EP7f, CN III OB Hemorrhage.pdf OBSTETRIC HEMORRHAGE. Amelia Indig RN Clinical Nurse III Candidate December 17, 2009

Transcription

1 OBSTETRIC HEMORRHAGE Amelia Indig RN Clinical Nurse III Candidate December 17,

2 OBJECTIVE OF THE PROJECT EP7f, CN III OB Hemorrhage.pdf Determine opportunities to improve patient safety and quality of care using recognized quality improvement methods Provide a catalog of risk based recommendations that will guide improvements in patient safety, and decreased of morbidity and mortality related to OB hemorrhage. These recommendations are focused on: Improving readiness and response to OB hemorrhage. Improving professional practice, policies and procedures to provide high level of patient care in a safe environment. 2

3 WHY DO WE NEED TO IMPROVE? Inadequate communication between care providers or between care providers and patients/families is consistently the main root cause of sentinel events. 1 Thus a Team of Experts in Healthcare does not necessary make an Expert Team 1 The Joint Commission: Serious Adverse Events - issue # 30 3

4 TRADITIONAL CYCLE OF RISK REDUCTION EP7f, CN III OB Hemorrhage.pdf In the traditional system the adverse incident must occur before corrective measures can be taken. 4

5 METHODOLOGY: PROACTIVE QUALITY IMPROVMENT Define the topic and narrow the scope of the analysis: OB Hemorrhage Assemble a multidisciplinary team Describe graphically the process: create a process flow (Process mapping) Conduct a harm analysis: listing all potential failure modes to determine their probability and severity Determines actions to take and identify outcome measures to analyze and test the redesigned process 5

6 DEFINE THE TOPIC: OBSTETRIC HEMORRHAGE Obstetric crisis, unlike any other crisis that occurs in patients, affects two lives at the same time: mother and baby. Major cause of maternal death around the world The most preventable hemorrhage Incidence is between 2-11% 6

7 DEFINE THE TOPIC: BACKGROUND Focused priority state- and nation-wide The Joint Commission (TJC) California Perinatal Quality Care Collaborative (CPQCC) California Maternal Quality Care Collaborative (CMQCC) CMQCC Hemorrhage Task Force The Local Assistance for Maternal Health (LAMH) 7

8 ESTABLISH A MULTIDISCIPLINARY TEAM Obstetricians (Attending, Fellows, Residents) Anesthesiologists (Attending, Residents, CRNA) Nurse Educator Charge Nurses Perinatal Nurses NICU team Improvement Practice Advisor 8

9 PROCESS MAPPING Review the flow of the patient through OB Department Review each step of patient care, the critical decisions, questions and solutions available at the beginning of the analysis 9

10 POSTPARTUM MATERNAL HEMORRHAGE 10

11 ANTEPATRUM / INTRAPARTUM MATERNAL HEMORRHAGE EP7f, CN III OB Hemorrhage.pdf 11

12 CONDUCT A HARM ANALYSIS: FMEA Key principals of a Failure Modes and Effects Analysis: It assumes no matter how knowledgeable or careful people are, errors will occur in some situations. A systematic approach of a process Gives a prospective evaluation Identify vulnerabilities Identify ways to effectively reduce risk or harm Prioritize the objectives of which areas of a process to focus efforts on 12

13 Failure Mode Effect Analysis POSTPARTUM OB HEMORRHAGE EP7f, CN III OB Hemorrhage.pdf Process Failure Modes (what might happen) Failure Causes (Why it happens) Failure Effects Likelihood of Occurrence Likelihood of Detection Severity Overall Harm Score Recommendations and Actions to improve outcomes Mother bleeding 1. Delay in recognition by nurse (failure to recognize early signs as well as overt bleeding) 2. Delay in recognition by patient (patient doesn t realize she is bleeding) 3. Patient found bleeding by someone other than bedside nurse (I.e. aide) 1. Nurse not at bedside/too busy; nurse not adequately trained/inexp erienced unit understaffed 2. Patient not educated 3. Someone other than bedside nurse observes bleeding or is told by patient that she is bleeding 1. Patient becomes hemodyn amic unstable 2. Patient at risk for morbidity and mortality 3. Someone other than bedside nurse does not understan d issue and bedside nurse not notified in timely manner Standardized risk assessment at admission and periodically throughout stay 2. Additional training of nurses 3. Provide additional patient education/ensure education is appropriate to patients age and language 4. Consider flexible nursing assignments or changes in staffing ratios for patients identified at risk 5. Education regarding OB hemorrhage 13

