Department of Obstetrics and Gynecology PPH: We don’t need NO stinkin’ blood! June 11, 2015

Background Postpartum hemorrhage is a leading cause of maternal mortality. Several morbidity events at St. Joseph Medical Center led to our focus on this problem.

Lots of places to record EBL Lots of handoffs with no EBL Lots of opportunities to treat Few opportunities to diagnosis Cum EBL not calculated to measure Cum EBL not visible EBL hard Protocols unclear Safety net too late More accurate and timely collection of EBL data Real-time cum EBL running total – highly visible Robust protocol with clear triggers Ultimately, 95% of our Vag pts will be below the 15% trigger Methodology

Walk the process

What we had to fix 1.Many places to record EBL 2.Handoffs without EBL included 3.Many opportunities to treat 4.Few opportunities to diagnose

Highlights of implementation Interventions Standardized :  Timing of postpartum oxytocin  Timing of postpartum hemoglobin Assembled PPH carts Developed intervention algorithm Developed massive transfusion protocol

Highlights of implementation Quantification of blood loss Purchased scales for every room in L&D and postpartum floor Purchased graduated drapes for vaginal deliveries Educated MDs and CNMs to announce EBL at both c/s and vaginal deliveries Educated nurses to teach patients re: need to weigh all peri-pads for the 1 st 24 hours

Highlights of implementation Communication Added blood loss entry to I’s +O’s in EMR Added EBL to communication tool for nursing handoff from L&D to postpartum

California Maternal Quality Care Collaborative Hemorrhage Task Force 2009

2013: transfusing 1+ pts per week. Now: transfusing 1 per month. Assuming $500 per RBC unit not given, from Jan 2014 to April 2015: estimated $45,500 saved.

Current state: sustainment Education of providers: Transfuse to symptomatic patients Transfuse single unit at a time Chart review: 100% of delivering patients receiving blood products Feedback to all providers and staff

Lessons learned Clinical  Change in perspective  “We measure everything else, why not blood?”  Change in process results in fewer surprises

Lessons learned Teamwork  Multidisciplinary approach including the day to day staff  Involvement in creating the solution engenders enthusiasm and buy in  Standardized approach and walking the process is profoundly valuable

Kelly Archer, RN L&D David Brinker, MD Blood Bank Advisory Chair Mary Beth Campbell, RN L&D Alice Cootauco, MD MFM Phi Duong, Blood Bank Tracey Duke, MD OB/GYN Lisa Everhart, RN Clinical Educator Maria Giachini, RN L&D Robin Harper, RN Postpartum Diane Interrante, RN Quality Nikki Koklanaris, MD MFM Mary Knauer, CNM Laurie Mathis, RN Postpartum Maureen Paul, Laboratory Charlie Rizzuto, MD Anesthesiology Nancy Stec, Blood Bank Karen Tomcho, RN Postpartum Judy Rossiter, MD Chief OB/GYN The PPH initiative team: it takes a village!