What to Do When you Find Yourself in a Puddle of Blood

Transcription

1 What to Do When you Find Yourself in a Puddle of Blood Dodi Gauthier, M.Ed, RNC-OB, C-EFM Educator, Perinatal Services & Clinical Nurse, L&D Cottage Health System Santa Barbara, CA dgauthie@sbch.org 2013 Objectives Describe why obstetrical hemorrhage is still a leading cause of maternal morbidity and mortality. Define and implement best practice for obstetrical hemorrhage. Promote collaboration and communication among obstetrical providers Special Thanks and Acknowledgement Mimi Dent, BSN, RNC-OB AWHONN Chapter Co-Coordinator Preceptor and fantastic Clinical Resource Nurse Esteemed colleague & friend This class started as her dream and her hard work. Where I live! SB County: 3 Fires in 10 Months Mindfulness The ability to concentrate on what is going on here and now. Mindfulness involves preventing the mind from wandering and being distracted. Being mindful..planning, observing, intervening. Weick and Sutcliffe(2007) Managing the Unexpected, 2 nd Edition 1

2 Mindfulness Why Be Concerned with Hemorrhage? Mindfulness weakens the tendency to simplify occurrences into familiar events (tendency to normalize ). It strengthens the tendency to redefine the event into something less familiar. Every four minutes, a woman dies from a post partum hemorrhage. It is the leading cause of death in pregnancy worldwide and is second only to thromboembolic events in Europe and North America. 75% of these hemorrhages are preventable! Remember. Reasons for Bad Outcomes 1. First, do no harm. 2. Post partum hemorrhage is a SIGN not a DIAGNOSIS. Inadequate IV access and fluid administration Inadequate anticipation or determination of the degree of hemorrhage Poor communication Lack of attention to anesthetics effect on uterine tone Lack of understanding of sequence of coagulopathic changes during a massive OB hemorrhage Delay in the involvement of the anesthesiologist (and others who can help) Failure or Delay in Consequences of PPH Identifying! Using alterative meds Moving patient to OR Moving back from PACU to OR Ordering blood products Giving FFP and/or platelets with RBCs Hypovolemic shock Blood transfusions and its complications Surgical injury Fever and infection Renal and hepatic failure Acute Respiratory Distress Syndrome (ARDS) DIC Loss of fertility Sheehan s syndrome Loss of life 2

3 We need a protocol! California has 550,000 births each year. 2% involve hemorrhage. That is 11,000 women. And the survey says The 4 Rs of CMQCC Only 60% of hospitals responding to the CMQCC survey had a hemorrhage response protocol. Inconsistent definitions of hemorrhage all around the state. Only 30% of hospitals perform drills (usually not multidisciplinary). Most reported no access to alternative therapies (anything other than uterotonics) Readiness Recognition Response Reporting OB Hemorrhage Checklist Recognition Anticipate and expect possible trouble. Development and improvement of critical thinking skills. Improve collaboration among teams and team members (multidisciplinary). Being mindful of who is at risk. Mindfully quantifying blood loss. Vital Sign Triggers. Communicating among all disciplines involved including the current and total amount of blood loss. 3

4 CRITICAL THINKING Consider potential etiology: Uterine atony Trauma/laceration Retained placenta Amniotic fluid embolism Uterine inversion Coagulopathy Infection/sepsis Readiness Policy and Procedure Critical supplies: cart, trays, kits Procedures for communicating with other units and disciplines including Blood Bank Equipment familiarity Training staff members to scrub for an emergency hysterectomy and for a C-hyst 4

