The North Carolina Statewide OB

Hemorrhage Project

Arthur Ollendorff, MD

Learning Session
March 28, 2018
 Game Plan
• Review statewide Severe Maternal Morbidity
(SMM) data
• Share OBH project data?
• Brief introduction to simulation?
 AIM OBH Participating Sites
As of March 1, 2018

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Alamance Harris Regional Pardee ★
Cape Fear Valley Haywood County Park Ridge
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Carolina East (Craven) High Point Regional Randolph ★
CHS Blue Ridge Iredell Rex Hospital
CHS Cleveland Lake Norman Regional Sampson
CHS Lincoln Lenoir Scotland
CHS Northeast Marla Parham Sentara Albermarle
CHS Pineville Martin General Southeastern Health
CHS Stanly McDowell UNC Birth Centers
CHS Union Mission Vidant Baby + Co. (Cary)
CHS University Nash General Vidant Beaufort Baby + Co. (Charlotte)
CMC-Main New Hanover Vidant Chowan Baby + Co. (Winston-Salem)
Carteret Northern Hospital Surry Vidant Duplin Natural Beginnings (Statesville)
Catawba Valley Novant Forsyth Vidant Edgecombe Women’s Birth and Wellness (Chapel Hill)
Columbus Regional Novant Huntersville Vidant Roanoke WNC Birth Center (Asheville)
Cone Women’s Novant Matthews Wake Med
Davis Regional Novant Presbyterian Wake Med-Cary
Duke Regional Novant Rowan Wake Med North
Duke University Novant Thomasville Wayne Memorial
First Moore Regional Outer Banks Regional
Halifax Regional Onslow Memorial
Hospital Level SMM Is the Canary In
the Coal Mine
 Severe Maternal Morbidity
• NCHA is partnering with PQCNC to abstract
SMM from hospital discharge data
– Data validation in progress
• Latest statewide NC data (CY 2016)
– Overall SMM = 168 per 10,000 deliveries
– SMM (excl. transfusion)=77.6 per 10,000 deliveries
Snapshot Data From NC OBH Project
 NC OBH Project Snapshot Data-October 2017

AIM Structure Measures

43
SYSTEM DEBRIEFS FOR MAJOR COMPLICATIONS
57

40
SYSTEM-LEVEL REVIEWS
60

13
CART
87

30
POLICY
70

34
EMR INTEGRATION
66

57
PROTOCOLS TO SUPPORT STAFF AND FAMILY
43

0 10 20 30 40 50 60 70 80 90 100

Percentage of Teams
No Yes
NC OBH Project Snapshot Data-October 2017

Percentage of teams with 100% of Structure Metrics

32%

yes
no
NC OBH Project Snapshot Data-October 2017

% of Sites with a Recorded Risk Assessment

25%

0%
45% less than 50%
70 to 90%
100%
19%

11%
NC OBH Project Snapshot Data-October 2017

% of Women who had QBL measured after delivery

17%

36% 37 0%
51 % less than 50%
17% % 70 to 90%
100%

30%
12
%
 Number of RBC Units Transfused in NC/1000 patients
400
372
350 359

300
280
271
250

200

150

100

50

0
SEP-17 OCT-17 NOV-17 DEC-17
NC OBH Project Snapshot Data-October 2017
What barriers have been identified in past OB specific QI
efforts?

14%
25%
Competing Priorities
Lack of Time
Lack of Engagement
29%
Other

32%
NC OBH Project Snapshot Data-October 2017
What worked well in past OB specific QI efforts

21%

Multidisciplinary Engagement
Data Collection
14% 54% Simulations
Other
11%
 Team Drills = Deliberate Practice
• Mastery of a skill is an individual effort that is
achieved by many hours of deliberate practice
• Effective teamwork is dependent on people
knowing their role, communicating effectively
and being prepared
– Team drills are ideal to develop and maintain skills
especially for events that are associated with
harm to patients
 Simulations and Drills

Low Fidelity Simulation High Fidelity Simulation In situ Drill

 OB Hemorrhage
• Skills that can be simulated
– Bakri™ Balloon Placement
– B-Lynch suture placement
– QBL calculation
• Behaviors that can be drilled
– Identification and communication of an OBH
– How to order, access and administer emergency
medications and blood
– Interactions with other services (anesthesia, blood
bank, interventional radiology)
 Quantitative Blood Loss
• Accurate assessment of EBL is an important AIM
measures
• Please exercise discretion and do not let QBL
assessment lead your team to lose focus on all
elements of OBH recognition and prevention
• Reasonable approaches include using EBL
“triggers” to lead to weighing of all sponges, etc
– What is the clinical significance of an EBL v QBL of less
than 750 mL?