Download OB Harm Reduction - slides - Ohio Hospital Association

Premier’s Focus: OB Harm Reduction
Deborah Kilday, MSN, RN
Senior Performance Partner
Premier, Inc.
September 11, 2015
Maternal mortality
Approximately 4.1 million women in the U.S. between the ages of 15
and 50 gave birth from May 2013 to May 2014.
In 2013, 18 mothers died in the U.S. for every 100,000 live births,
The U.S. has FALLEN to 64th in the world on maternal mortality.
The U.S. ranks 3rd in the world for C/S, where 30% of women have
surgical deliveries
Adverse events occur in approximately 9% of all deliveries in the US.
at a cost of $17 billion annually
Leading causes of maternal death:
1. Obstetric Hemorrhage
2. Preeclampsia
3. Embolism
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Just the tip of the iceberg
For every 1,000 deaths, there are 10.000 cases of severe morbidity
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Preventable harm
Maternal Hemorrhage
Preeclampsia and Eclampsia
Early Elective Deliveries
Perineal Trauma
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“The 4 R’s”
Improve Readiness
• Implementing standardized protocols
• Regular ongoing unit based team drills and education
• Rapid availability of resources and medications
Improve Recognition
• Patient family education and communication
• Assessment of risk on admission - ongoing
• Early warning tools for vitals and symptoms
Improve Response
• Using standardized protocols with checklists
• Trained and activated teams
Improve Reporting
• Multidisciplinary monitoring and review
• Debrief/Huddles
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Safety Bundles
“What every birthing facility in the U.S. should have…”
1. Maternal Early Obstetrical Warning
System
2. Obstetric Hemorrhage
3. Hypertension in Pregnancy
4. Venous Thromboembolism in
Pregnancy
5. Reducing low-risk primary cesarean
deliveries
6. Reduction of Peripartum Racial
Disparities
7. Patient Family and Staff Support
8. Standards of Care for the
Interconception/Postpartum Visit
The Council on Patient Safety in Maternal Health Care
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QUEST perinatal resources and support
Process Maps
Perinatal Safety Index
Performance Partner
QUEST Workgroups
• Mortality Workgroup
• Safety Workgroup
National Meetings
Learning Collaboratives
Alliance for Innovation on
Maternal Health (AIM)
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Collaboration and education
Links to recorded 2015 webinars:
May 8: Improving outcomes in hypertensive disorders of pregnancy - Premier Advisor Live
May 20: What providers should know about maternal opioid use and abuse - Premier Advisor Live
June 9: Maternal substance abuse and neonatal abstinence syndrome - Premier Advisor Live
July 21: Introduction of the national safety obstetrical VTE bundle - Premier Advisor Live
Upcoming 2015 webinars:
September 23, 1:00 – 2:30 pm EST: Perinatal Care Core Measures Update - THA
October 21, 11:00 am – 12:00 pm EST: Exclusive breastfeeding – GHA
October 27, 12:00 pm – 1:00 pm EST: Postpartum Hemorrhage - THA
November 18th at 3:00 pm EST: Reducing primary cesarean births - Premier Advisor Live
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Additional areas of focus
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Premier Connect Resources
Perinatal Safety Community
Open to all Premier Members
• Networking
• Share knowledge
• Current resources
• Advance evidence-based
clinical practices and
processes
• Promote safe, reliable,
quality care
• Links to education
External link to the Premier Safety Institute coming soon!
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Culture of Safety
Improving Team “Readiness, Recognition and Response”
Safety culture concepts;
Strong leadership
Multidisciplinary team
interaction
Adherence to principles of
evidence based medicine
Standardized policies and
procedures for clinical
operations
Common terminology
Timely communication
High degree of emergency
readiness
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“Collective Mindfulness”
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Collaborating Partner Links
Advisor Live Education
American College of Obstetricians and Gynecologists
Association of Women’s Health, Obstetric, and Neonatal
Nurses
Council on Patient Safety in Women's Health Care
California Maternal Quality Care Collaborative
The Preeclampsia Foundation
Premier Safety Institute
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Questions and Contact information
Deb Kilday, MSN, RN
Senior Performance Partner
Clinical Advisory Services
[email protected]
678-773-5052
or
Kelly Conklin, MSN, RN
Senior Director
Member Engagement
[email protected]
828-334-4442
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