Accepted Manuscript

Obstetrical Hemorrhage Reporting and Systems Learning

Laurence E Shields MD , Suzanne Wiesner RNMBA/HCM

PII: S0146-0005(18)30130-7
DOI: https://doi.org/10.1053/j.semperi.2018.11.010
Reference: YSPER 51100

To appear in: Seminars in Perinatology

Please cite this article as: Laurence E Shields MD , Suzanne Wiesner RNMBA/HCM , Obstet-
rical Hemorrhage Reporting and Systems Learning, Seminars in Perinatology (2018), doi:
https://doi.org/10.1053/j.semperi.2018.11.010

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Obstetrical Hemorrhage Reporting and Systems Learning

Laurence E Shields, MD1,2 and Suzanne Wiesner, RN, MBA/HCM2
1: Marian Regional Medical Center, Santa Maria CA
1400 E Church St, Santa Maria, CA 93454
2: Dignity Health Patient Safety
185 Berry St #300, San Francisco, CA 94107, USA
Corresponding Author:
Laurence E Shields, MD
1400 E Church St, Santa Maria, CA 93454

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805-739-3280

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805-739-3380 (fax)

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ABSTRACT:

Reporting and systems learning provide the backbone for a sustainable comprehensive
response to maternal hemorrhage. Reporting back to the institution requires capturing

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various elements such as compliance, results of debriefs, and comprehensive reviews of
cases where there has been severe maternal morbidity. The system then learns from
these reviews, and modifies as necessary any areas not performing as desired.
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Compliance monitoring, aside from review of an adverse event, is also an essential
element of the reporting process by assessing for drift, returning to pre-implementation
practices.
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Once the key elements of Readiness, Recognition, and Response have been identified
for a comprehensive standardized maternal hemorrhage improvement program, the
structure of “Reporting and Systems Learning” will have to be put in place. This bundle
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element will be essential to ensure that the original goal of improving the institutional
response to obstetrical hemorrhage has a positive impact on outcomes and continues to
function as intended. To provide the most value, reporting should include multiple areas
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of compliance monitoring and assess the hospital’s readiness, recognition, and response
effectiveness.1
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The rationale for compliance monitoring is two-fold. First, assuring a high level of
compliance with the safety bundle and second, assessing for drift or returning to
“business as usual.” The experience within our multi-facility health system
demonstrates the importance of compliance monitoring. A number of evidenced-based
standardized patient safety bundles and toolkits were implemented over several years,
including obstetrical hemorrhage and hypertension in pregnancy. Usually, these were
standardized policy templates and “white papers.” Although both safety bundles had
been distributed to all hospitals within the system, compliance was relatively low prior
to systematic review and compliance reporting to individual sites. With hemorrhage,
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initial compliance was only 54% and with monitoring and compliance reporting, this
increased to 80% in less than one year.2 A similar increase in compliance was noted with
a standardized hypertension bundle where compliance increased from 43% to >90% in
less than 1 year.3 Others have noted similar improvements in hypertension bundle
compliance when monitoring was put into place.4, 5 These findings suggest that ongoing
monitoring of patient quality improvement measures and key elements of patient care
are essential for “hardwiring” key elements of care and achieving desired success. The
most commonly cited reasons for non-compliance was providers not willing to change
practice patterns or unaware of revised recommendations. In addition, nursing staff are

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frequently uncomfortable challenging obstetric providers when they fail to follow new

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standardized guidelines.

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When the first recommendations for standardizing management of obstetrical
hemorrhage were released they were primarily based on “expert opinion,” with limited
data to support various elements of toolkit or bundle recommendations.6 Since that
time, there have been a number of publications to support these original expert

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opinions. 2, 7, 8 Details of these and other recommendations have been outlined in other
chapters of this monograph. It is worth noting that many of these elements are now
clearly evidence-based and should be used for process and outcome monitoring with
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little rationale for non-compliance. Patient admission risk-assessment, while not
perfect, increases awareness of those at high risk for hemorrhage.9, 10 Staged response
and early interventions reduce utilization of blood products.2, 7 Using a standardized
obstetrical hemorrhage bundle reduces severe maternal morbidity.8 At this point in
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hemorrhage management there should be little “push-back” on recommendations for

“lack of data.“
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In Reporting and Systems Learning, the determination of what constitutes key items for
review will need to be individually established at each hospital, based on their perceived
needs and volume. Most recommended approaches for recognizing and managing
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obstetrical hemorrhage use a “staged response.”2, 11, 12 Identifying key items at each
stage and assessing these for compliance would ensure that the program is functioning
optimally or identify elements that need “re-tooling.” These key items for measurement
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will depend on patient volume, department workflows and participation by staff and
providers. Larger volume facilities will experience obstetrical hemorrhages with relative
regularity and may choose to review only the higher “stage” events while smaller
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facilities with infrequent exposure to obstetrical hemorrhage will benefit from reviewing
a higher percentage of their hemorrhage cases and should have frequent simulation or
drills to ensure readiness (see chapter xx). Participation in drills and simulations should
be part of all facilities monitoring process.

