A BEST PRACTICES APPROACH TO TREATING MATERNAL HEMORRHAGE Titus Regional Medical Center | Mount Pleasant, Texas MATERNAL HEALTH CASE STUDY Overview the first two hours following delivery are the most dangerous for a new mother," says West, "so we More than seven years ago, Pamela West, M.Ed., R.N., implemented a protocol in which staff administer a director of women's and children's services at Titus vitals and bleeding assessment every 15 minutes Regional Medical Center, was working in the labor during that initial two-hour period." In addition, and delivery unit at a hospital near the Texas-Mexico West realized that Titus Regional was only using border when she experienced the tragedy of a young one hemorrhage medication. In response, West and mother bleeding to death her team worked with after giving birth to twins. the hospital's pharmacy This devastating incident to develop a protocol that forever changed West. As allows for easy access to a result, she dedicated her three different medication career to addressing the options to help stop causes of maternal mortality, hemorrhaging. particularly emergent The hospital also situations involving maternal implemented "hemorrhage hemorrhaging. carts" that includes a second In 2016, West brought her IV kit, a blood warmer and knowledge to Titus Regional, cartridges, bags of saline, a 174-bed hospital located an EBB balloon, a Foley in Mount Pleasant, Texas. catheter, and a scale for Although the hospital had a weighing items in grams. massive transfusion protocol Along with the hemorrhage in place, West observed that cart, West's team added an the post-partum recovery additional step in the post- unit – where most maternal Nurses at Titus Regional Medical Center participate partum monitoring protocol hemorrhaging occurs – in hemorrhage simulation, weighing pads to quantify – a worksheet listing the dry- was not optimizing best blood loss. weight measures for items practices. At that time, Titus such as sheets or a pad. Regional was above the Texas and national averages These can quantify blood loss for maternal morbidity – specifically for cases related making a critical difference in the care of that patient. to hemorrhaging. In response, Titus began making "When we began simulating emergent hemorrhage changes to adopt best practices in maternal safety. situations, we would ask staff how much blood they For example, Titus Regional now takes a stage-based thought had been lost just by looking at a bloody approach to maternal hemorrhage. "We know that sheet," says West. "Then we weighed the item, they ©2020 American Hospital Association | February 2020 Page 1 | www.aha.org were always surprised to learn how much more it adopted the ACOG Labetalol, Apresoline and Nifedipine was than they thought. Adding this step was a major protocols to treat systolic blood pressures. Data behavioral change for our staff, and we provided collection for this initiative began in January. intense education regarding the physiology of a hemorrhage and how to keep the patient comfortable Many of the improvements West has spearheaded in by keeping her warm and lowering the head of her bed her career have been motivated by the tragedy she to decrease the workload of the heart while perfusing witnessed. "I never want a patient, her family, or my vital organs such as the brain. These may seem like staff to experience something so profound and life- basic steps, but they are critical in providing the highest changing," says West, "and I will do everything I can to quality care." prevent it from happening again." Impact Contact Since implementing best practices related to maternal Pamela West, M.Ed., R.N. hemorrhaging, the hospital's maternal morbidity Director, Women's and Children's Services rate related to blood loss dropped from 51% in 2016 (903) 577-6257 to nearly 40% in 2018. In January, Titus Regional Pamela.West@TitusRegional.com began tracking detailed statistics related to maternal hemorrhage. Staff now quantifies delivery blood loss and recovery blood loss. If the patient was transfused, the number of units of blood is noted. The hospital also is tracking racial and ethnic data to identify any health disparities. Lessons Learned For every new protocol or practice that is introduced, staff receive intense education that is followed with a simulation activity. "The simulation exercises have been an important part of the process," says West. "Testing knowledge in a simulated setting takes some of the fear out of executing a new step or protocol." Titus Regional also recommends implementing every new practice in a multi-step process. "We try to break things into manageable bytes," West says. "People can only handle so much change at one time. If we want the changes to stick, we've learned that we focus on one step until it becomes hardwired, and then we move to the next." Future Goals Titus Regional is intensifying its focus on patients with severe pre-eclampsia. To that end, the hospital ©2020 American Hospital Association | February 2020 Page 2 | www.aha.org