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SIM CORNER

AIM Obstetric Hemorrhage Safety Bundle
January, 2018


by: Stacy Norton, MD

Ready, Educate, Simulate, Repeat!

As OBGYN hospitalists, we fill a unique role on the Labor and Delivery Unit. We serve as the liaison between the hospital’s healthcare staff, administration, private physicians, and the patient. It is this unique role that makes us the perfect providers to be the champion for implementation of the AIM Patient Safety Bundles at our individual institutions. AIM, or the Alliance for Innovation on Maternal Health, works at national, state, and facility levels to promote safe health care for every woman.
With this in mind, I’d like to focus this first Simulation Corner of 2018 to the AIM Obstetric Hemorrhage Safety Bundle.

Department Ready: 

  • A department that promotes a CULTURE OF SAFETY!
  • Ensure members work as a team, communicate well, have mutual respect and support, and a shared mental model. If not, perhaps an education on TeamSTEPPS or other communication tools is needed.
  • Commit your unit to a standardization of health care processes.
  • Recognition that a reduction in variation has been shown to improve outcomes and quality of care (2).
Equipment Ready:
  • Hemorrhage cart(s): supplies, check lists, and instructions for balloons and compression stiches (see addendum).
  • Immediate access to hemorrhage medications: involve pharmacy. Periodic re-evaluation of medications to reflect current guidelines and recommendation.
  • Massive Transfusion Protocol specific for OB. Involve blood bank and if applicable trauma team.
  • Establish OB Emergency Response Team: ob/gyn hospitalist, specific nursing staff, other rapid response teams, advanced gyn surgery etc.
Educate:
  • Providers and nursing staff on location and contents of carts. Gnosis modules or similar programs (4).
  • Physicians on use of medicines, devices and procedures used in obstetric hemorrhage.
Simulate:
  • Regularly scheduled and unscheduled unit-based drills.
  • Post drill debriefs.
  • Debrief actual hemorrhages.
  • Post event debrief - identify successes and opportunities for improvement.
  • Fill in education gaps, apply process improvements as needed, specific to your facility
Repeat & Report:
  • Review serious hemorrhages and look for opportunity for improvements.
  • Monitor outcomes and keep metrics for quality improvement.

 

Simulation:
Length: 10-30 minutes depending on end point chosen by user.

Physical Space: Delivery room with possible transfer to operating room.

Primary Issue being assessed: Staff knowledge and treatment of obstetric hemorrhage. (Keep in mind user may modify drill to assess effective communication in emergencies, patient flow in a physical space, unit’s preparedness with necessary tools and materials to meet staff’s needs in an emergency etc.).

Scenario:

  • Ms. A.N. is a 37-year-old, G6P4 who just delivered a 4100 gm male infant. She had gestational diabetes (poorly controlled) and polyhydramnios.
  • The placenta has not yet delivered. Her blood pressure is 128/71, Pulse 102, Temp 36.7 Celsius.
  • There is a large amount of vaginal bleeding.
  • Pt is conscious and alert currently. States she is starting to feel funny.
  • Scene opens with primary Ob, labor room nurse, patient and concerned family member in the delivery room.
Additional Information:
Weight: 225 lb
PMH: Gestational diabetes
PSH: None
NKDA
Meds: glyburide 5mg daily, PNV
SH: denies all toxic habits
FH all healthy per pt
 
Labs:
Blood type  B+
CBC : WBC 11.2    H/H  11.7/33.1   Plts  165
She is typed and screened, no crossed matched blood.
 
