Obstetric Hemorrhage - Paul Ogburn, MD - PowerPoint .

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OBSTETRICHEMORRHAGEPaul Ogburn, MDDirector, Maternal-Fetal MedicineStony Brook University

IMPROVEMENTS INHEALTHCAREMOTIVATIONKNOWLEDGERESOURCESSYSTEMS

OBJECTIVESMotivate your involvement in decreasingmaternal mortality due to HemorrhageIncrease your Knowledge in treatingObstetric HemorrhageDescribe a System for managingObstetrical Hemorrhage emergenciesOffer Resource assistance for yourdevelopment of systems improvement

MOTIVATIONEvery day across the United States, 2-3 womendie due to pregnancy-related complications(World Health Report 2005)New York State has the highest rate of maternalmortality in the United States, 12.8/100,000 (2002).The most common causes of maternal death arepregnancy induced hypertension (PIH),embolism, obstetrical hemorrhage and infection.Obstetrical hemorrhage is known as the mostpreventable cause of maternal mortality.

MOTIVATION IIHemorrhage accounted for 15.2% of all reportedmaternal mortalities in New York State between2003 and 2005 (SMI ACOG Report 2005).Ninety-seven percent (97%) of all hemorrhagicdeaths occurred while women were hospitalized.These deaths spanned all socioeconomicclasses; in addition to the deaths, an even largernumber of “near misses”, women who had severehemorrhages but survived, were reported.

MOTIVATION IIITo Decrease Maternal Mortality due toHemorrhage, ACOG and the NYDOHrecommend that all Obstetric Unitsdevelop effective guidelines for themanagement of Obstetrical Hemorrhage.

KNOWLEDGEWhat is the mechanism of death in acuteobstetric hemorrhage?How can you delay this death with onehand?

KNOWLEDGEWhat is the mechanism of death in acutehemorrhage? --- Cardiac DecompensationThe coronary arteries fill only in diastole.Hemorrhage decreases diastolic pressureand filling time (decreasing O2 to theheart) while increasing cardiac oxygenrequirements.

KNOWLEDGEHow can you delay this death with onehand? --- Manual Compression at theBifurcation of the Aorta.Restores diastolic pressure and slows heartrate to allow improved coronary perfusionand decreased cardiac oxygenconsumption.“Buys time” until blood and help can come.

SYSTEMIn an effort to decrease therisk of maternalhemorrhage relatedmorbidity and mortality, thePerinatal Service at StonyBrook University Hospitaldeveloped a MaternalHemorrhage Task Force.

Code Noelle:An Interdisciplinary Approachto Reducing Maternal Morbidity andMortalitySecondary to Maternal HemorrhageA. Combs, RNC, W. Davila, RNC,A. Lynch, RNC, D. Galanakis, MD,T. Griffin, MD, P. Ogburn, MD,E. Steinberg, MD, R. Adsumelli, MD

METHODS IAn interdisciplinary group was formed andcharged with improving the processesrelated to caring for pregnant women atrisk for hemorrhage and systems thatimpact their care.The task force then developedinterdisciplinary hemorrhage protocols withemphasis on rapid access to bloodproducts.

METHODS IIEducational programs with didacticcomponents and simulation drills weredeveloped to assist the staff withpreparing for emergencies and toidentify system issues.Monthly debriefing meetings to reviewthe responses to simulated and realmaternal hemorrhages and to identifyareas of strength and areas that requireimprovement have been established.

OUTCOMES IOrder sets have been developed by ateam including Nursing, Obstetrics,Anesthesiology, and Blood Bank.The order sets include admission ordersfor all OB patients which identify risk ofhemorrhage and a set of ordersspecifically designed for maternalhemorrhage.A “Code Noelle” administrative policyand procedure has been developed.

OUTCOMES IIEducation and ongoing simulation drillsutilizing a computerized obstetricalmannequin are ongoing.Monthly interdisciplinary meetings occur toaddress issues identified by reviewingevaluation tools from simulations and chartreview for any actual maternalhemorrhage.

OUTCOMESORDERS for L&DINCLUDES:1. Risk Assessment2. Risk AppropriateOrders

Obstetrical HemorrhageOrders

Developing Simulation DrillsNoelle, TM, Gaumard Scientific Company Inc is anObstetric, computerized mannequin.She has the capability to give birth,elicit simulated FHR strips and can beused with ultrasound technology.Noelle was modified to be used inhemorrhage simulation.

Noelle TM,Gaumard Scientific Company Inc.