14 Detection Rating Table for FMEA EP7f, CN III OB Hemorrhage.pdf Occurrence/Frequency Rating Criteria Almost never 1 1/1,000 patients Occasionally 2 10/1,000 patients Sometimes 3 25/1,000 patients Often 4 50/1,000 patients Very often 5 100/1,000 patients Detection Rating Criteria Almost always 1 Controls are in place and almost certain to detect the failure Occasionally 2 High likelihood current controls will detect the failure Sometimes 3 Slight likelihood current controls will detect the failure Often 4 Very slight likelihood current controls will detect the failure Almost never 5 No controls in place to detect the failure Severity / Effect Rating Criteria Slight effect 1 No patient harm, but effects efficiency, regulatory, etc. Moderate effect 2 Minimal/temporary patient harm (increased monitoring, treatment needed) Significant effect 3 Moderate patient harm/temporary (treatment, readmission) Major effect 4 Severe patient harm/permanent harm (anaphylaxis, cardiac arrest Extreme effect 5 Death Overall Harm Score: multiply the likelihood off occurrence with the severity. Maximum score = 125 Scores > 94 are highest priority Scores > 75 are moderate priority Scores < 75 are lowest priority 14

15 OVERALL HARM SCORE Antepartum Intrapartum Postpartum Mother bleeding Nurse evaluates patient Nurse notifies MD Nurse provides care MD responds MD assess severity of bleeding MD evaluates gestational age 3 3 N/A MD order blood First line treatment (mild hemorrhage) First line treatment (moderate hemorrhage) Evaluation of bleeding control Patient needs surgery MD order antibiotic (pre op) Patient needs post op Adult Critical Care /care Patient needs post op Adult Critical Care/system

16 DETERMINING ACTIONS TO TAKE: SUMMARY OF MAJOR ACTIONS EP7f, CN III OB Hemorrhage.pdf Improvements in obtaining blood for patients with severe OB hemorrhage - massive blood transfusion protocol Improvement in communication people and technology Improvement in early recognition of potential risk Unifying definition of OB Hemorrhage Quantification of the blood loss Standardization of care across the units clinical algorithm and order sets Involvement of Intensivists for post-op critical care management 16

17 EARLY VICTORIES Lay the path leading to improvements in care and safety in OB hemorrhage patients 1. Focused priority for UCIMC Lay the path to better communication between Blood Bank and Perinatal Services, 1. Development of a massive transfusion protocol for Perinatal Services Collaboration with Trauma-Critical Care Team to ensure immediate, efficient transfer of the patient in need for adult critical care 17

18 NEXT STEPS Implementation of identified opportunities for improvement 1. Policies and Procedures 2. Forms 3. Technology 4. Equipment Education and Training Simulation Drills Full Roll Out 18

19 PERSONAL NOTES My project is not only a Practice Improvement: is also a personal improvement. Paying attention and analyzing deeper the routine of your daily life at work and elsewhere will surprise you. I found a the benefits to listen. Given a chance to somebody to speak out it will give you a chance to be heard. The professional discussions can be friendly and some times funny. The sense of humor helps to break the ice. The hardest part is to get buy-in for steps. For me the person to person approach worked best. The word spreads and others become interested and willing to help I met new people Involvement in quality improvement initiative is professionally rewarding and being involved in CMQCC scope and give my project a special dimension. 19

20 REFERENCES EP7f, CN III OB Hemorrhage.pdf Althabe F, Buekens P, Bergel E, Belizan JM, Campbell MK, Moss N, Hatwell T, Wright LL, A behavioral Intervention to Improve Obstetrical Care N Engl J Med 208; 358: Buckland SS, Homer CS, Estimating blood loss after birth: using simulated clinical examples. Women Birth 2007; 20:85-8 Galler S, Adams MG, Miller S A Continuum of Care Model for Postpartum Hemorrhage. International Journal of Fertility & Women s Health 2007; 52: H,Tomberg DN Sachs BP Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obst Gynecol 2007 OB Hemorrhage Protocol CMQC Hemorrhage Task Force 06/15/2009 Shields, L et al. OB Hemorrhage blood product replacement. CMQCC Hemorrhage Task Force 03/06/2009 World Health Organization: Department of Making Pregnancy Safer: WHO recommendations for the prevention of postpartum hemorrhage. 20

21 Happy Holidays EP7f, CN III OB Hemorrhage.pdf Amelia 21