better health for mothers and babies
TRANSCRIPT
Agenda
Welcome
Background
Review AHA Initiative
Quality Improvement Approaches from a health system
Using data to drive improvement
Maternal Mortality Review Boards
Questions
Improving Maternal Health
Establish or Reaffirm Commitment
DATA
Regularly review internal data with interdisciplinary team and look for improvement opportunities.
Access across continuum of care
Health Disparities
Prioritize and implement targeted strategies known to combat risk factors
Accountability
Review care protocols and discharge transitions
Advance evidence based practices
Listen to Mothers:
Engage Mothers and work with like-minded community based organizations to improve public education to lower risk
Initiative: Better Health for Mothers and Babies (BHMB)New website: https://www.aha.org/better-health-for-mothers-and-babies
Center for Health
Innovation
Field Engagement
Public Policy
Better Health for mothers
and Babies
Provide a forum for hospitals to engage in sharing leading practices through webinars like this one, case studies, and podcasts, etc.
Convene national summit of stakeholders to share leading practices and identify collaborative actions
Share quality improvement tools and facilitate QI training to address improvement and disparities
Partner with community based organizations
Urging Final Passage of S. 1112, Maternal Health Accountability Act
Maternal Mortality Review Committees (MMRCs)2015: Maternal Mortality Review Information Application (MMRIA or “MARIA”)
• Supports MMRCs and provides resources to promote a standard approach to case review
• Key decisions for each death reviewed:• Was the death pregnancy-related?• Underlying cause of death?• What factors contributed to the death?• Recommendations and actions to address contributing
factors?• Anticipated impact of actions if implemented?• Was the death preventable?
Centers for Disease Control and Prevention. Report from Maternal Mortality Review Committees: a view into their critical role. https://www.cdcfoundation.org/sites/default/files/files/MMRIAReport.pdfAccessed December 20, 2017 and MMRIA. Review to Action. http://reviewtoaction.org/implement/mmria. Accessed February 20, 2018.
Preventability
63.2%
Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.
• Report of 9 MMRCs in 2018 estimated that 63.2% of pregnancy-related deaths were preventable• 70% of deaths from hemorrhage
were preventable• 63.2% of deaths from cardiac
disease were preventable• Report of 4 MMRCs in 2017
determined that 59% of pregnancy-related deaths were preventable
Preventability
Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol, 2005; 106(6): 1228-34.
Review of North Carolina maternal deaths: 21% of maternal deaths could have been prevented had care conformed to nationally recognized standards
Preventability varies by cause of death
17%
22%
40%
42%
60%
89%
93%
Pulmonary embolism
Cardiomyopathy
Cardiovascular conditions
Infection
Preeclampsia
Chronic medical conditions
Hemorrhage
• What was the chance to alter outcome (good chance, some chance, no chance, unable to determine)?
• Contributing factors and description• Patient/family
• Provider
• Facility
• System
• Community
• Recommendations / specific feasible actions that if implemented should have or might have altered the course of events
Standardized Decision Form for MMRCs: Preventability
Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.
Focus on Reducing Severe Maternal Morbidity: Review by Birthing Facility
Pregnancy
complication or pre-
existing medical
condition
Potentially life-
threatening
condition with
predisposition to
end-organ injury
Survival despite
experiencing an
unanticipated event
likely to result in
death
Adapted from: Witcher PM, Lindsay MK. Maternal morbidity and mortality. In: Troiano NH, Witcher PM, Baird SM (eds). High Risk and Critical Care Obstetrics, 2019; Wolters Kluwer: Philadelphia and Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-mortality-surveillance-system.htm. Accessed on 10/30/2018
0.5 -3% of pregnancies
SMM to maternal deaths: 100:1
18.0 per 100,000 live births in 2014
Continuum of Morbidity and Mortality
Severe Maternal Morbidity Review
• Purpose: identification of improvements in processes and systems
• SMM Committee• Presentation of abstracted review• Identification of opportunities to improve outcomes• Focus on systems and processes• Refer cases to peer review as indicated• Aggregate, trend and disseminate data• Sanction by facility to provide peer review protection in
accordance with state’s legislation and statutes
• Root cause analysis for sentinel events
Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: Rationale and process. Obstet Gynecol, 2014; 124(2 Pt 1): 361-6.
Severe Maternal Morbidity Review
Timing of Review
Multidisciplinary Review CommitteeReviewable Events
Review Methodology
• A peripartum event (pregnancy to first 24 hours postpartum) that requires 4 or more units RBCs
• A peripartum event that necessitates ICU admission
• Unexpected and severe event that occurs during pregnancy, peripartum, or postpartum
• OB providers• Anesthesia providers• Obstetric nurses• Quality
improvement team• Administration
• Consider patient advocate
• Scribe• Consider
partnership with regional perinatal center (small center)
• Timing of review will be determined by the severity of the event and number of events (i.e. larger birth facility may consider regularly scheduled meetings)
• Peer review protection (gather confidentiality statements from members)
• Past and current medical records
• Trained abstractor• Presentation of
primary review• Utilize standardized
format• Conclude
recommendations
Specific resources available at: https://safehealthcareforeverywoman.org/patient-safety-tools/
Debriefing
• Care providers involved in the SMM event
• Supplements standardized SMM review by multidisciplinary committee
Resources:Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity
review: Rationale and process. Obstet Gynecol, 2014; 124(2 Pt 1): 361-6.https://www.cmqcc.org/resources/1533/download
Type of event: _______________________ Date: ________________Location of event: ____________________ Members of team present: _________
Systems and processes that went well
Opportunities for improvement• Human factors (such
as communication, teamwork, situational awareness, decision making)
• Systems issues (such as availability of equipment, supplies, or medications; blood products; transport issues; staffing
IssueActions to be taken
Person responsible
Severe Maternal Morbidity, 1993-2014
Source: CDC. Severe maternal morbidity in the United States. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Updated on 11/27/2017. Retrieved on 2/19/2018.
