OB Harm Initiative Webinar

OB Harm Initiative Webinar July 9, 2014 Sharon Burnett Vice President of Clinical and Regulatory Affairs Missouri Hospital Association 1

Webinar Objectives Provide an update on regulations and legislation applicable to OBs Provide an overview of lessons learned at the OB Harm regional workshops Feature successes and lessons learned including barriers and strategies to overcome them from the efforts of early adopters Provide information on upcoming events and deadlines 2

Homestretch of Reducing EEDs Hospital reported data for 2014 EED rate is.07%! If you haven t gone far enough to reduce EEDs, http://health.usf.edu/publichealth/chiles/fpqc/eed Early Elective Delivery No Payment Rule Final published July 15, effective Sept. 1 STR Codes and Diagnosis and MO HealthNet Draft Bulletin http://web.mhanet.com/mha-constituency-groups 3

Other Regulatory and Legislative Updates CCHD Screening required by law 1/1/2014. Reporting voluntary now using DHSS form until reporting rules written. DHSS plans to collect data via HL7 interface in the future. http://health.mo.gov/living/families/genetics/birthdefects/cchd.php Donor Milk Payment - Requires the MO HealthNet to reimburse hospitals for donor human milk provided to critically ill infants under three months of age in the neonatal intensive care unit. (SB 680, SB 754) Signed by Governor Umbilical Cord Blood Bank - Beginning July 1, 2015, DHSS to transport collected, donated umbilical cord blood samples from approved collection sites to a nonprofit umbilical cord blood bank located in St. Louis City. (SB 716, 567 and 754) Delivered to Governor 4

Other Regulatory and Legislative Updates HB 2010 authorizes additional state funding to expand the newborn testing courier service to additional sites and Saturday pickup. Vetoed by Governor Not enacted HB 1898, SB 716 to create Perinatal Advisory Council to define neonatal and maternal care regions and levels Not enacted HB 1807 to require hospitals to designate responsible person and tract collection and transport of newborn blood samples Missouri Task Force on Prematurity and Infant Mortality Report. http://media.wix.com/ugd/79d087_21e483ed0539428c8a35c2d627a759a5.p df. Interim workgroup established 5

Pre-Work! 6

5 sites 140 attendees 9 physicians 43 hospitals What I Learned Along The Way!

How Do You Get Started? JUST DO IT! 8

No documentation of actual blood loss past the delivery record Under estimation of blood loss Lack of equipment and proper use if available Delay in communication to team players Delay in gathering equipment once emergency began Lack of an organized approach Freeman Health System 9

Post-Partum Hemorrhage Risk Assessment

HEMORRHAGE EDUCATION, ASSESSMENT AND PLANNING Staff education: hemorrhage skills lab and communication Risk assessment: Two pathways to identify our patients at high risk for maternal hemorrhage: Prenatal clinic sending over patient records: flagging chart in red folder Admission nursing assessment: flagging chart with red clipboard & blood charm Planning for high risk: Type and screen vs. type and cross, hemorrhage cart outside door, hemorrhage medication kit in McKesson dispensers Lake Regional Health System 11

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Ongoing email communications Education on Bakri balloon insertion and rapid installation provided by Cook Medical for nurses and physicians. Presentations at staff meeting of PPH cart. Scavenger Hunt in the cart Videos and quizzes Mock PPH drill scenarios began with staff Go Live scheduled after 95% of nursing staff completed education. Postpartum Hemorrhage Order set provided framework for prompt initiation of appropriate clinical management. Examples are in your handouts 14

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What Is Wrong With This Picture Rest for 10 mins. Bare arm, patient seated, feet on the floor, not pushing Correct cuff size, cover 80% of arm, cuff at level of heart, no side lying BPs 2 BPs, 4 hours apart to make diagnosis Repeat 15 mins if BP> 160 SBP or >110 DBP 16

You Have to Have. Maternal Prompt Prompt Effective Early Reporting Bedside Escalation Warning Evaluation Policy Criteria 17

