Na0onal

Ini0a0ves to Improve
Maternal Safety:
Na0onal Partnerships

Perinatal Quality Collabora0ve of North Carolina

February 11, 2015

Disclosures and Alia0ons

M. Kathryn Menard, MD, MPH
kmenard@med.unc.edu
Professor and Vice Chair ObGyn
University of North Carolina School of Medicine
Division of Maternal Fetal Medicine
Co-Director of UNCs Center for Maternal and Infant Health
Co-Lead of Region IV and VI Regionaliza0on WorkGroup
Past President, Society for Maternal Fetal Medicine, 2012-13
Medical Director, North Carolinas Pregnancy Medical Home

Materials presented have been shared by Partnership colleagues: Main,
DAlton, Kilpatrick, Callaghan, Mahoney, Bingham, Cornell and others

Learning Objec0ves
The case for maternal quality work
What is the Na0onal Partnership for
Maternal Safety
Why did it convene?
What are the products coming from the
Partnership? Maternal Safety Bundles.
What is the Council on Pa0ent Safety in
Womens Health?
How can this work help support perinatal
quality collabora0ves?

What is the purpose and content of the

newly developed Levels of Maternal Care?

U.S. Maternal Mortality

Maternal Deaths per 100,000 Live Births

40
35

Total

White

Black

30
25
20

13.3

15

16.1

8.2

10
5
0
1982

1985

1988

1991

1994

1997

2000

2003

2006

2009

Source: Singh GK. Maternal Mortality in the United States. A 75th Anniversary Title V Publica0on. HRSA 2010 5

 Maternal Mortality

Maternal Morbidity

Maternal Mortality and Morbidity

10 deaths per

100,000 live births

(1990)

16.7 deaths per

100,000 live births

(2010)

52,000 experienced a severe morbidity in 2012

MATERNAL MORTALITY PER 100,00 LIVEBORN INFANTS

2.6

9.0

6.5

5.0

10.3

10.1

9.2

10.9

9.0

15.0

7.2
7.8

10.0
10.9

21.0

8.2

9.0
9.9

7.1

2.9

16.5

16.0
19.0

10.5

17.9

8.3
10.9

11.0
20.1

18.7

10.4

11.6

12.0
20.9

14.8

3.2

13.9

Source: NLWC from Center for Disease

Control and Preven0on, Na0onal Center
for Health Sta0s0cs 1999-2006

4.8
7.5 5.2
16.5

8.2

12.7

12.5
7.6

18.9
10.1

17.0

1.2

10.3

> 18.0
13.0 -18.0
<13.0

What is the Na0onal Partnership

for Maternal Safety?

A converging of ini0a0ves and

leadership toward one goal:
Decrease maternal morbidity and
mortality in the United States

Public Health Ini0a0ves

Division of Reproductive Health

CDC: Maternal Mortality Ini0a0ve for
strengthening exis0ng or guiding
new MM Review commicees

Maternal Child Health Bureau

COIIN (Collabora0ve Improvement

and Innova0on Network) to Reduce
Infant Mortality
Emphasis on Life Course Perspec0ve

AMCHP Every
Mother Initiative

Merck for Mothers MMR

Action Learning Collaborative
Enabling and enhancing state MM and SMM reviews

The MMR Ac0on Cycle

Recommend &
Take Ac0on

Case Review &

Synthesis

Case Iden0ca0on
& Selec0on

Data Collec0on
& Abstrac0on

**Adapted from: Berg, CJ. From Iden0ca0on and Review to Ac0onMaternal Mortality
Review in the United States. Semin Perinatol 2012; 36(1): 7-13.

Professional Socie0es

Pukng the M back in MFM

Division of Reproductive Health

Maternal Mortality Review

Postpartum Hemorrhage Project

A Call to Ac0on

What are we doing to reduce

maternal mortality and
morbidity in a maternal
popula7on with an
increasing incidence of
chronic disease?
DAlton ME, Obstet Gynecol 2010;116:14014

Recommended Guidelines
Urgent development of na0onal
management guidelines:
Hypertensive disorders in pregnancy
Postpartum hemorrhage
Preven0on of venous thromboembolism
Diagnosis and management of placenta accreta
Management of the obese obstetrical pa0ent
Management of cardiac disease in pregnancy
Pu;ng the M back in maternal-fetal medicine. Am J Obstet Gynecol. 2013 Jun;208(6):442-8


Obstetrical Care and Services
High risk women:
Timely iden0ca0on and referral of pa0ents for
ter0ary care

Low risk women:

Comprehensive na0onal eort to educate all
providers on the preven0on and treatment of
obstetrical complica0ons

Pu;ng the M back in maternal-fetal medicine. Am J Obstet Gynecol. 2013 Jun;208(6):442-8

State Quality Collabora0ves

ACOG-CDC Work Group

ACOG-CDC Maternal Mortality/Severe Morbidity Ac0on Mee0ng
occurred in Atlanta, November 2012
Par0cipants iden0ed key priori0es
Core Pa0ent Safety Bundles
Obstetric Hemorrhage
Severe Hypertension in Pregnancy
Venous Thromboembolism Preven0on in Pregnancy
Supplemental Pa0ent Safety Bundles
Maternal Early Warning Criteria
Facility Review
Family and Sta Support

6 mul0disciplinary working groups were formed

Prelim products presented in New Orleans 2013
DAlton ME, et al. Obstet Gynecol 2014 May;123(5):973-977.

