I N F OCUS CNE ABSTRACT. JOGNN, 47, ; /j.jogn

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1 I N F OCUS Continuing Nursing Education () Credit A total of 1.3 contact hours may be earned as credit for reading Interdisciplinary Skills Review Program to Improve Team Responses During Postpartum Hemorrhage and for completing an online posttest and evaluation. AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AWHONN holds a California BRN number, California Provider #CEP Correspondence Marianne Bittle, MSN, RNC-OB, Hospital of the University of Pennsylvania, Women s Health Department, Silverstein 8, 3400 Spruce St., Philadelphia, PA marianne.bittle@uphs. upenn.edu Keywords academic medical centers interdisciplinary morbidity and mortality obstetric emergency obstetric hemorrhage postpartum hemorrhage program evaluation quantification of blood loss skills station Interdisciplinary Skills Review Program to Improve Team Responses During Postpartum Hemorrhage Marianne Bittle, Kathleen O Rourke, and Sindhu K. Srinivas ABSTRACT Objective: To develop an interdisciplinary, interactive, skills review program to improve team responses during a postpartum hemorrhage (PPH). Design: Online didactic modules in combination with an interdisciplinary skills program consisting of seven hemorrhage-related stations. Setting/Local Problem: The project was conducted in the Women s Health Department in a quaternary-care Magnetand Baby Friendly designated academic medical center in Philadelphia, Pennsylvania. Women cared for at this center have comorbidities that place them at greater risk for PPH. A need was identified to implement a multidisciplinary and comprehensive program to assess hemorrhage risk and appropriately recognize and intervene with all PPHs in this setting. Participants: The 276 participants, including registered nurses, obstetric and family medicine attending physicians and residents, advanced practice nurses, and ancillary staff in the hospital s Women s Health Department, completed the initial obstetric hemorrhage program. Intervention/Measurements: The program included online didactic modules, seven interdisciplinary skills stations led by trained nurses and providers, and an in situ simulation. Successful completion of the online modules was a prerequisite for participation in the skills stations. All participants completed a written program evaluation at the conclusion of the program. Results: Results of the postassessment survey indicated that participants rated the program 3.94 of 4.00 for overall effectiveness to improve interdisciplinary team responses to PPH. Comments were overwhelmingly positive, and participants expressed increased confidence and knowledge related to PPH after completion of the program. Conclusion: An interdisciplinary program that included online didactic modules, interactive skills stations, and simulation improved team confidence and responses to PPH. JOGNN, 47, ; Accepted September 2017 MarianneBittle,MSN,RNC- OB, is a clinical practice leader, Silverstein 8, Hospital of the University of Pennsylvania, Philadelphia, PA. (Continued) The authors and planners for this activity report no conflict of interest or relevant financial relationships. No commercial support was received for this educational activity. Problem Description Postpartum hemorrhage (PPH) is a significant obstetric emergency and a leading cause of maternal morbidity and mortality worldwide despite the fact that it is often preventable and treatable (Goffman, Nathan, & Chazotte, 2016). In Africa and Asia, approximately one third of all pregnancy-related deaths are caused by PPH (Sheldon et al., 2014, World Health Organization, 2004); in the United States, approximately 11% to 12% of maternal deaths are caused by PPH (Creanga et al., 2015, Goffman et al., 2016). From analysis of a large, comparative data set from the United States, one group of researchers reported that during the time period studied (1999 to 2008), the rate of PPH increased from 1.9 to 4.2 per 1,000 births (D Alton et al., 2014). Creanga (2017) reviewed population-based data published from 2011 to 2013 and found that 11.4% of pregnancy-related deaths were the result of hemorrhage. Available Knowledge Recognition of the need to reduce maternal mortality and morbidity rates in the United States led to the creation of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women s Health Care (D Alton et al., 2014). From this national partnership, numerous maternal safety bundles have 254 ª 2018 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

2 Bittle, M., O Rourke, K., and Srinivas, S. K. I N F OCUS been developed to address issues including venous thromboembolism, mental health, severe hypertension in pregnancy, and obstetric hemorrhage (Council on Patient Safety in Women s Health Care, 2014). The implementation of an obstetric hemorrhage safety bundle is necessary to prevent PPH and to help staff to proactively respond in the event that PPH does occur. The four key components of the obstetric hemorrhage safety bundle are Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning (Main et al., 2015). Nurses and physicians who care for women during the intrapartum and postpartum periods need the knowledge and skills to respond to clinical emergencies such as PPH. Prevention of adverse outcomes as a result of PPH is dependent on the ability of health care providers to recognize risk factors, identify abnormal bleeding, and initiate appropriate clinical interventions (Troiano, Harvey, & Chez, 2013). All