Transcript Safety Action Series - California Maternal Quality Care Collaborative

Elliott Main, MD
Stanford University
California Maternal Quality
Care Collaborative
Maternal Deaths per 100,000 Live Births
Maternal Mortality Rate,
California and United States; 1999-2010
HP 2020 Objective – 11.4 Deaths per 100,000 Live Births
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤ 42
days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective
were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for
2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at
http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and
Adolescent Health Division, April, 2013.
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Maternal Mortality and Severe Morbidity
Approximate distributions, compiled from multiple studies
Mortality
Cause
(1-2 per
10,000)
ICU Admit Severe Morbid
(1-2 per
(1-2 per
1,000)
100)
VTE and AFE
15%
5%
2%
Infection
10%
5%
5%
Hemorrhage
15%
30%
45%
Preeclampsia
15%
30%
30%
Cardiac Disease
25%
20%
10%
Dominance of Provider QI Opportunities:
Hemorrhage and Preeclampsia
• California Pregnancy Associated Mortality Reviews
– Missed triggers/risk factors: abnormal vital signs, pain,
altered mental status/lack of planning for at risk patients
– Underutilization
of key
and treatments
Present
inmedications
>95% of cases
– Difficulties getting physician to the bedside
– “Location of care” issues involving Postpartum, ED and PACU
• University of Illinois Regional Perinatal Network
- Failure to identify high-risk status
- IncompletePresent
or inappropriate
management
in >90%
of cases
CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR):
Report from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC.org)
Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with
severity. Am J Obstet Gynecol 2004; 191: 939-44.
Federal
(MCH-B, CDC,
CMS/CMMI)
Obstetricians
(ACOG/SMFM/
ACOOG)
Nurses
(AWHONN)
Midwives
(ACNM)
Family Practice
(AAFP)
OB Anesthesia
(SOAP)
Maternal
Safety
Blood Banks
(AABC)
Hospitals
(AHA, VHA)
Perinatal Quality
Collaboratives
(many)
State
(AMCHP, ASTHO,
MCH)
Nurse
Practitioners
(NPWH)
Birthing Centers
(AABC)
Direct Providers
Safety,
Credentials
(TJC)
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123(5):973-977, May 2014
4 Domains: OB Hemorrhage
Patient Safety Bundle
• Improve readiness to hemorrhage by identifying
standardized protocols (general and massive)
• Improve recognition of OB hemorrhage by
performing on-going objective quantification of
actual blood loss
• Improve response to hemorrhage by utilizing unitstandard, stage-based, obstetric hemorrhage
emergency management plans with checklists
• Improve reporting/systems learning of OB
hemorrhage by performing regular on-site multiprofessional hemorrhage drills
Obstetric Hemorrhage Key Elements
Readiness - Every Unit
1.
2.
3.
4.
5.
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)
Obstetric Hemorrhage Key Elements
Recognition - Every Patient
5. Assessment of hemorrhage risk (prenatal, on
admission, and at other appropriate times)
6. Measurement of cumulative blood loss
(formal, as quantitative as possible)
7. Active management of the 3rd stage of labor
(routine use of oxytocin)
Obstetric Hemorrhage Key Elements
Response - Every Hemorrhage
9. Unit-standard, stage-based,
obstetric hemorrhage
emergency management
plan with checklists
10.Support program for
patients, families, and staff
for all significant
hemorrhages
Obstetric Hemorrhage Key Elements
Reporting/Systems Learning - Every Unit
11. Establish a culture of huddles for high risk
patients and post-event debriefs to identify
successes and opportunities
12.Multidisciplinary review of serious
hemorrhages for systems issues
13. Monitor outcomes and process metrics in
perinatal quality improvement (QI)
committee
4 Keys
• Have a “Safety Bundle”
• “Standard Work”—Check list for putting
the bundle into action
• Practice (drills)
• Feedback and tweaking (debriefs and
formal case reviews
Key OB Hemorrhage QI Toolkits:
Full of Resources
www.CMQCC.org
www.pphproject.org
v2.0 available soon
www.safehealthcareforeverywoman.org
Large-Scale Implementation
How do we reach EVERY hospital in the CA?
Engage every Professional organization
State-level groups
Engage every Hospital organization
The Joint Commission
CMMI: Hospital Engagement Networks
State Agencies
State Maternal Quality Collaborative
Different models of QI (mentoring)
Things to Remember
• The development of a multidisciplinary taskforce
with physician and nursing champions from OB,
anesthesia, and blood bank is critical for success
• Don’t reinvent the wheel – use available resources to
help develop and implement your hospital’s
individualized response plan
• Simulation is a great way to educate, practice new
behaviors and test your infrastructure – make time
for it
• Debriefings are critical for continuous quality
improvement and effective debriefing is a skill that
needs to be taught and practiced
Maternal Deaths per 100,000 Live Births
Maternal Mortality Rate,
California and United States; 1999-2010
HP 2020 Objective – 11.4 Deaths per 100,000 Live Births
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤ 42
days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective
were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for
2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at
http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and
Adolescent Health Division, April, 2013.
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