Lessons Learned From a Gap Analysis of Obstetric Hemorrhage Protocols across a Health System
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Lessons Learned From a Gap Analysis of Obstetric Hemorrhage Protocols across a Health System Francis M. Hacker1 · Faina Linkov1,2,3 · Allison E. Serra1 · Vivian Petticord1 · Mary T. Zabielski1 · Hyagriv N. Simhan1,2 · Sara B. Sakamoto1 Accepted: 6 November 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Introduction The United States has experienced a rising incidence of maternal deaths, including those attributable to obstetric hemorrhage (OBH). In response, the National Partnership for Maternal Safety developed a standardized OBH Consensus Bundle with the goal of universal adoption. In 2016 a large western Pennsylvania health system adopted the OBH Consensus Bundle across its 8 obstetrical units, with the goal to improve maternal outcomes. Methods Gap analysis was used to identify differences between existing OBH protocols and the OBH Consensus Bundle from January to June 2016. Identified gaps as well as existing practices of success were used to systematically develop and implement a standardized system-wide OBH improvement initiative. Hospitals were then categorized by annual birth volume as high (> 2000), medium (500–2000), and low ( 2000 annual births), medium (500–2000 annual births), and low ( 2000 births), medium (500–2000 births), and low ( 1500 mL. This threshold was chosen to ensure that significant events were included but limiting the amount to a feasible number of cases that could be reviewed. Findings identified that may improve future outcomes would be summarized with recommendations for changes, and shared throughout the health system. Five of 8 hospitals were monitoring and recording outcomes and process metrics, though not uniformly (element 13). To assist in accurately recording hemorrhage cases, the working group collaborated with systems analytics to build ICD-10 codes into the hemorrhage documentation forms. A systems analyst created a dashboard to track pertinent aspects of OBH including admission hemoglobin, transfusion, uterine tamponade balloon insertion, utilization of cell salvage, uterine artery embolization, return to the OR, ICU admission, QBL documentation, and OBH risk. The intent is to use this information to track outcomes and identify areas for improvement. Following this initial granular analysis, system-wide protocols were formulated summarizing the gaps that were most prevalent throughout the hospitals and organized by domains (Table 3). The working group emphasized these gaps during meetings and site visits. To achieve buy in, system-wide memos were generated, site visits were performed by members of the working group, and grand rounds at the teaching hospital were conducted
Maternal and Child Health Journal Table 3 Obstetric hemorrhage protocol system-wide actions Readiness
Recognition & prevention
Response Reporting & system learning
Standardized hemorrhage carts on all inpatient units including checklists Hemorrhage kits with standardized drugs and dosing charts Obstetric rapid response teams established Stand
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