Regardless of the threshold for determining what cases require detailed review, an
initial debriefing should always occur after a hemorrhage event and should function as a
quick “recap” of the event. This would include a huddle with all available team
members, a quick written report that can be reviewed later as part of a systematic
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review process. An example of a debriefing tool is outlined in Figure 1. These debriefing

forms should be collected by a designated member of the obstetric safety team,
collated and used for multidisciplinary process reviews, Figure 2. In the event of a
significant hemorrhage, a more detailed event review should be completed, Figure 3.
Criteria for this higher level of review generally should include criteria meeting the
definition of severe maternal morbidity review. 13, 14 Event reviews should include
timelines to establish potential system deficits in carrying out the desired response. The
review process must adhere to a methodology that reviews the event or cases as a
“process improvement opportunity” and eliminates any effort to establish who is at

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fault or “responsible.” Hospitals with large provider “buy-in” or acceptance from both

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the nursing and providers (physician and midwife) will have a different experience than
those from hospitals where nursing and providers are reluctant or unwilling to change

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practice patterns. When there are concerns about providers who performed below
expectations, there should be a separate format for review, and most likely through the
peer review process.

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In our system, we chose to monitor compliance based on each stage of the hemorrhage
response.2 This format allows review of the documentation to ensure that key items at
each stage are carried out as desired and, in aggregate, an overall view of hospital
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response. For example, a key item for all patients (Stage 0) would include the correct
risk assessment for hemorrhage on admission. This is a key item for early recognition
and response to obstetrical hemorrhage. Another key item for compliance monitoring
would include the assessment of blood product administration to ensure that repetitive
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use of pack red blood cells was not used without concomitant use of fresh frozen
plasma as platelets.15, 16 Examples of key items for each stage in compliance monitoring
is outlined in Table 1. Compliance monitoring for individual key items can identify
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opportunities for improvement, but a stricter method of compliance analysis, an all-or-

none method should be utilized. In this methodology, if any element outlined in Table 1
is not completed, the case receives a “zero” score; and if all elements are completed the
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score would 100%. Tracking of the cumulative score then provides a meaningful method
to assess the hospital’s performance.
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In addition to compliance reporting, “report-back education” for all providers should be

an integral part of the “systems learning.” This is necessary to foster continuous process
improvement and provider engagement. Care providers who potentially interact with a
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complicated pregnant patient, particular with regard to obstetrical hemorrhage, cross

many areas of the hospital. These include personnel that normally work only in the
obstetrical department (physicians, labor and postpartum nurses, unit clerks, labor and
delivery operating room staff), but also include individuals in areas of the hospital that
become involved through the hemorrhage response (laboratory medicine, blood
banking, intensive care unit). While the tendency is to only provide reporting to
obstetrical nursing and physician providers, other key members of the response team
need to be included. Failure to include all members of the larger team and to have
regularly scheduled updates and inclusion on hemorrhage response as part of new
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employee education will eventually result in system breakdown and avoidable morbidity
or mortality.

Compliance monitoring can require substantial resources, especially when individual

record review is required. With the widespread use of electronic health records and
data warehouse platforms, developing automated reporting systems would ensure
standardized retrieval of data, and provide a more efficient method of data collection
and analysis. When key items of a care bundle can be automatically “mined” from the
medical record, information technology colleagues can become key members of the

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quality improvement team by designing reporting systems that support compliance

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monitoring. In the future, it is likely this type of data collection will be part of provider
“reports” and part of hospital credentialing and contracting.

