914: A Patient Safety Initiative; The Complex Obstetric Surgery (COS) Program

Abstract

A multidisciplinary Complex Obstetric Surgery program was established to regionalize patient care, improve preoperative assessment, develop a comprehensive surgical plan and reduce surgical morbidity. The COS program identifies patients at high risk for intrapartum and postpartum complications such as those with morbidly adherent placenta (MAP), placenta previa (PP), history of 4 or more cesarean sections (PCS), prior complicated abdominal surgery (AS), super-morbid obesity (SMO, BMI>50) and patients requiring Ex Utero Intrapartum Treatment (EXIT). We reviewed performance of the COS program as a quality improvement initiative. Retrospective review of patients with COS abnormalities in 7/1/14 to 6/30/17. In context of demographics and obstetric characteristics we studied core outcomes: planned versus urgent procedures, estimated blood loss (EBL), blood products administered (packed red blood cell (pRBC)/fresh frozen plasma (FFP)), intra and postoperative complications and need for re-operation. Protocol adherence (obtaining relevant consultations, delivery location, preoperative preparation) was studied. Outcomes were compared to those with similar diagnoses for the 3 years prior to program onset. We identified 67 COS patients (MAP:26, PP:17, PCS/AS: 24). Protocol adherence was 100% for all. Overall 68% of cases were performed as scheduled (62% of MAP, 47% of PP, 92% of PCS/AS). Average blood loss: MAP 2848 ml, PP 1364 ml, PCS/AS 1075ml. Mean transfusion of pRBC/FFP: MAP 4/2, PP 1/1 and PCS/AS 1/0. Intraoperative complication occurred in 7 (15%) MAP, zero (0%) PP, and 1 (4%) PCS/AS. In MAP, 85% of intraoperative complications were genitourinary tract injury. Reoperation was needed in MAP 4 times (15%), PP 3 (18%) and PCS/AS (0%). Compared to the prior 3 years, there was no difference in the selected outcomes for PP or PCS/AS. In MAP, EBL decreased by 40% (2848ml v 4725ml) and use of blood products (pRBC/FFP) fell 60-70% ( 4/2 v 10/9) with corresponding reduction in ICU time. Coordinated care of patients with complex obstetrical conditions reduces blood loss, use of blood products transfused per patient and overall surgical morbidity. Implementation of the COS program as a quality improvement project has significantly improved surgical outcomes in our own institution and provides regionalized surgical expertise to pregnant women in Maryland.