May 2013, New Orleans: Na0onal Partnership

Partnership
M
ilestones
for Maternal Safety was born
Consensus mee0ng sponsored by HRSA MCHB and convened by
ACOG/CDC Maternal Mortality Commicee and the Society for
Maternal and Fetal Medicine
Representa0on from major Medical Socie0es, State and Federal Public
Health, Payers and Regulatory agencies

Safety bundles
Obstetric hemorrhage
Severe Hypertension/Preeclampsia
Preven0on of Venous Thromboembolism in Pregnancy
Suppor0ng materials
Facility based reviews of Severe Maternal Morbidity
Maternal Early Warning Signs
Family and Sta Support

Na0onal Partnership for Maternal Safety was born

Organiza0ons Represented at
May 2013 SMFM-ACOG Mee0ng
Professional Organiza0ons

Pa0ent Safety and Quality Care Organiza0ons

American Associa0on of Blood Banks

American Academy of Family Prac0ce
American College of Nurse Midwives
American College of Obstetricians and Gynecologists
Associa0on of Maternal and Child Health Programs
Associa0on of Womens Health Obstetric & Neonatal
Nurses
Society for Maternal and Fetal Medicine
Society of Obstetric Anesthesia & Perinatology
Na0onal Associa0on of Nurse Prac00oners in
Womens Health

California Maternal Quality Care Collabora0ve

CRICO
Cynosure Health
Ohio Perinatal Quality Collabora0ve
Pa0ent Safety Council
The Joint Commission

Federal Agencies
Armed Services
Centers for Disease Control
Indian Health Service
Maternal and Child Health Bureau
Na0onal Ins0tute of Child Health and Development

Perinatal Care Facili0es

American Associa0on of Birth Centers
American Hospital Associa0on
Hospital Corpora0on of America
Voluntary Hospital Associa0on
Founda0ons and Advocacy
Merck for Mothers
Preeclampsia Founda0on

What is the Council of Pa0ent Safety in

Women's Health?
Mission: Con0nually improve pa0ent safety in womens health
care through mul0disciplinary collabora0on that drives culture
change
Vision: Safe health care for every woman
Purpose: To reduce harm in pa0ents by fostering
Inves0ga0on to becer understand the causa0on of harm

Programs and tools to implement pa0ent safety ini0a0ves

Educa0on to promote pa0ent safety
Dissemina0on of pa0ent safety informa0on
A health care culture of respect, transparency and accountability

hcp://www.safehealthcareforeverywoman.org/

July 2013: Na0onal Partnership for Maternal

Safety adopted by Council on Pa0ent Safety
What every birthing facility
in the US should have
3 Bundles in three years
Obstetric Hemorrhage
Preeclampsia/ Hypertension
Preven0on of VTE in Pregnancy
Note: The bundles represent outlines of highly recommended protocols and materials
important to safe care BUT the specic contents and protocols should be
individualized to meet local capabili7es. Example materials are available from
perinatal collabor7ves and other organiza7ons.

The bundle is available

for download on the
Council website

hcp://
www.safehealthcarefore
verywoman.org/

Implementa0on Support Materials

 Status as of Feb 2015

Core Pa0ent Safety Bundles

Council

Published

Obstetric Hemorrhage

July 2014

Final Submiced

Current Status of Bundles

Severe Hypertension in Pregnancy

Feb 2015

TBS Apr 2015

Venous Thromboembolism Preven0on in Pregnancy

Feb 2015

TBS Apr 2015

Supplemental Pa0ent Safety Bundles

Status

Published

Complete

Oct 2014

Facility Review

Complete

May 2014

Family and Sta Support

In progress

TBS Apr 2015

Maternal Early Warning Criteria

Hypertension Safety Bundle (Drau)

Readiness: (every unit)

Standards for early warning signs, diagnos0c criteria, monitoring

Unit team educa0on, reinforced by regular unit-based drills with debriefs.
Process for a 0mely triage and evalua0on of pregnant and postpartum women with
hypertension including ED and outpa0ent areas.
Rapid access to medica0ons used for severe hypertension/eclampsia:
System plan for escala0on, obtaining appropriate consulta0on and maternal transport,

Recogni0on: (every pa0ent)

Standard protocol for measurement and assessment of BP and urine protein

Standard response to maternal early warning signs including listening to and inves0ga0ng
pa0ent symptoms.
Facility-wide standards for educa0ng prenatal and postpartum women

Response: (all severe hypertension/preeclampsia)

Facility-wide standard protocols with checklists and escala0on policies for management and
treatment of: Severe hypertension; Eclampsia, seizure prophylaxis, and magnesium over-
dosage; and Postpartum presenta0on of severe hypertension/ preeclampsia
Support plan for pa0ents, families and sta for ICU admissions and serious

Repor0ng/Systems Learning

Care team huddle for high risk cases and team debrief following SMM event
Review all severe hypertension/eclampsia cases admiced to ICU for systems issues
Monitor outcomes and process metrics.