• Acute MI• Aneurysm• Acute renal failure• ARDS• Cardiac arrest / v-fib• Conversion of cardiac
rhythm• DIC• Eclampsia• Heart failure / arrest
during procedure• Puerperal cerebral
disorders• Pulmonary edema• Sepsis• Shock• SCD• Air & thrombotic
embolism• Blood transfusion• Hysterectomy• Temporary
tracheostomy• Ventilation
SMM indicators and corresponding ICD codes during delivery hospitalization
SMM in 25 US Hospitals2008 - 2011
Grobman WA, Bailit JL, Rice MM, et al. Frequency of and factors associated with severe maternal morbidity. ObstetGynecol, 2014; 123(4): 804-10.
Secondary analysis of Eunice Kennedy Shriver NICHD MFMU Network cohort of women and neonates in 25 US hospitals
Obstetric Hemorrhage: Prioritization for Improving Quality of Care
Report and review:• Post-event debriefs• Multidisciplinary review • Monitor outcomes• Use data to guide
quality improvement initiatives
Systematic review of deliveries that require 4 or more units RBC
Target: 20-30% reduction in use of blood products
• Total number of transfusions in deliveries > 20 weeks
• Number of massive transfusions in deliveries > 20 weeks
http://www.jointcommission.org/sentinel_event _policy_and_procedures/
Main E. OB hemorrhage measures for hospital QI projects. CMQCC. Available at: https://www.cmqcc.org/resource/ob-hem-hemorrhage-measures-hospital-qi-projects. Published 3/24/2015. Accessed 2/20/2018
Council on Patient Safety in Women’s Health Care. http://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Obstetric-Hemorrhage-Bundle.pdf. Accessed 2/20/2018.
SMM Review: Other Priorities
• Appropriate and timely recognition of hypertensive disorder?
• Appropriate magnesium sulfate prophylaxis?
• Timely and appropriate recognition and treatment of severe hypertension?
• Appropriate timing of delivery• Appropriate management of
complicationsExample quality metrics• Cases admitted to ICU due to systems
issues• Elapsed time from onset of confirmed,
severe hypertension to initiation of antihypertensive therapy
• Total number of women with severe features of preeclampsia who receive magnesium sulfate for seizure prophylaxis
Hypertensive Disorders of Pregnancy
• Appropriate thromboprophylaxis?• Timely diagnosis of VTE?• Recognition of risk factors for VTE?
Venous Thromboembolism
• Timely diagnosis of sepsis or infection• Appropriate timing and selection of
antibiotics?• Appropriate (adequate) IVF volume• Identification of risk factors?
Infection / Sepsis
• Appropriate and timely diagnosis and management?
• Were risk factors recognized?• Appropriate consultation?
Cardiac Disease / Cardiomyopathy
https://safehealthcareforeverywoman.org/patient-safety-tools/severe-maternal-morbidity-review/
Maternal Safety Toolkits
Organization
Patient Safety Toolkits
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Sign
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ACOG District II Safe Motherhood Initiative
Council on Patient Safety in Women’s Healthcare
+AIM
+AIM
+AIM
+AIM
+AIM
+AIM
+AIM
CMQCC
PEC
Safe Motherhood Initiative (SMI)ACOG District II
• May, 2013• Standardized review and reporting of maternal
deaths in NY• Standardized practices for obstetric emergencies
associated with maternal mortality and morbidity• Education/engagement
Safety bundles
https://www.acog.org/About-ACOG/ACOG-Districts/District-II/Safe-Motherhood-Initiative. Accessed 2/20/2018
OB Hemorrhage
Severe Hypertension
VTE
• Maternal health initiative• Alliance for Innovation on Maternal Health (AIM)
• September, 2014• National data-driven maternal safety and quality
improvement initiative• Funded through MCHB
OB Hemorrhage
Maternal VTE
Severe hypertension
Maternal mental health-depression and
anxiety
Opioid use disorder
Postpartum basics
Prevention of retained vaginal sponge
Peripartumracial/ethnic disparities
Safe in primary C/S
Support after severe maternal event
Maternal early warning criteria
Severe maternal morbidity review
Toolkits for Quality Improvement
Safety bundles Safety tools
http://safehealthcareforeverywoman.org/. Accessed 2/20/2018
Som
e m
emb
ers
Heart Safe Motherhood: Innovation to Improve Maternal Outcomes, Experience and Cost Wednesday, November 28, at 2 p.m. ET
Meeting the Challenges to Reduce Maternal Risk: A Dialogue with Neel Shah, MDWednesday, December 5, at 12 p.m. ET
Reducing Maternal Morbidity and Mortality: The Providence Oregon ApproachThursday, December 13, at 12 p.m. ET
Upcoming Webinars
QUESTIONS?
Robyn Begley, DNP, R.N.AHA Senior Vice President and Chief Nursing Officer & CEO, American Organization of Nurse [email protected]
Jay Bhatt, D.O.AHA Senior Vice President and Chief Medical [email protected]
Patricia (Trish) M. Witcher, MSN, RNC-OBClinical Outcomes Manager, Northside Hospital [email protected]