Meeting the New Joint Commission's Maternal Safety Requirements: A Quantitative Blood Loss Train-the-Trainer Program for Improved Process and Outcomes.

INTRODUCTION: Recently, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice encouraged the use of quantitative and cumulative assessment of maternal blood loss (QBL) as part of safety bundles for prevention of postpartum hemorrhage. The aim of this study was to determine whether our train-the-trainer QBL program improved process and patient outcomes. METHODS: In this pre-post interventional study, 26 "champions" participated in the QBL train-the-trainer program in preparation for patient safety bundle rollout. The multipart program included at least 3 simulated C-section hemorrhage scenarios and rapid-cycle debriefing. Champions used the curriculum for broad staff training for 2 months before safety bundle implementation.Six months each of preintervention and postintervention data were collected from medical records of all qualified cases (N = 4413). Process outcomes were evaluated by comparing number of women who received QBL. Patient outcomes were evaluated by comparing blood transfusion rates and number of morbid cases (≥4 packed red blood cell units). χ2 test was used for analyses. RESULTS: Review of medical records indicated that 99.8% of 2218 women received QBL posttraining compared with 16.6% of 2195 women receiving QBL before training (P = 0.0001.) Transfusion rates increased from 54.47 to 69.25 units/1000 mothers. The rate of morbid cases (≥4 red blood cell units) dropped from 2.13 to 0.48 cases/1000 mothers. CONCLUSIONS: Our findings suggest the train-the-trainer QBL program was associated with improved process and decreased morbidity when implemented with a hemorrhage safety bundle. Further research is required to examine components of simulation-based QBL training methods and implementation to evaluate their impact on clinical outcomes.

User Perceptions of an Electronic Maternal Alerting System.

This survey study evaluates the user experience of an electronic maternal early warning system that generates automated pages. Survey domains included the system's effect on patient care, alarm fatigue, and continued use of the system. The response rate was 47.7% (273 of 572). A majority, 83%, felt that the system should remain in use, and 64.5% felt it improved patient safety. Of those who believed that they had received a page, 51.4% felt that they received pages "too frequently." Although alarm fatigue was not fully evaluated, providers on our unit support the continued use of this automated maternal electronic surveillance system.

Use of a Novel Electronic Maternal Surveillance System and the Maternal Early Warning Criteria to Detect Severe Postpartum Hemorrhage.

BACKGROUND: A leading cause of preventable maternal death is related to delayed response to clinical warning signs. Electronic surveillance systems may improve detection of maternal morbidity with automated notifications. This retrospective observational study evaluates the ability of an automated surveillance system and the Maternal Early Warning Criteria (MEWC) to detect severely morbid postpartum hemorrhage (sPPH) after delivery. METHODS: The electronic health records of adult obstetric patients of any gestational age delivering between April 1, 2017 and December 1, 2018 were queried to identify scheduled or unscheduled vaginal or cesarean deliveries. Deliveries complicated by sPPH were identified and defined by operative management of postpartum hemorrhage, transfusion of ≥4 units of packed red blood cells (pRBCs), ≥2 units of pRBCs and ≥2 units of fresh-frozen plasma, transfusion with >1 dose of furosemide, or transfer to the intensive care unit. The test characteristics of automated pages and the MEWC for identification of sPPH 24 hours after delivery were determined and compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and their 95% confidence intervals (CIs). McNemar test was used to compare these estimates for both early warning systems. RESULTS: The average age at admission was 30.7 years (standard deviation [SD] = 5.1 years), mean gestational age 38 weeks 4 days, and cesarean delivery accounted for 30.0% of deliveries. Of 7853 deliveries, 120 (1.5%) were complicated by sPPH. The sensitivity of automated pages for sPPH within 24 hours of delivery was 60.8% (95% CI, 52.1-69.6), specificity 82.5% (95% CI, 81.7-83.4), PPV 5.1% (95% CI, 4.0-6.3), and NPV 99.3% (95% CI, 99.1-99.5). The test characteristics of the MEWC for sPPH were sensitivity 75.0% (95% CI, 67.3-82.7), specificity 66.3% (95% CI, 65.2-67.3), PPV 3.3% (95% CI, 2.7-4.0), and NPV 99.4% (95% CI, 99.2-99.6). There were 10 sPPH cases identified by automated pages, but not by the MEWC. Six of these cases were identified by a page for anemia, and 4 cases were the result of vital signs detected by the bedside monitor, but not recorded in the patient's medical record by the bedside nurse. Therefore, the combined sensitivity of the 2 systems was 83.3% (95% CI, 75.4-89.5). CONCLUSIONS: The automated system identified 10 of 120 deliveries complicated by sPPH not identified by the MEWC. Using an automated alerting system in combination with a labor and delivery unit's existing nursing-driven early warning system may improve detection of sPPH.