre-Work!

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What I Learned Along The Way!

5 sites 140 attendees 9 physicians 43 hospitals

How Do You Get Started?

JUST DO IT! 8

No documentation of actual blood loss past the delivery record

Under estimation of blood loss Lack of equipment and proper

use if available Delay in communication to

team players Delay in gathering equipment

once emergency began Lack of an organized approach

Freeman Health System 9

Post-Partum Hemorrhage Risk Assessment

HEMORRHAGE EDUCATION, ASSESSMENT AND PLANNING

Staff education: hemorrhage skills lab and communication Risk assessment: Two pathways to identify our patients at high risk for maternal hemorrhage:

Prenatal clinic sending over patient records: flagging chart in red folder Admission nursing assessment: flagging chart with red clipboard & blood charm

Planning for high risk: Type and screen vs. type and cross, hemorrhage cart outside door, hemorrhage medication

kit in McKesson dispensers

Lake Regional Health System 11

A

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• Ongoing email communications • Education on Bakri balloon insertion and rapid installation

provided by Cook Medical for nurses and physicians. • Presentations at staff meeting of PPH cart. • “Scavenger Hunt” in the cart • Videos and quizzes • Mock PPH drill scenarios began with staff • Go Live scheduled after 95% of nursing staff completed education. • Postpartum Hemorrhage Order set provided framework for prompt initiation of appropriate clinical management.

•Examples are in your handouts

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What Is Wrong With This Picture

– Rest for ≥ 10 mins. – Bare arm, patient seated, feet

on the floor, not pushing – Correct cuff size, cover 80% of

arm, cuff at level of heart, no side lying BPs

– 2 BPs, 4 hours apart to make diagnosis

– Repeat ≥ 15 mins if BP> 160 SBP or >110 DBP

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You Have to Have….

Effective Escalation

Policy

Maternal Early

Warning Criteria

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Prompt Bedside

Evaluation

Prompt Reporting

Maternal Early Warning Criteria • Systolic BP; mmHg <90 or >160 • Diastolic BP; mmHg >100 • Heart rate; beats per min <50 or >120 • Respiratory rate; <10 or >30 breaths per min • Oxygen saturation; % <95 room air, sea level • Oliguria; <30 mL/hr for 2 hours

Maternal agitation, confusion, or unresponsiveness Patient with hypertension reporting a non-remitting headache

or shortness of breath

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Effective Escalation Policy

An abnormal parameter requires: 1. Prompt reporting to a physician or other qualified clinician 2. Prompt bedside evaluation by a physician or other qualified

clinician with the ability to activate resources in order to initiate emergency diagnostic and therapeutic interventions as needed. Who are you going to call next?

3. Plan for and implementation of diagnostic work-up 4. Close follow up by senior provider of patient’s status until: Abnormality resolves, or Parameter judged to be of benign etiology, or Patient is determined to be potentially critically ill and care

is escalated (rapid response, higher acuity setting)

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Treatment of Blood Pressure greater than or equal to 160/xx OR xx/110: Position: semi-fowlers; cuff at level of heart; displace uterus

BP ≥ 160/xx or xx/110? May recheck with manual cuff* in 10 minutes

*(for verification)

Recommend: Recheck every

30 minutes.

Primary RN Notify OB of BP

Notify Charge RN

OB Provider

• Order IV push labetalol or

hydralazine * • Admit patient

Remains

≥ 160/xx or xx/110?

30-60 min timeframe begins

yes

• Difficult IV start, > 30-60 mins? Give PO nifedipine 10 mg for first med dose.

• Does Patient meet criteria for severe preeclampsia? Magnesium Sulfate 4gm

loading dose.

*MED NOTES: Labetalol IVP:

Peak response within 5 minutes *Requires continuous pulse

oximetry monitoring in L & D; *Requires cardiac monitoring on

M/B Unit – contact Mgr re equip/staff. Contraindicated: Bronchial Asthma or

Heart Block Hydralazine IVP:

Onset: 5-15 min Peak response: 10-80 min Contraindicated: Mitral Valvular

disease

and

Rev 2/7/14

no

then

• Start IV and draw Labs • Recommend IVP med* within 30-60 min of 2nd BP • Monitor BP q 5 min ◊

• Monitor EFM • Admit patient

consider ◊ Recommend: Continue BPs

q 5 min. until BPs remain less than 160/xx or xx/110, then may repeat

BP measurement • every 10 mins for 1 hour,

• then every 15 mins for 1 hour, • then every 30 mins for 1 hour,

• and then every hour for 4 hours. 20

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Preeclampsia Can Have Devastating Consequences

11-12% of all premature births—is from preeclampsia and other hypertensive disorders of pregnancy Preeclampsia increases risk of neonatal and maternal death,

stroke for life Importance of educating ED and clinic staff of S&S of

preeclampsia Importance of educating mothers and family - low awareness of

some of the specific symptoms such as headache and vision changes, that risk continues after baby is delivered

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Education and Training

MHA -- http://web.mhanet.com/mha-constituency-groups University of Oxford -- An interactive course for health

professionals, The Evidence-Based Management of Pre-eclampsia and Eclampsia http://www.gfmer.ch/SRH-Course-2010/pre-eclampsia-University-of-Oxford/index.htm Sharing and Caring: A Perinatal Loss Seminar, September 5 - 7,

2014 St. Charles, MO, For registration information, visit http://www.nationalshare.org/sharing-caring.html

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Maternal Hemorrhage Team Update

Beverly Koenig, MSN-C Nurse Manager/Obstetrics Service Perry County Memorial Hospital

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Preeclampsia Team Update

Rhonda Donnelly, RNC Nurse Manager L&D CoxHealth

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Next Steps

Save the date for next webinar, August 20, noon Enter EED data and OB hemorrhage measures (massive and total

OB blood transfusions) into CDS Set a team meeting date Create a staff education poster or resource Talk to senior management and OB physicians about the work

you are doing or contemplating

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