We would like to commend the Pennsylvania Patient Safety Authority for its excellent review and analysis of postpartum hemorrhage (PPH) events in the article Pregnancy-Related Unplanned Returns to the Operating Room in the September 2015 Pennsylvania Patient Safety Advisory. We write this letter to demonstrate how the strategies outlined in the article for reducing the incidence of PPH were applied in a statewide quality improvement collaborative.
As a partner to the Hospital and Healthsystem Association of Pennsylvania in the Pennsylvania Hospital Engagement Network, the Health Care Improvement Foundation (HCIF) led a multi-year obstetrical adverse events collaborative with hospitals across Pennsylvania.* With funding from the Centers for Medicare and Medicaid Services through Partnership for Patients, hospitals worked together over a four-year period to reduce adverse events in labor and delivery units, including PPH.
The 2015 Advisory article cites evidence that PPH is the fourth leading cause of pregnancy-related mortality in the United States. For this reason, Pennsylvania obstetrical leaders made the reduction of PPH a collaborative priority. The article also points to literature that demonstrates improved outcomes with the implementation of evidence-based protocols, specifically, the rapid identification and treatment of PPH. One evidence-based protocol that served as the basis for collaborative learning in Pennsylvania and was referenced in the Advisory article was the OB Hemorrhage toolkit developed by the California Maternal Quality Care Collaborative (CMQCC) OB Hemorrhage Task Force. The toolkit is designed to assist organizations with the implementation of the National Partnership for Maternal Safety Hemorrhage Bundle. In 2012, CMQCC Task Force Co-Chairs, Audrey Lyndon, PhD, and David Lagrew Jr., MD, audioconferenced with collaborative hospitals and presented the toolkit and the lessons they learned from its implementation.
Over the next four years, Pennsylvania hospitals implemented bundle strategies and shared their experiences, tools, and resources with one another. Examples include the following:
- Readiness: The formation of rapid response teams, implementation of PPH emergency response carts, development of massive transfusion protocols, and simulation training.
- Recognition: Prenatal risk screening; the adoption of a risk assessment checklist used on admission to identify patients at low, medium, and high risk for PPH; and nursing education and training on quantifying blood loss (as opposed to estimation).
- “Response”: The implementation of a PPH management protocol and checklist, earlier administration of prophylactic oxytocin during the third stage of labor, and improved communication and processes for the timely release and delivery of blood from the blood bank.
Collaborative hospitals measured their progress by collecting and reporting data on the following three PPH metrics: compliance in assessing risk on all patients admitted to Labor and Delivery, blood transfusion rates, and rate of severe morbidity in women with PPH. Collaborative teams used their results to drive improvement.
The Advisory article includes information about the value of simulation training as an effective strategy for improving patient outcomes. Patient safety concepts and approaches were integrated into the collaboration’s program and included safety huddles for high-risk patients, post-event debriefs, and simulation training. Over the course of the collaborative, a number of educational activities were conducted, highlighting some of the state’s leading simulation programs. A favorite activity was the “simulation showcase,” in which video clips of hospital simulations were featured during a webinar accompanied by brief presentations in which each hospital described its training and debriefing experiences. In the last year of the collaborative, Ellen Deutsch, MD, clinical director for the Pennsylvania Patient Safety Authority and editor of the Advisory, was a featured webinar presenter on simulation. She also contributed her time and expertise though the “Office Hours with Dr. Ellen Deutsch: Designing Simulations;” a networking call in which collaborative participants were given the opportunity to ask Dr. Deutsch questions about their maternal simulation programs. Topics that were discussed included suggestions for getting a program started, tips for engaging physicians, new and innovative simulation scenarios, ways to involve other disciplines, staffing challenges, and the benefits of conducting simulations in common areas visible to patients and visitors.
In the final year of the collaboration, an “OB Regional Coalition Program” was conducted, bringing together obstetrical leaders across the commonwealth to better understand causes of Pennsylvania’s maternal adverse events and to propose solutions to system shortfalls and gaps. The call by the American College of Obstetricians and Gynecologists (ACOG) and the Joint Commission for a systematic review of all maternal mortalities and morbidities made this program especially relevant. The standardized event reporting categories and definitions as outlined in the Authority’s Pennsylvania Patient Safety Reporting System (PA-PSRS) user manual were the basis for the event reporting discussion at two in-person coalition meetings. Meeting findings and recommendations were disseminated to hospitals across Pennsylvania through a written report and a webinar. A few examples of recommendations include the need to standardize maternal event definitions, a maternal event reporting taxonomy in PA-PSRS, better multi-disciplinary involvement in the adverse event review process, demonstration of the financial impact of maternal adverse events and the value of solutions, and forums to continue these discussions.
Although the collaboration concluded in September, Pennsylvania hospitals are well positioned to continue this important work though the relationships they developed, the strategies they implemented, and the resources and tools they shared with one another.