How a Standardized Approach to Care for Patients With Suspected Morbidly Adherent Placentas Improved Patient Outcomes

Abstract

To highlight the positive impacts of a nurse-driven initiative on patient outcomes in women with suspected morbidly adherent placentas (MAPs). The initiative is a multidisciplinary collaboration and has affected outcomes such as estimated blood loss (EBL), units of blood transfused (pRBCs), postoperative x-rays, intensive care unit (ICU) admissions, and total hysterectomies. To develop a collaborative process with representatives from 10 departments, including labor and delivery, anesthesia, operating room, interventional radiology, urology, gynecology–oncology, NICU, blood bank, pharmacy, and house supervisor. Representatives evaluate individual unit responsibilities and develop flowcharts for patient care. Collaborative review of flowcharts assesses for overlapping responsibilities and opportunities to refine. After several births of patients diagnosed with suspected MAPs, teams identified issues regarding communication, disorganization, and “turf wars” in different departments. Meetings, beginning in October 2017, discussed efficient processes and challenges identified with these births. Departmental flowcharts were created and then reviewed at the collaborative meetings for reformations. Meetings after subsequent MAP deliveries were used to debrief and evaluate for potential revisions. An order set was developed to be used in conjunction with current sets that includes additional considerations for suspected MAP births. There have been 11 births since the inception of this initiative; 45% were unscheduled or emergent. A single instrument set-up has eliminated incorrect counts and postoperative x-rays. Use of cell saver and tranexamic acid has decreased EBL and total pRBCs transfused. The median EBL (range = 650–6,500 ml) is 1,200 ml. Forty percent of the patients received 1–4 units pRBCs, all of which had an EBL of at least 1,800 ml. ICU admissions have decreased to only 27% of the cases. Several births were completed under epidural anesthesia, and a support person has been present in the delivery room. A total hysterectomy was not required in 3 patients. This multidisciplinary collaboration has strengthened interdepartmental relationships and improved transitions of care hospital-wide. Power struggles have been alleviated, and roles and responsibilities are better understood by those involved. Departmental flowcharts have been used, with positive feedback from staff and providers. Patient outcomes have improved, subsequently decreasing maternal morbidity.