Participants:
  1. Primary obstetrician
  2. Delivery room nurse
  3. Concerned family member
  4. Anesthesiologist
  5. Support nurse
  6. Support physician
  7. Runner for the blood bank.
  8. Simulation observer assessing whether objectives and goals are met.
Objectives:
Participants should go through steps of:
  1. Administration of postpartum pitocin immediately after cord is clamped and prior to delivery of placenta.
  2. RN and MD to have a running assessment of  qualitative blood loss.
  3. Call for additional help:  additional OB, anesthesiology, charge nurse, etc.
  4. Call for hemorrhage cart.
  5. Start another IV line.
  6. Begin use of uterotonics medications, then devices or sutures.
  7. Keep patient and family informed.
  8. Debrief the event.
Goals of the simulation include:
  1. Participants promptly recognize the diagnosis of postpartum hemorrhage.
  2. Participants recognize/identify changes in patient's vital signs and symptoms.
  3. Participants use best available evidence to treat hemorrhage.
  4. Participants understand the importance of good teamwork in the management of hemorrhage.
  5. Tasks are delegated and help is sought and received.
Simulation end options. Simulation drill ends with:
a)    Bleeding responds in delivery room with use of meds.
b)    Bleeding responds in OR s/p
- D&C for retained products or
- Identification and treatment of laceration or
- Placement of compression balloon

c)    Bleeding responds in OR s/p x-lap where compression sutures are used, or hysterectomy, or no response s/p hysterectomy and patient goes into DIC.

Debrief:
  1. What went well?
  2. What were some obstacles?
  3. What are areas for improvement?

I hope you will join me in my "New Year's Resolution" of helping my facility implement and execute both the AIM Patient Safety Bundles of Obstetric Hemorrhage and Hypertension by the end of 2018!
 
Happy New Year!
 

References and resources:

  1. Council on Patient Safety | Women & Mothers' Health Carewebsite www.safehealthcareforeverywoman.org
  2. ACOG Practice Bulletin Summary Number 183, October 2017
  3. ACOG Committee Opinion Number 629, April 2015
  4. TeamSTEPPS
  5. Gnosis; www.mygnosis.com
 
SOGH Simulation Co-Chair
STACY NORTON, MD F.A.C.O.G.
Dr. Norton is the Team Lead physician at Memorial Herman The Woodlands Medical Center. Questions or comments, please email us at newsletter@societyofobgynhospitalists.com
 
 
Addendum:
Sample Hemorrhage Cart
 
DRAWER # 1  
PPE’s (gown, hat, shoe covers) 1 set
Drapes 2
Buttocks Drapes 1
Massive Transfusion Protocol slip for Blood Bank 1
C/S Papers 1
Locks for drawers 1 pkg
Blood Transfusion Procedure 1
DRAWER #2  
KY Jelly 1
O2 Mask 1
Betadine 2
Red Rubber Catheter 1
IV Start PACK 1
Lab Draw Supplies - (Vacutainer, gauze, alcohol prep, blood tubes:1 blue, 1 pink, 2 gold, 1purple, tourniquet, band- aids) 1 pkg
Injection Needle & Syringe3 (22 gauge) 3 each
Extras tray- 2 ea: 18G, 20G & Butterfly catheters, 3 vacutainer hubs, 5 vacutainer needles, 5 vacutainer adaptors  
Blood tubing & Pressure Bag 1 each
DRAWER #3  
Gloves Various sizes
Sutures-1-0 Chromic CT-1, 2-0 Chromic CT-1, 2-0 Chromic SH, 2-0 Chromic V-34,3-0 Chromic CT-1, 3-0 Chromic SH,2-0 Vicryl CT-1, 2-0 Vicryl SH, 3-0 Vicryl CT-1, 3-0 Vicryl SH 3 each
16” Vaginal Swabs 4
Sterile Towels 1 pkg
Laps 2 pkg
Kerlix 1 pkg
Vaginal Packing Large & Small 1 each
4x4’s 2 pkg
RF Assure Drape 1 pkg
DRAWER # 4  
Disposable Speculum 1
Instruments: Large Curette, Rt. Angle Retractor, 1 each
Postpartum Hemorrhage Instrument Tray 1
Postpartum Hemorrhage Balloon 1
Foley 1
60 cc syringe 2
Leg Bag for Balloon drainage 1