The Challenge: Alarming National Statistics
The United States is the only developed nation where maternal deaths and injuries have increased. Approximately 700 women in the U.S. die annually from pregnancy-related complications. According to the U.S. Centers for Disease Control and Prevention (CDC), more than 60% of these pregnancy-related deaths are preventable. Postpartum hemorrhage (PPH) and cardiovascular/coronary conditions are the two leading causes of these complications, each accounting for 14% of maternal deaths.
As one of the nation’s largest health care systems with more than 72,000 annual births, Providence St. Joseph Health (PSJH) took these alarming statistics to heart. The situation hit home after a PPH-related maternal death devastated caregivers. The executives of our Women and Children’s Institute, which was formed to promote best practices among our 51 hospitals, called for volunteers to review postpartum hemorrhage protocols and processes, an effort they later expanded to include maternal hypertension. Their task was to make organization-wide changes to prevent future maternal deaths and injuries.
The 20-member team represented a variety of stakeholders from across the health system: obstetricians, midwives, nurses, pathologists, laboratory personnel, operating room staff, educators, and administrators. Communicating through virtual meetings and regular check-ins, the team began by reviewing the case that framed its purpose and underscored its urgency. A young and healthy pregnant woman had been admitted to a PSJH hospital with a prenatal record that did not suggest she had any areas of concern during her pregnancy. Her labor progressed and appeared normal, delivering a stable newborn. However, the patient began hemorrhaging shortly after delivery. Despite a rapid response of all involved and several units of blood products and other emergent procedures, this young mother passed away. The case became the team’s rallying call.
The Goals: Standardize Protocols and Transition from Reaction to Prevention
The team reviewed the maternal death case along with other PPH cases that resulted in massive blood transfusions, ICU admissions, and hysterectomies, ultimately identifying two issues at play. First was lack of protocol standardization, a problem common across the country. The situation was amplified for PSJH, given the health system’s rapid 5-year growth following several mergers and affiliations. During this period, the health system was working to transition from a holding company, where decisions were made locally, to a more centralized operations company, but changing cultural norms to embrace collaboration and standardization had been difficult. The PPH team was an excellent example of system-wide collaboration.
Digging even deeper, the team recognized that standardization wasn’t the only challenge. Another was changing from a reactive to proactive perspective to prevent complications in the first place. Most of the available protocols for PPH had been written to respond to an emergency. However, the team realized that serious maternal morbidity could be avoided by identifying patient risk factors as early as possible.
Data specialists created a tool to help evaluate a patient’s PPH risk upon admission and provide caregivers with standardized protocols for care. The primary requirements for the tool were that it be embedded into the electronic medical record (EMR), be easy to use, appear on just one screen, and provide easy-to-follow instructions for care.
The resulting EMR Hemorrhage Risk Assessment fit the bill. The evaluation process is purposefully brief: Upon intake, the caregiver records responses to just five key data points recommended by the California Maternal Quality Care Collaborative for PPH risk assessment (past pregnancies, problems with current pregnancy, history of gestational hypertension, current vital signs, and multiple births). The tool then uses an algorithm to assess these data points along with the health history available on the EMR, stratifying the patient as high, medium, or low risk. The caregiver sees a green, yellow, or red screen based on the patient’s risk level and is provided corresponding instructions for care.
This simple EMR modification — designed with the EMR vendor and in-house IT teams — also ensures a new caregiver assuming management of the patient has immediate access to the risk status. Moreover, if the patient’s danger of hemorrhage increases, an alert is triggered and the EMR automatically generates new orders, facilitating caregivers’ abilities to respond swiftly to an unexpected risk escalation.
Lessons Learned and Problems Avoided
With our new tool, we now have a system-wide preventive response where caregivers know their roles and act in a standardized manner to prevent and respond to a postpartum hemorrhage situation. Continued review of experiences and key metrics from each market — ICU admission rates, hysterectomies, and blood product usage (see graph) — ensures progressive quality improvement. Teams make necessary changes to enhance outcomes and their ability to respond to each patient’s individual needs.
Among our lessons learned is the importance of didactic devices to ensure compliance with new tools and procedures across a large health system. Teams used comprehensive tool kits to teach caregivers how to perform the EMR risk assessment and respond effectively and rapidly to emergent situations. In partnership with other teams, we also introduced exercises with simulation mannequins and participation scenarios specific to maternal hemorrhage.
Additionally, the team discussed and tested the risk assessment tool with a wide range of stakeholders. When lab personnel expressed concerns that the protocols within the tool would trigger an unnecessary increase in type and hold for blood products, the situation was closely monitored. With more patients having their blood typed as part of the preventive protocols, blood testing costs did initially increase. However, usage rates decreased over time because the massive transfusions necessary in an emergent PPH case were avoided.
Staff concerns associated with EMR changes were also overcome. Collaboration among caregivers and IT specialists helped us build an assessment screen that was intentionally simple and involved just a few basic questions. As we found, many clinical teams were already asking these questions, although not with the assistance of the electronic risk assessment tool. Therefore, the time spent in assessment was mostly unchanged.
As testimony to our success, teams have further developed similar protocols for hypertension. These were combined with PPH efforts to establish a suite of EMR tools that we call the Maternal Early Warning Trigger System, now used across the health system.
Further Work: Developing a Culture for Maternal-Fetal Well-Being
It is essential to recognize that standardized protocols and early risk assessment during labor are only two of the necessary actions to prevent fetal deaths. PSJH is a High-Reliability Organization, which means we empower caregivers to voice concerns related to any potential threat to the care team or patient outcomes. This policy includes specific language and tools that require everyone on a care team, especially teams dealing with maternal complications, to stop and listen to a concern and develop an action plan on how to proceed whenever a potential patient safety issue arises.
As noted in a recent CDC study, no single intervention is sufficient for reducing pregnancy-related deaths. Improving women’s health before and during pregnancy also plays a part. For this reason, PSJH extends its efforts into the community to evaluate and educate communities that are at risk for OB-related health concerns, thereby getting to the root of many maternal health complications. Many of our PSJH acute care hospitals provide direct maternal health programming to the local community, which includes perinatal and prenatal care to help prevent maternal complications.
Additionally, our innovation team works to empower mothers at all income levels with digital tools. One home-grown innovation is a software application developed to educate mothers on maternal health issues. The Circle smartphone app provides mothers with trusted health information and services to support them throughout pregnancy and into parenthood. It delivers provider-approved content 24-7, including articles about pregnancy, parenting, and children’s growth from ages 0–18; answers to frequently asked questions; breastfeeding support videos; a guide to local resources; and health-tracking tools so mothers can update providers about their pregnancy and growing child. This tool is also linked back to the EMR to provide physicians with patient-generated data that can paint a fuller health profile.
We recognize that there is more to do and we are clearly on the right path. Since the implementation of the protocols and EMR tools, PSJH has screened 98.7% of patients for OB hemorrhage and is tracking improvement in the identification and treatment of hypertension, including readmissions. In 2017, PSJH had zero preventable maternal deaths across our seven-state health system.
Blood transfusions, ICU admissions, and hysterectomy — all associated with PPH — have decreased at PSJH hospitals.