Download Improving Patient Safety through the Initiation of a Massive

Initiation of a Massive
Transfusion Protocol in the
Obstetric Hemorrhage Patient
Brittany Waggoner MSN,RN, AGCNS-BC
Hendricks Regional Health
Danville, IN.
Hendricks Regional Health
Danville, IN.
• Childbirth Center
– Labor & Delivery
– Postpartum
– Level II NICU
– Approximately 1,200
deliveries/year
Objectives
• Identify obstetric hemorrhage and massive
transfusion protocol implementation strategies
• Explain the purpose of quantified blood loss
• Understand how to Standardize a Postpartum
Hemorrhage Process to include a Massive
Transfusion Protocol
• Identify ways to address barriers to
implementation
Introduction
• Obstetric hemorrhage remains one of the
leading causes of severe morbidity and
mortality in the United States.
• The overall rate in the United States increased
26% between 1994 – 2006
• Obstetric hemorrhage is one of the National
Partnership for Maternal Safety Initiatives.
Implementation
• Get your Quality Department to start the discussion.
• Create OB Harm Quality Improvement Team
• Identify which measure is your # 1 priority
– OB Hemorrhage
• Developed an OB Hemorrhage QI Team
– Set a timeline of 6 months
– Developed taskforces
•
•
•
•
Readiness
Response
Recognition
Reporting
Readiness
•
•
•
•
Hemorrhage Cart
Hemorrhage Kit
Resources
Mock Drills
Recognition
• Prenatal Assessment and Planning
• Hemorrhage Risk Assessment
– Admission
– Delivery
– Postpartum
• Standardize Measuring Blood Loss
– QBL vs. EBL
Quantified Blood Loss
• How do you do it?
– Weigh blood soaked items
– Measure using calibrated items
• Every Birth, Every Time
– Standardizes the process
– Too late when you “think” you need to do it
Estimating Blood Loss
Estimating Blood Loss
Nurses Estimating Blood Loss
19%
81%
Failed to
accurately
measure/diagnose
hemorrhage
Adequately
measured/diagnose
d hemorrhage
Estimating Blood Loss
A Comparision of Methods to Measure Blood Loss
3000
ML of Blood Loss
2500
2450
2000
1950
1900
1500
1650
1600
Guessing EBL
1500
1350
QBL - weighing
Based on drop in HgB
1000
500
1000
500
600
1050
1000
500
900
500
450
350
0
Guessing EBL
QBL - weighing
Based on drop in HgB
200 0
0
0
0
0
100 0
100 0
1
500
2
600
3
200
4
1000
5
500
6
500
7
350
8
100
9
100
1600
1900
0
0
0
0
0
0
0
1350
1950
1500
2450
1000
1650
1050
450
900
Response
• Advance through Postpartum Hemorrhage
Protocol
• Mobilize help and blood bank support
• Activate Massive Transfusion Protocol
• Assist in moving toward invasive surgical
approaches to control bleeding.
To ensure rapid and timely availability of
blood components to facilitate
resuscitation.
Postpartum Hemorrhage Protocol
• Stage 0
– Every woman in labor/giving birth
– Focus on risk assessment and active management
of third stage labor
• Stage 1
– Quantitative blood loss >500ml for vaginal delivery
or > 1000ml for cesarean section.
– Activate Postpartum Hemorrhage Protocol
Postpartum Hemorrhage Protocol
• Standardized process
–
–
–
–
–
–
–
–
–
Primary Nurse
First Responder
Second Responder
Recorder
Tech
Manager
Anesthesia
Provider
House Supervisor
Postpartum Hemorrhage Protocol
• Stage 2
– Continued bleeding or vital sign instability, and total
blood loss remains < 1500ml
– Advance through medications and procedures
– Mobilizing help
• Stage 3
– Total QBL > 1500 ml or > 2 u PRBC’s given,Vital sign
unstable, possible DIC
– Focus on Massive Transfusion Protocol and invasive
surgical control of bleeding.
Massive Transfusion Protocol
• Collaborative process between medical staff
and blood bank to provide blood component
therapy for massively bleeding patients.
• Adults requiring four units of packed red
blood cells within four hours or ten or more
units in less than 24 hours would qualify.
Process
The provider
recognizes the
need for and
initiates
Call is made to
the blood bank
to initiate with
the appropriate
patient
information
Runner is sent
to pick up 2
units of “ONegative”
uncrossmatched
PRBC’s.
They will stay
stationed in the
Blood Bank
when not
delivering blood.
Additional MTP
packs are sent
continuously
Blood Bank will
continue to
supply MTP
packs until the
someone
notifies them to
stop.
MTP Pack
Package
PRBC
PLASMA
PLATELETS
CRYO
1
4
4
-
-
2
4
4
1
1
3
4
4
-
-
4
4
4
1
1
Addressing the Barriers
• Difficulty obtaining blood product in a timely
manner when patients did not have a Type &
Screen upon admission
– Began Type & Screening every laboring patient’s
blood upon admission.
– Reduced our process steps by 60% and
crossmatched blood is available immediately.
Addressing the Barriers
• Lack of trust in the process
– Mock Drills!
– Mock Drills!
– Mock Drills!
Results
400
350
300
250
Blood Products Transfused
200
Deliveries
Per 1,000 Patients
150
100
50
0
3rd Quarter
2014
4th Quarter
2014
1st Quarter
2015
2nd Quarter
2015
3rd Quarter
2015
4th Quarter
2015
1st Quarter
2016
Results
• Reduced Blood Product Administration by 37%
Summary
• Most maternal mortalities and near misses due
to hemorrhage are preventable
• Preparation is key
–
–
–
–
1/3 of patients will have no risk factors prior to labor
Must be prepared for every patient
QBL every delivery so can respond early
Requires support not on individuals but on team
approach
Summary
• Early recognition
• Team work
• Sequential standardized application of patient
monitoring, evaluation, medications, and
procedures
References
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•
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Awhonn PPH Project.
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California Maternal Quality Care Collaborative; OB Hemorrhage Toolkit V. 2.0
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