Developing Simulation DrillsNoelle is admitted tothe hospital censuswith a MRN andencounter number.Blood is also drawnand processed by thelab and blood bank.Results appear underher name in the PowerChart system.

Developing Simulation DrillsThe hospital operatorscall an overhead CodeNoelle and initiate a“Group Page” of criticalpersonnel.Distribution servicesassist during the drillwith the transporting ofblood products,specimens NOELLENURSEMANAGERL&DGYN-ONCSURGEONADN

Pictured above: T. Griffin and “Noelle” TM,Gaumard Scientific Company Inc.

Pictured above: L. Gioia, MD, A. Miller, RN, A. Hall, RNand other members of the L&D staff during a “Code Noelle” drill.

Pictured Above: E. Steinberg, MD, M. Kang, MD, A. Hall, RN, S. Micelli, RN during simulation.

OB Residents ApplyingBimanual CompressionPictured Above: N. Ostrov, MD and M. McDowell, MD.

OB and AnesthesiaPictured Above: P. Ogburn, MD, M. Kang, MD and T. Saunders, MD

Post Code Noelle Debriefing

Code Noelle DrillEvaluation Forms

Monthly Code Debriefing

PHYSICIAN OBSTETRICALHEMORRHAGE FLOW SHEETPaul L. Ogburn, MD

PRACTICE CHANGES:COMMUNICATIONThe development of an overhead “Code Noelle”group page to rapidly notify critical personnelThe development of roles for the professional andancillary nursing staff including triage, nursescribe and runnersThe involvement of distribution services tofacilitate elevator availability to move specimens,blood products and personnelThe development of a unit based telephonedirectory that contains important hospitalextensions

PRACTICE CHANGES:DOCUMENTATIONThe creation of forms to assistclinicians in the assignment ofhemorrhage risk and thedevelopment of a complete order setto facilitate rapid response in theevent of an actual hemorrhageThe development andimplementation of the MD OBHemorrhage Flow Sheet for interservice ongoing patient assessmentand management

PRACTICE CHANGES:EQUIPMENTOrganization of supplies for OBemergenciesSynchronization of the clocks in theLDRs and ORs on the computersystems, to assure accuracy andproper documentation of eventsThe review of existing surgical traysfor adequacy of instruments

PRACTICE CHANGES:EDUCATIONComprehensive interdisciplinary OBHemorrhage Education for all faculty,private physicians, midwives and inhospital OB staffImproved education regarding bloodproducts, how to requisition themand differentiating between stat andemergency blood requestsThe development of objective criteriato call a “Code Noelle”

CONCLUSIONSA systematic, team based, maternalhemorrhage protocol has beenimplemented at SBUH.Drills provide a platform to identify systemissues and prepare for maternalemergencies.Hemorrhage drills and systematic, nonpunitive chart review of actual maternalhemorrhages will decrease the risk ofadverse maternal outcomes.

Obstetric HemorrhageStony Brook University Hospital hasimplemented a system for dealing withobstetrical hemorrhage to decrease the risk ofmaternal mortality. The components of thesystem stence5.Continuous improvement

Obstetric Hemorrhage1. Education – includes an educational CD.2. Preparation – includes:a.standard admission orders for labor/delivery;b.standard orders for obstetrical hemorrhageemergency;c.a system developed to maintain obstetricalcontinuity with Maternal Fetal Medicinesupervision for 24 hours after initiation of theobstetrical hemorrhage emergency;d.appropriate equipment for labor and delivery;e.appropriate training for physicians andnurses.

Obstetric Hemorrhage3. Vigilance - is maintained by virtue of thesystem of orders, training, and monitoringwhich includes the education and preparationmentioned above.4. Persistence - occurs for each individual patientby virtue of the mandated 24 hour monitoring(supervised by the perinatal and obstetricalteams) following the acute hemorrhage event.5. Formal training - concerning obstetricalhemorrhage will occur for physicians andnurses (with additional practical drills).

RESOURCESCopy of this Powerpoint presentationCopy of SBUH mandatory educationalPowerpoint presentationCommitment from Stony Brook RPC togive technical assistance (if requested) toeach obstetric unit/hospital in SuffolkCounty in developing individualizedObstetric Hemorrhage protocols

SPECULATIONContinued focus onimprovingsystems andinterdisciplinarycommunicationwill decrease longterm maternalmorbidity andmortality.

Obstetric Hemorrhage - Paul Ogburn, MD - PowerPoint Presentation Author: Paul Ogburn, MD, Director, Maternal-Fetal Medicine, Stony Brook University Subject: Obstetric Hemorrhage - The information posted provides information about how to prevent and best manage maternal

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