health care providers who care for women in the obstetric setting should be prepared to identify and respond appropriately to this complication of pregnancy because PPH is a potentially life-threatening emergency (Troiano et al., 2013). Local Problem As a quaternary-care, 789-bed, Magnetdesignated academic medical center, the Hospital of the University of Pennsylvania has more than 4,100 births per year. Baby Friendly designated patient care areas within the Women s Health Department include the labor and delivery unit, Perinatal Evaluation Center for obstetric triage, mother baby unit, NICU, and a gynecology/oncology unit. The labor and delivery unit has 13 labor and delivery rooms, 3 perinatal operating rooms, and a 2-bed postanesthesia care unit. In the Perinatal Evaluation Center, an average of 800 pregnant women are triaged each month. Couplet nursing care is provided in the 33-bed mother baby unit, and frail newborns are cared for in the 36-bed Level III NICU. Additionally, in the 27-bed gynecology/oncology women s health unit, comprehensive care is provided for newborns and women across the health continuum, including the antepartum and postpartum periods. The Hospital of the University of Pennsylvania serves a disadvantaged urban community and is used regionally as a referral center for pregnant women at high risk for adverse outcomes; these women have comorbidities that place them at higher risk for PPH, such as multiparity, chronic anemia, prior Maternity care providers need knowledge and skills to respond immediately and effectively to postpartum hemorrhage. caesarean birth, and uterine surgery. Rates of PPH in fiscal years 2014, 2015, and 2016 were 3.0%, 4.6%, and 6.0%, respectively. In response to the National Partnership for Maternal Safety s Call to Action (D Alton et al., 2014), a review of local hemorrhage cases, and the need for systems-based improvements, we undertook a quality improvement (QI) project to develop a standard hemorrhage protocol for women in the antepartum and postpartum periods and implemented a multidisciplinary comprehensive program to assess hemorrhage risk and appropriately recognize and intervene for all PPHs that occur in our facilities. Rationale for Intended Improvement The ability to recognize, intervene appropriately, and respond in a timely manner during PPH was identified as a critical learning need during shift huddles, staff meetings, and open forums with nurse leaders in the Women s Health Department. We learned that members of the nursing staff had feelings of fear and lacked confidence in responding to PPH, especially those who had no prior experience. The current practice of discussion and verbal review of the PPH protocol was insufficient to adequately prepare staff and lacked any didactic or skills training. Staff learned through trial by fire at the bedside, which could be traumatic for practitioners and carried a potential risk of increased morbidity for the woman. A number of studies and QI projects show the benefit of interdisciplinary education about PPH (Burke, Grobman, & Miller, 2013; Einerson, Miller, & Grobman, 2015; The Joint Commission, 2004). Interdisciplinary team training is a common strategy to improve team processes and is associated with improvements in patient safety outcomes (Weaver, Dy, & Rosen, 2014). The Joint Commission (2004) recommended the use of team training and clinical drills for serious clinical events such as PPH. Team training is periodically paired with simulation training, such as task-level training, which is focused on performance of particular skills, or clinical context simulation, in which participants make decisions that are based on clinical assessments (Utz, Kana, & Van der Broek, 2015). Overall, the use of obstetric skills training and simulation drills can increase the Kathleen O Rourke, MSN, RNC-OB, is a clinical practice leader in the Labor and Delivery/Perinatal Evaluation Center, Hospital of the University of Pennsylvania, Philadelphia, PA. Sindhu K. Srinivas, MD, MSCE, is an associate professor, Director of Obstetrical Services, and Vice Chair for Quality and Safety in the Department of Obstetrics & Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA. JOGNN 2018; Vol. 47, Issue 2 255

3 I N F OCUS Program to Improve Team Responses During PPH The ability to recognize, intervene appropriately, and respond in a timely manner during a postpartum hemorrhage was identified as a critical learning need. confidence and competency of staff and improve response, assessment, and treatment of PPH (Kominiarek et al., 2017; Marshall, Vanderhoeven, Eden, Segal, & Guise, 2015; Utz et al., 2015). In some training programs, PPH skills are incorporated within other obstetric emergency trainings, whereas in others, the trainings are very specific for PPH. These programs may include didactic content, task-level skills training, or simulation, but not all components, and none of the PPH training programs that we identified in the literature included ancillary personnel as learners. For this reason, we decided that an extensive multidisciplinary program required for professional and support staff that included a didactic prerequisite, interactive skills training stations, and a simulation with a debriefing component would be the most comprehensive and effective. Specific Aim The specific aim for this project was to improve the team s application of knowledge during PPH through the provision of an interdisciplinary staff PPH education program that included didactic and interactive