Maternal Early Warning Criteria Systolic BP; mmhg <90 or >160 Diastolic BP; mmhg >100 Heart rate; beats per min <50 or >120 Respiratory rate; <10 or >30 breaths per min Oxygen saturation; % <95 room air, sea level Oliguria; <30 ml/hr for 2 hours Maternal agitation, confusion, or unresponsiveness Patient with hypertension reporting a non-remitting headache or shortness of breath 18

Effective Escalation Policy An abnormal parameter requires: 1. Prompt reporting to a physician or other qualified clinician 2. Prompt bedside evaluation by a physician or other qualified clinician with the ability to activate resources in order to initiate emergency diagnostic and therapeutic interventions as needed. Who are you going to call next? 3. Plan for and implementation of diagnostic work-up 4. Close follow up by senior provider of patient s status until: Abnormality resolves, or Parameter judged to be of benign etiology, or Patient is determined to be potentially critically ill and care is escalated (rapid response, higher acuity setting) 19

Treatment of Blood Pressure greater than or equal to 160/xx OR xx/110: Position: semi-fowlers; cuff at level of heart; displace uterus 20 Primary RN Notify OB of BP Notify Charge RN and Start IV and draw Labs Recommend IVP med* within 30-60 min of 2 nd BP Monitor BP q 5 min Monitor EFM Admit patient then Recommend: Continue BPs q 5 min. until BPs remain less than 160/xx or xx/110, then may repeat BP measurement every 10 mins for 1 hour, then every 15 mins for 1 hour, then every 30 mins for 1 hour, and then every hour for 4 hours. yes Remains 160/xx or xx/110? 30-60 min timeframe begins OB Provider Order IV push labetalol or hydralazine * Admit patient consider Difficult IV start, > 30-60 mins? Give PO nifedipine 10 mg for first med dose. Does Patient meet criteria for severe preeclampsia? Magnesium Sulfate 4gm loading dose. BP 160/xx or xx/110? May recheck with manual cuff* in 10 minutes no *(for verification) Recommend: Recheck every 30 minutes. *MED NOTES: Labetalol IVP: Peak response within 5 minutes *Requires continuous pulse oximetry monitoring in L & D; *Requires cardiac monitoring on M/B Unit contact Mgr re equip/staff. Contraindicated: Bronchial Asthma or Heart Block Hydralazine IVP: Onset: 5-15 min Peak response: 10-80 min Contraindicated: Mitral Valvular disease Rev 2/7/14

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Preeclampsia Can Have Devastating Consequences 11-12% of all premature births is from preeclampsia and other hypertensive disorders of pregnancy Preeclampsia increases risk of neonatal and maternal death, stroke for life Importance of educating ED and clinic staff of S&S of preeclampsia Importance of educating mothers and family - low awareness of some of the specific symptoms such as headache and vision changes, that risk continues after baby is delivered 22

Education and Training MHA -- http://web.mhanet.com/mha-constituency-groups University of Oxford -- An interactive course for health professionals, The Evidence-Based Management of Pre-eclampsia and Eclampsia http://www.gfmer.ch/srh-course-2010/pre-eclampsia- University-of-Oxford/index.htm Sharing and Caring: A Perinatal Loss Seminar, September 5-7, 2014 St. Charles, MO, For registration information, visit http://www.nationalshare.org/sharing-caring.html 23

Maternal Hemorrhage Team Update Beverly Koenig, MSN-C Nurse Manager/Obstetrics Service Perry County Memorial Hospital 24

Preeclampsia Team Update Rhonda Donnelly, RNC Nurse Manager L&D CoxHealth 25

Next Steps Save the date for next webinar, August 20, noon Enter EED data and OB hemorrhage measures (massive and total OB blood transfusions) into CDS Set a team meeting date Create a staff education poster or resource Talk to senior management and OB physicians about the work you are doing or contemplating 26