371: Opportunities for improvement in care among women with severe maternal morbidity

Abstract

Severe maternal morbidity (SMM) is increasing in the US and has been estimated to occur in up to 1.6% of all deliveries. Our objective was to use a recently recommended process to review and assess women with SMM to determine the incidence of opportunities for improvement in care. We conducted a retrospective cohort study of all women admitted for delivery at a large urban academic medical center between January 1, 2012 and June 30, 2014. Medical records were screened for SMM using the following criteria: ICD-9 codes for severe illness identified by the Centers for Disease Control and Prevention, prolonged length of stay, ICU admission, transfusion of 4 or more units of blood, or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in depth review of each medical record that screened positive for SMM to determine if true SMM occurred. Each true SMM case was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible or none. The incidence of identified opportunities for improvement was determined and characterized by system, provider and/or patient. Morbidity was classified by primary cause, organ system and underlying medical condition. There were 15,713 deliveries, of which 386 (2.5%) screened positive for SMM. Following review of each case, true SMM was present in 154 (0.98%) deliveries. We determined there was strong or possible opportunity for improvement in 13.6% and 28.6% of cases, respectively. The two most common etiologies of SMM were obstetric hemorrhage (OBH) (70.8%) and hypertensive disorders (HTN) (12.3%). There was strong or possible opportunity for improvement in 8.3% and 28.4% of OBH cases and 10.5% and 31.6% of HTN cases (p=0.62). Provider factors affecting opportunities for improvement in care were more common in OBH cases while patient factors were more common in HTN cases (p = 0.02). There was strong or possible opportunity for improvement in care in 42% of SMM cases, and provider factors were particularly common in OBH cases. Similar to maternal mortality data, these findings support national efforts to perform SMM reviews and implement appropriate changes in care to reduce maternal morbidity.