components. The PPH program would serve as a sustainable educational model to allow for consistent training of all new and current staff. Methods Context for Planning the Intervention Our interdisciplinary team, including nurses, physicians, and quality and safety representatives, recognized the need for the proposed program and assembled with the goal to address antenatal and intrapartum risk assessment, improve real-time assessment of blood loss, centralize equipment, and review multidisciplinary policies to standardize responses to PPH. Program champions included nurse and physician leaders from the hospital s Women s Health Department, obstetric and family practice attending physicians and residents, and advanced practice nurses (APNs). The education intervention targeted all staff members within the Women s Health Department, including labor and delivery and postpartum nurses, obstetric and family medicine attending physicians and residents, attending and resident anesthesiologists, nurse-midwives, women s health nurse practitioners, and ancillary staff. The planning and implementation were interdisciplinary efforts in which all of these stakeholders were incorporated. The QI team members agreed that an evidence-based program that included all domains of learning would be most effective to increase knowledge and retention of learning. Planning considerations are outlined in Table 1. Online Modules The required components of the interdisciplinary educational intervention included completion of two online modules and attendance and participation in one skills session (see Table 2). The online modules were developed through a partnership with the hospital s Department of Professional Development, which provided an instructional designer and video and audio equipment and personnel to operate it. The two online modules, Classification and Etiology of Postpartum Hemorrhage and Quantification of Blood Loss in the Postpartum Patient, were prerequisites for participation in the skills session. Objectives for learners in the first online module included the following: to identify the different classifications of PPH, identify the etiology of PPH, review risk factors and reasons for PPH, and differentiate the various intervention methods used for PPH. This 12-minute module included didactic information, video simulation of a PPH, and review of the collaborative team approach to create and implement an effective plan of care, including appropriate use of uterotonic medications and procedural interventions. A virtual hospital room at the Penn Medicine Center for Innovation and Learning was used to film the simulated PPH. A 2-minute PPH simulation embedded within the module engaged participants to act out various roles as a woman who experiences PPH, a primary nurse, responding providers, and clinical nurses. The simulation was filmed using still-shot photography with recorded voice-over dialogue, and graphics were used to illustrate trends in vital signs that were overlaid on the slides to provide enhanced clinical information. The script was written by the QI team members and based on the National Partnership for Maternal Safety s obstetric hemorrhage safety bundle, which emphasizes interprofessional collaboration and communication, appropriate intervention based on patient response, and systematic quantification of blood loss (QBL; Council on Patient Safety in Women s Health 256 JOGNN, 47, ;

4 Bittle, M., O Rourke, K., and Srinivas, S. K. I N F OCUS Table 1: Planning Considerations for the Interdisciplinary Postpartum Hemorrhage Training Program Factor Time Time for planning Duration of each skills session Duration of complete program Time of day for offering Frequency of offerings Consider off-shift staff needs Related Issues Space Commitment in planning Equipment Personnel Budget/administration Availability of space (i.e., classroom, conference room) Proximity of space to participant s work site to maximize participation Consider noise level/privacy, especially if close to patient care areas Consider size of space, depending on station requirements If offering multiple sessions, consider securing space for the length of your program offering Account for setup and breakdown time of skills stations Ample notice to accommodate interdisciplinary schedules Consider ability of off-shift staff members to participate in planning Consider representation from each discipline Scheduling facilitators, room availability, advertising, collaboration with scheduling committees Leadership support from each discipline Low fidelity versus high fidelity for skills and simulation Audiovisual equipment requirements Information technology support requirements Furniture requirements needed; chairs, tables Consider using mocked-up, alternative equipment rather than borrowing unit-based equipment to maintain patient safety Consult other experts with experience in other clinical emergencies such as Rapid Response Team and Code Team Consider didactic prerequisite before participation Consider which disciplines will participate Decide curriculum for each participating discipline Consider facilitators from all professional disciplines Consider offering continuing education credits Consider time for continuing education application process Decide whether participation occurs during productive or nonproductive time Develop skills station tracking tools and program evaluations for each discipline Consider strategy to communicate participation as well as noncompliance Care, 2015). Multiple-choice questions