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As noted above, initial focus on standardized management will be in deriving the correct
comprehensive system for identification, preventing, and treating patients with
obstetrical hemorrhage. As part of implementation, similar care and forethought should

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be given towards developing a robust “reporting and systems learning” program. This
program should focus on use of immediate debriefings and comprehensive severe
maternal morbidity reviews, along with compliance monitoring and action plans for
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continuous process improvement developed with the use of a multidisciplinary maternal
safety review committee. Finally, regularly scheduled reports and educational sessions
that include all areas of the hospital that interact with patients who experience an
obstetrical hemorrhage will be essential for ongoing success of the program.
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Figure 1. Debriefing Tool for Obstetrical Hemorrhage Event

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Legend Figure 1: Figure 1 is an example of a post-hemorrhage debriefing tool for quick

review and feedback. Over time, these should be collated and summary information
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should be presented to the all hospital personnel and providers to help ensure that
areas of concerns or omissions are addressed and corrected.
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Figure 2. Multidisciplinary Reporting Process

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Legend Figure 2: Figure 2 outlines the key features of a comprehensive reporting and
systems leaning program. It would include of both a debrief tool (Figure 1) and severe
maternal morbidity review form (Figure 3). The Multidisciplinary Perinatal Safety
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Review Committee* members should include: obstetrical providers (obstetricians,

midwives, family medicine, maternal-fetal medicine), anesthesia, critical care specialist,
obstetrical support staff, nursing and nursing leadership, blood bank and laboratory
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medicine, and the hospital quality improvement team. The Multidisciplinary Perinatal
Safety Review Committee findings should be used to modify standardized policies,
provide data review and provider education, as well as be used to organize simulation
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and drills designed to overcome any difficult or trouble areas that are identified.

Figure 3. Hemorrhage with Severe Maternal Morbidity Review Forms

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Patient Information
Age Height Weight BMI
OBSTETRIC HISTORY
Gravida Para Term Premature Aborted Living
PRENATAL CARE (PNC)
Initiation of prenatal care: wks Number of visits:

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Primary obstetric provider:
Additional providers: Timing of hemorrhage event:

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OB: Antepartum: on arrival or antepartum
Anesthesia: inpatient

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Critical Care: Intrapartum:
Postpartum:
Post-discharge:
DELIVERY INFORMATION
Gestational age at presentation:
Singleton Yes No US
weeks
Multiple birth: Yes No Type: twins, triplets, other
Planned delivery at this facility: Yes No
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Risk factors known and appropriate for hospital’s level of care Yes No
Risk factors know and appropriate antepartum preparation and consultations obtained:
Yes No
Complicating Factors: Induction of Labor, Preeclampsia, Prolong Oxytocin use,
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Chorioamnionitis, Multiple Fibroids, Previous C-section

Delivery type: Vaginal Operative Vaginal C-section (planned, unplanned in labor,
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emergent)
C-section or Operative vaginal delivery indication:
Previous history of postpartum hemorrhage: Yes No
Known abnormal placentation: No Yes (circle) previa accreta/suspected morbidly
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adherent placenta
Uterotonics (n): Methylergonovine: Carboprost: Misoprostol:
Blood Loss: EBL: ml Quantitative blood loss (QBL): ml
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Uterine tamponade: Yes No Type: b-Lynch, balloon, combination

D&C: Yes No
Hysterectomy: Yes No Planned with abnormal placenta: Yes No
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Interventional Radiology: Yes No

Intensive Care Admission: Yes No Mechanical Ventilation: Yes No
Blood products (n): pRBCs: Platelets: Cryoprecipitate:
FFP:
Blood products cross matched: Yes No Delay in obtaining blood products: Yes No
Tranexamic acid: 1 dose 2 doses
Timeline:
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Legend Figure 3: Severe maternal morbidity review form. This type of form is designed
to be used in all cases of significant hemorrhage. Summary information should be part
of the comprehensive reporting and systems leaning outlined in Figure 2.

Table 1. Comprehensive Obstetric Hemorrhage Compliance Assessment

Hemorrhage Stage2 Compliance Element

Stage 0 Admission risk assessment completed

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Blood bank specimen correct for risk category
Stage 1 Physician evaluation if > 2 uterotonic agents used

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Stage 2 Correct laboratory studies performed (ie. DIC panel)
Blood bank request completed

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Stage 3 Blood products administered according to
recommendations
Stage 1-3 Quantitative blood loss assessment completed

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Legend Table 1: Table 1 identifies different compliance monitoring elements for a
hemorrhage response that utilizes a staged (0-3) system. For example with a Stage 3
hemorrhage, expectations would be that an initial risk assessment was done, if more
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than two uterotonics were used the physician would be completed a bedside
evaluation, if the patient reached Stage 2 that appropriate labs were collected, and if
transfusion was needed that the appropriate combinations of blood products were
used. Compliance would be scored as “all-or-none” that is 0% or 100%. Over time, the
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hospital level compliance would be scored with a goal for >90% overall compliance, i.e.
nine of ten cases all elements are correctly completed.
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Conflict Of Interest:

The authors report no conflict of interest.

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