VTE Preven0on Safety Bundle (drau)

READINESS (Every Unit)

Standardized thromboembolism risk assessment tools with recommenda0ons for prophylaxis

during:
Outpa0ent prenatal care
Antepartum hospitaliza0on
Hospitaliza0on auer cesarean or vaginal deliveries
Postpartum period (up to 6 weeks auer delivery)

RECOGNITION (Every Pa0ent)

Apply standardized tools to assess thromboembolism risk at various 0me points during
pregnancy
Iden0fy appropriate pa0ents for thromboprophylaxis
Provide pa0ent educa0on

RESPONSE (Every Unit)

Recommenda0ons for mechanical thromboprophylaxis
Recommenda0ons for dosing of prophylac0c and therapeu0c pharmacologic an0coagula0on
Recommenda0ons for appropriate 0ming of pharmacologic prophylaxis with neuraxial anesthesia

REPORTING/SYSTEMS LEARNING (Every Unit)

Review all thromboembolism events for systems issues and compliance with protocols
Monitor process metrics and outcomes in a standardized fashion
Assess for complica0ons of pharmacologic thromboprophylaxis

Key Partner: The Joint Commission

Revision of Sen0nel Event Deni0on for Obstetrics:

All cases of maternal Severe Morbidity.
1. Transfusion of 4 units of packed red cells
2. Admission of the mother to an ICU
.have a RCA (systems improvement assessment)

Pa0ent Safety Council website posts facility

based review forms

Improving OB Safety/Reducing Maternal Harm:

Severe Morbidity Measures:

For internal hospital use:
All mothers admiced to ICU or 4 units of
transfusion (any product) mini-RCA
For popula0on use:
--CDC study using ICD9 diagnosis and
procedure codes to iden0fy major organ
failure (eg ven0la0on, renal failure) (~1%)

Bundle Implementa0on

October 2014: Grant awarded by MCHB
Alliance for Innova0on on Maternal Health (AIM)
State based collabora0ves, engaging hospitals, providers,
public health and payers
Emphasis on popula0on based and hospital based data
Includes development of bundle to prevent primary
cesarean and strategy for educa0on
Added partners: AMCHP, ASTHO, PCHHC, IHI
$1,000,000/year for 4 years

Perinatal Quality Collaboratives in the US:

Work in progress for publica0on. Please do not share outside of this group.

Most Common Maternal and

Neonatal Projects
Maternal Projects

Neonatal Projects

Hemorrhage (11)

Elec0ve deliveries < 39 weeks (24)

Preven0ng rst cesarean (6)

Neonatal Abs0nence Syndrome(10)

Hypertension (4)

Promo0on of Breas}eeding (9)

Tobacco cessa0on (4)

Preven0ng catheter associated blood

stream infec0ons (6)

Screening for alcohol and depression (3)

Preven0ng PTB (5)

LARC (2)

Antenatal steroids (3)

Preconcep0on (2)

Golden Hour (3)

Preven0ng SIDS (3)

Projects by State

CA

FL

NC

NY

OH

TN

IL

X
X
X

X

X



X

X
X

X

X

X

X
X

X
X

Breast feeding/Human
milk
Catheter associated
infec0ons

X X

X X

Neonatal abs0nence
syndrome

X X

Ob Hemorrhage
Preven0ng cesarean
Hypertension
Antenatal Steroids
Elec0ve delivery <39
weeks
Preterm birth
preven0on/Prog

SMFM 2012
Obstetrical Care and Services
High risk women:
Timely iden0ca0on and referral of pa0ents for
ter0ary care

Low risk women:

Comprehensive na0onal eort to educate all
providers on the preven0on and treatment of
obstetrical complica0ons

Pu;ng the M back in maternal-fetal medicine. Am J Obstet Gynecol. 2013 Jun;208(6):442-8

NUMBERS OF
HOSPITALS

Annual Birth Volume

in U.S. Hospitals, 2008

n = 3,265

Simpson KR, JOGNN 40, 2011

ACOG / SMFM / AWHONN/ ACNM

Levels of Maternal Care (LOMC)

Uniform designa0ons of LOMC that are
complimentary but dis0nct from levels of
neonatal care
First ever ACOG/SMFM guidance that establishes
levels of care specic for the pregnant woman
Addi0onal endorsement and support from AABC,
ACNM, AWHONN, Commission for the
Accredita0on of Birth Centers, AAP, ASA, SOAP
Emphasizes role of Level III/IV (Regional) Centers
to support educa0on and quality improvement
among their referring facili0es

Pregnancy-related mortality ra0o*

U.S. Trends in Maternal Mortality

auer Safety Bundles
20
18
16
14
12
10
8
6
4
2
0

Pregnancy-Related Mortality,
United States, 1987-2020

*Number of pregnancy-related deaths per 100,000 live births

Source: Figure adapted from : hcp://www.cdc.gov/reproduc0vehealth/maternalinfanthealth/pmss.html
Data source: Pregnancy Mortality Surveillance System, CDC and Menards dreams