at the end of the module were used to test for knowledge of the content. Objectives for the second online module were to define and identify the importance of QBL, compare estimation of blood loss to QBL, and identify the appropriate methods and tools for QBL. This interactive online module, completed at the learner s pace, highlighted a variety of topics related to the measurement of blood loss, including myths and facts about blood loss measurement in the postpartum unit and QBL in the operating room. The learner was also asked to drag and drop the correct estimated blood lost onto a virtual scale. A short video tutorial was embedded in the module to demonstrate how to weigh blood-soaked items to obtain the quantified blood lost. This live-action sequence was filmed within the hospital with the aid of a clinical nurse to demonstrate use of a scale for items soaked with an artificial blood product. Multiplechoice questions at the end of the module were used to test for knowledge of the content. JOGNN 2018; Vol. 47, Issue 2 257

5 I N F OCUS Program to Improve Team Responses During PPH Table 2: Postpartum Hemorrhage Skills Stations and Learning Objectives Skills Station SBAR, hemorrhage guidelines, and risk stratification Emergency response protocols Blood administration and exsanguination protocol Hemorrhage cart and uterotonic medications Quantification of blood loss Intrauterine tamponade balloon initiation B-Lynch suture and uterine tamponade balloon placement Learning Objective Accurately apply hemorrhage guidelines and risk assessment to a case example. Demonstrate appropriate interprofessional SBAR communication to a case example. Demonstrate appropriate actions for activating the emergency response system on each unit within the Women s Health Department. Identify and accurately match appropriate audible tone to level of emergency. Demonstrate ability to activate exsanguination protocol to request blood products and safely and accurately prepare a simulated blood product for administration through an infusion pump. Identify placement of key items in the hemorrhage cart and accurately and safely demonstrate preparation of commonly ordered uterotonic medications. Describe methods to quantify blood loss during a postpartum hemorrhage and demonstrate accurate blood loss measurement with the use of imitation blood products and standard hospital linens. Demonstrate setup of uterine tamponade balloon and accurately identify considerations related to placement and postremoval surveillance. Physician: Demonstrate placement of the uterine tamponade balloon after a cesarean birth. Demonstrate accurate use of the B-Lynch uterine suturing technique through the use of a low-fidelity, simulated uterine model. Nurse/obstetric technician: Understand indications for the use of the B-Lynch uterine suturing technique during cesarean birth and intrauterine placement of the uterine tamponade balloon during a cesarean birth. Describe postoperative nursing considerations for women with intrauterine tamponade balloon and B-Lynch suture placements. Note. SBAR ¼ Situation, Background, Assessment, Recommendation. Individual staff members had access to the online modules through the health system s online learning management system, and these modules were populated within the learning plan. The modules were considered to be complete when the learner obtained a minimum of 80% on the embedded multiple-choice quizzes. After successful completion of the modules, downloadable certificates were awarded and presented at the PPH skills session as evidence of completion. Ancillary staff members had access to the modules and were encouraged to view them; these staff members were not required to complete the modules as a prerequisite to attend the skills session, although many did complete them. After successful completion of the two assigned modules, staff attended one PPH skills session that consisted of seven stations and took approximately 1 hour to complete. Each station was allotted approximately 8 minutes for discussion, return demonstration, and response to questions. All stations were led by trained interdisciplinary health care providers. The seven stations included Situation, Background, Assessment, Recommendation (SBAR), hemorrhage guidelines, and risk stratification; emergency response protocols; blood administration and exsanguination protocol; hemorrhage cart and uterotonic medications; QBL; intrauterine tamponade balloon initiation; and B-Lynch suture procedure and intrauterine 258 JOGNN, 47, ;

6 Bittle, M., O Rourke, K., and Srinivas, S. K. I N F OCUS tamponade balloon placement. A role-specific skills validation checklist was signed by the station facilitator after the participant met each station s learning objectives. Seven Skills Stations SBAR, hemorrhage guidelines, and risk stratification. The learning objectives for the SBAR, hemorrhage guidelines, and risk stratification skills station were to demonstrate appropriate SBAR communication, identify and assign a level of risk for PPH on the basis of a PPH risk-stratification tool, and accurately apply hemorrhage guidelines to a case example. Detailed scenarios that included pertinent patient history, laboratory values, vital signs, and clinical issues to be discussed were outlined on laminated cards so that the cards could be reused. The station facilitator selected a scenario appropriate to a participant s clinical area and used the SBAR communication technique to simulate a one-on-one verbal interaction. The facilitator