5 Hemorrhage Cart Level 1 Rapid Infuser IV equipment Lab tubes Hespan Flo Seal Bakri Balloon Curettes Weighted speculum Protocol Book Level 1 Fast Flow Fluid Warmer Minimizes hypothermia by heating fluid Infuses fluid very rapidly for resuscitation Bair Hugger BAKRI Balloon Various types to minimize hypothermia and it s complications. Assists with patient comfort in both the OR and the PACU Warning Will Robinson! Be Mindful of the 4 Ts QBL > 500 ml vaginal or > 1000 ml Cesarean OR Vital signs change HR > 110, B/P < 85/45, O2 sat < 95% or > 15% change from baseline OR Increased bleeding during recovery or post partum 1. Tone (uterine atony) 2. Trauma (tear or inversion of uterus) 3. Tissue (retained) 4. Thrombin (blood not clotting) Not unlike the Hs and Ts in ACLS! 5

6 Response Massive Transfusion Protocol (MTP) Medications Surgical Techniques Volume and blood replacement Massive transfusion policy CMQCC Toolkit 6-8 units transfused in less than 4 hours Ordered by anesthesiologist or OB Once initiated, 4 units of uncrossed, unmatched O neg blood and 2 units of JFFP are placed in Wizard and made ready for pick up Blood is continued to be prepared every 30 minutes until the MTP is de-activated The Wizard is for those blood products needing refrigeration (RBCs and FFP) Reporting Guess the Blood Loss at this Birth! Rapid Response Team SBAR hand-offs and/or reporting to MD Consistent ICD-9 and ICD-10 coding for hemorrhage on patient s chart Quantifying Blood Loss Underestimating blood loss is killing women. We must start objectively quantifying blood loss. 6

7 Communication Issues: SBAR Situation I am calling about and the problem is. I am concerned. Background State the pertinent information (what have you done) already. State any pertinent medical history. Assessment Most recent vital signs Fundus, EBL, lab results Recommendation I need you to come in and see the patient right now. I need some orders for additional tests, medication, etc. Develop relationships with those who may care for your patient. Recommendations Multidisciplinary drills Simulation Quarterly drills Practice using equipment Scavenger hunts Use the CMQCC checklists Documentation as you go How has this improved the PROCESS and OUTCOME of patients with obstetrical hemorrhage? Use reflective questions to assess critical thinking skills. Reflective Thinking Questions Simulation/Mock Codes/Drills: Why? What could go wrong here? What are your main concerns here? What evidence supports your conclusion? What do you think you should do next? How long can you wait to intervene? What task can wait until later? Who can help? What would you like to see happen? The ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives. Weick and Sutcliffe (2007) Managing the Unexpected 7

8 Jesusita Fire, Santa Barbara, 2009 Recommendations for Drills 3 rd disastrous fire in a 10 month period More than 200 homes and other structures were lost. Not one person died. Create situations that are as real as possible with the tools that you have. Low fidelity simulation is not to be scoffed at! Be creative and resourceful. Have a treasure hunt. Get your hands dirty and use the equipment. Involve as many people as you can.the more the merrier with drills and simulation. Recommendations Begin with didactic information so everyone is relatively on the same page. Don t forget about the motor skills! Using the equipment takes practice. Lots of practice. Collaboration among units and disciplines is vital. Recognize that some will feel I don t need to know this information. Use a Checklist History IV access Vital signs/fhr Recognize bleeding Assess TONE Fundal massage Labs Second IV Call for help Use a Checklist How It Can Work! Order medications Oxygen supplementation BAIR hugger to keep warm? Warm crystalloids Order blood Surgical intervention needed? Hysterectomy necessary? CMQCC Toolkit Readiness Recognition Response Report Education Practice Mindfulness 8

9 Being mindful and paying attention to the process led to this outcome.. Summary and Recommendations It starts with one fire fighter and one shovel. -Andy DeMeizio, Fire Chief SB County It also starts with one nurse making the right thing easy to do so that this is the result! References Hemorrhage Toolkit (2009 with edition 2 coming in 2014) Download the entire toolkit Weick, Karl and Sutcliffe, Kathleen M. (2007) Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2 nd Edition. Jossey Bass. Gawande, Atul (2009) The Checklist Manifesto: How to Get Things Right. Metropolitan Books. 9