and participants evaluated the interaction to determine whether all of the indicators were included, and, if not, how the interaction could be remediated. For the same case example, participants were then asked to identify PPH risk factors and assign a level of risk from 0 to 2 with the use of a riskstratification tool created by the QI obstetric hemorrhage committee. A risk level of 0 indicates an average risk for PPH, a risk level of 1 indicates an elevated risk for PPH, and a risk level of 2 indicates a high risk for PPH conferred by known risk factors such as placenta previa, coagulopathy before birth, active bleeding, and so forth. The risk stratification tool is used on admission to the labor and delivery unit and throughout the course of labor. The level of risk is determined during triage and documented in a woman s electronic medical record and on a safety timeout board in the woman s labor room. Ongoing PPH risk assessment occurs on admission to the labor and delivery unit, during interdisciplinary rounds, and in the predelivery huddle if the woman has an elevated or high risk for PPH. After demonstration of SBAR, assigned risk stratification, and applied hemorrhage guidelines, the station facilitator provided feedback to participants about their assigned case example, including accuracy of assigned risk and areas to improve SBAR communication. Emergency response protocols. At the emergency response protocols skills station, participants were required to demonstrate appropriate actions for the activation of the obstetric emergency response system on each of the nursing units within and outside of the Women s Health Department. Staff members of the labor and delivery unit use a three-tiered approach to emergencies by activating a nurse call system located in each woman s room. An obstetric emergency warrants immediate response at the local level and throughout the Women s Health Department via a paging system, and the obstetric attending physician and obstetric chief resident, attending and resident anesthesiologists, charge nurse, primary nurse, obstetric technician, pharmacist, unit clerk, nursing coordinator, and NICU team are all notified. Each of the three emergency notifications is identified by a distinctive tone. The facilitator at this skills station used a recording of each notification tone and played back audio recordings of each level of emergency response during the skills station. The participants were required to identify the correct tone related to the level of emergency. Because of the diversity of the patient population and the types of emergencies within the clinical units of the Women s Health Department, each unit is required to use an individualized approach to emergency responses. Obstetric emergency is used on the mother baby unit only when there is a PPH; all other emergencies on this unit are handled by the rapid response team. The gynecology/oncology women s health unit uses obstetric emergency with every PPH or when a mother s or newborn s life may be in danger; the rapid response team responds to all other emergencies on the unit. Obstetric emergencies throughout the rest of the hospital will activate an obstetric rapid response that alerts similar staff. Blood administration and exsanguination protocol. At the blood administration and exsanguination protocol skills station, the hospital s policy and procedure for the exsanguination protocol and correct administration of blood products were reviewed. Providers and nurses must know their roles in requesting and obtaining blood products as well as how to safely and quickly administer them when indicated. Participants were required to review the hospital s exsanguination protocol and demonstrate the ability to activate this process when indicated. The exsanguination protocol is activated when there is massive bleeding without a clear endpoint. With this automated system, deliveries JOGNN 2018; Vol. 47, Issue 2 259

7 I N F OCUS Program to Improve Team Responses During PPH of specified quantities of blood products, including packed red blood cells, plasma, and platelets, are repeatedly sent until a request to stop is issued. The decision to proceed quickly with transfusion should be guided by a woman s vital signs and cumulative QBL. Participants were taught that the standardized definition of PPH is blood loss greater than or equal to 1,000 ml for any birth. The hospital policy for safe and accurate administration of blood products through an infusion pump was reviewed. This skills station used a storyboard on which information related to the hospital policy on blood product administration was posted. An infusion pump, blood infusion tubing, and a transfusion bag that contained synthetic blood substitute were available for participants to simulate the setup and administration of a blood product. Hemorrhage cart and uterotonic medications. At the hemorrhage cart and uterotonic medications skills station, participants were provided with the opportunity to become familiar with the contents of the hemorrhage carts located on the labor and delivery and postpartum units and to review common uterotonic medications used in the treatment of a PPH. Hemorrhage carts are readily available as needed and placed outside of the rooms of women at highest risk for PPH. Participants reviewed the contents of a cart and tried to find randomly assigned items in the shortest amount of time. Accurate and safe preparation of commonly ordered uterotonic medications was also discussed and demonstrated, and contraindications to each medication were reviewed with the participants. Because our hospital dispenses some medications commonly used during a PPH in glass vials, participants were given the opportunity to practice safe injection preparation from a glass vial with the use of a filter needle. Many participants remarked that they were unaware of the time and complexity required to break and withdraw medication safely from a glass vial. Quantification of blood loss. At the QBL skills station, methods to quantify blood loss during a PPH were described, and accurate measurement of blood lost was demonstrated. Participants were asked to state an estimation of blood loss for a collection of synthetic blood-soaked items on a table. The blood-soaked items were then weighed on a scale and predetermined dry weights for each item were subtracted to equal the quantified blood lost. Estimates were compared with actual quantified weights, which allowed for discussion. Underestimation of blood loss during PPH is common, and accuracy is not dependent on a clinician s years of experience (Bingham, 2012). Strategies for QBL for vaginal and cesarean births were discussed as well as the use of measurement devices such as calibrated drapes. Intrauterine tamponade balloon initiation. At the intrauterine tamponade balloon skills station, the equipment and steps required to initiate intrauterine tamponade balloon placement were demonstrated. The station facilitator reviewed nursing considerations related to balloon placement, ongoing evaluation, and postremoval surveillance. Participants viewed a tutorial video created by the company that provides the intrauterine tamponade balloon for use in our hospital. The video showed a demonstration of how to assemble and prepare the intrauterine tamponade balloon and the procedural steps for its placement. Laminated cards with questions related to indications, management, and nursing considerations were used to offer participants additional opportunities for knowledge before a return skills demonstration. B-Lynch suture procedure and intrauterine tamponade balloon placement. The B-Lynch suture (brace suture) procedure and intraoperative intrauterine tamponade balloon placement skills station was facilitated by a maternal fetal medicine provider. The provider reviewed more invasive interventions that included considerations for placement of the intrauterine tamponade balloon during a cesarean birth and demonstrated the B-Lynch suturing technique, a form of compression suture used to mechanically compress an atonic uterus. This technique can be an initial alternative intervention to hysterectomy in the setting of PPH secondary to atony. Obstetric attending physician and resident participants verbalized intrauterine tamponade balloon placement considerations and provided return demonstrations of the B-Lynch suturing technique to the facilitator with the use of suture on a firm pillow placed within a length of nylon stocking. Other staff participants verbalized understanding of considerations for intrauterine tamponade balloon placement during a cesarean birth and indications for the B-Lynch suturing technique. 260 JOGNN, 47, ;

8 Bittle, M., O Rourke, K., and Srinivas, S. K. I N F OCUS Because of the critical nature of the content within this educational offering, the leadership team mandated attendance and completion of the modules and skills session. To obtain 100% staff completion, 34 hours of scheduled skills session times were offered within a 6-week period on six separate dates to provide ample time and opportunity for all participants to attend sessions that met their scheduling needs. Study of Intervention To study the overall intervention, a postprogram completion survey was administered to evaluate the participants perceptions of their confidence and competency to improve response times as well as assessment and treatment of PPH. Subcomponents of the intervention were studied by percentage of module completion and skills station debriefings. Successful completion of the modules was shown with a downloadable certificate that was awarded and presented at the PPH skills session as evidence of completion. Participation in the interactive skills training stations was followed by a debriefing session. Main Outcome Measure Postprogram completion survey. An 11-item program survey was developed by the investigative team to determine the amount of progress participants made with regard to the administration of emergent care during a PPH as a result of their completion of this training. Survey responses were measured with a 4-point Likert scale that ranged from 1 (poor or not at all) to4(excellent or very much so). The survey took about 5 minutes to complete. Analysis The program survey was completed by participants to evaluate application of knowledge regarding women who have obstetric or postpartum hemorrhage. Ethical Considerations Our project was submitted to the Institutional Review Board. The project qualified as a QI initiative that did not meet the definition of human participant research, and therefore further Institutional Review Board review was not required. Results Over the course of the 6 weeks, 276 individuals participated in the obstetric hemorrhage skills sessions. This represented an overall compliance An interdisciplinary program that included two didactic modules, seven interactive skills stations, and in situ simulation improved team confidence and responses to postpartum hemorrhage. rate of more than 92% of all eligible staff members. A proportionate number of participants (69%) represented nurses and ancillary staff. Eighty-six (31%) of the participants represented APNs and anesthesia, obstetric, and family medicine attending physicians and residents. Response to this mandatory department-wide education initiative was overwhelmingly positive, and the overall program effectiveness score was 3.94 (range: 1 4). Furthermore, participants evaluated the overall purpose and goal of the program, which was to demonstrate application of knowledge surrounding identification and response to obstetric hemorrhage, as 3.95 (range: 1 4). In their comments, participants expressed increased feelings of confidence and knowledge about obstetric hemorrhage: I feel more confident going into a hemorrhage situation and filled in gaps in my knowledge. Examples of comments regarding the interdisciplinary nature of the program included good for all of us to get on the same page and helpful to learn from all disciplines and specialties. Negative comments were very few but centered on the time required to complete the program and relevance of some of the stations to certain roles. Discussion Summary This PPH program was based on didactic and interdisciplinary, interactive skills education. Developed and implemented by a diverse interdisciplinary team that represented clinical and administrative nurses and physicians, the program was designed to improve interdisciplinary team responses to PPH through the use of the four key components described in the obstetric hemorrhage safety bundle: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning (Main et al., 2015). The use of the program provided knowledge about PPH for the foundation needed to increase the team s confidence with all facets of PPH through the inclusion of online modules and interactive skills stations. JOGNN 2018; Vol. 47, Issue 2 261

9 I N F OCUS Program to Improve Team Responses During PPH Suggestions for improvement of the skills session included a new session with a patient scenario and an annual refresher PPH education skills station for staff. Online obstetric hemorrhage modules and skills stations are offered annually to staff and are used during orientation for newly hired staff, including registered nurses, APNs, physicians, and ancillary staff. After the completion of our initial six skills stations session offerings, we employed the assistance of the Penn Medicine Simulation Center to simulate a PPH on the mother baby unit. Standardized patients were hired and provided scripts to role-play the patient and support person. The simulation was filmed so that staff who were not present were able to view the simulation in real time in a nearby conference room. Simulation facilitators were present to oversee the scenario and debrief with participants at the conclusion. Use of this scenario allowed the members of the interdisciplinary team responding to the PPH to test their knowledge learned from the two online modules and seven interactive skills stations. Interpretation We continue to track the incidence of PPH through the hospital s safety reporting system. Implementation of a PPH bundle is intended to decrease morbidity rates associated with PPH. Data collected on our comprehensive obstetric hemorrhage bundle will be reported elsewhere, but preliminary data indicated that after implementation of the PPH bundle, specifically the inclusion of assessment of QBL, an increased detection of PPH occurred but without a reduction in blood transfusions (Hamm, Wang, O Rourke, Romanos, & Srinivas, 2017). It is possible that we did not yet detect a decrease in morbidity because our evaluation occurred soon after bundle implementation. Future studies are needed to assess the long-term effects of the individual components of bundles as well as the long-term effects of a comprehensive obstetric hemorrhage bundle on morbidity. Limitations Initial planning and implementation of the seven skills stations facilitated by physicians and nurses was time-consuming for team members. It took approximately 2 years from inception to completion of the online modules, skills stations sessions, and PPH simulation. Educational offerings were difficult to coordinate, and budget limitations needed to be considered. A virtual hospital room at the Penn Medicine Center for Innovation and Learning was used to film the simulated PPH for future education of staff and newly hired employees. We used obstetric physicians and nurses instead of standardized patients for the filmed simulation because of budget constraints. Conclusion Although obstetric hemorrhage education planning and implementation were time-consuming and difficult to coordinate across various schedules, the program was an effective vehicle for the dissemination of obstetric hemorrhage skills to staff from all disciplines in a short time frame. An interdisciplinary program that included online and classroom time with a focus on interactive skills integration led to participants increased levels of confidence and preparation for obstetric hemorrhage. REFERENCES Bingham, D. (2012). Applying the generic errors modeling system to obstetric hemorrhage quality improvement efforts. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(4), Burke, C., Grobman, W., & Miller, D. (2013). Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting. Journal of Perinatal & Neonatal Nursing, 27(2), Council on Patient Safety in Women s Health Care. (2015). Obstetric hemorrhage þ AIM. 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