Montefiore Medical Center’s Initiative to Reduce Maternal Hemorrhage

Abstract

The purpose of this presentation is to discuss how our institution initiated and sustained interdisciplinary efforts to improve awareness, recognition, and management of immediate postpartum hemorrhage. Montefiore’s highly skilled and compassionate obstetric doctors and nurses welcome approximately 6,000 babies into the world each year. We serve a high-risk population with complex needs. We had been struggling to adopt a bundle for comprehensive management of postpartum hemorrhage that included quantification of blood loss at every delivery, until a sentinel event involving a postpartum hemorrhage spurred us to take a more coordinated action. We took this opportunity to use the Influencer Framework to implement quantification of blood loss (QBL). This model involves identifying a vital behavior to change and then addressing six domains to foster change: individuals’ ability and motivation, the ability and motivation of the group, and environmental factors that support the ability and motivation of individuals and the group. Our change concept was multidisciplinary and used a team-based approach on several levels, to include (a) increasing awareness of early recognition of hemorrhage via maternal early warning signs (MEWS); (b) establishing antepartum, intrapartum, and postpartum risk-factor assessments at every birth; (c) creating a tool for calculating QBL and timely establishment of standard work for QBL at all births; (d) documentation of QBL in the electronic medical record to ensure compliance; (e) twice-monthly, in situ simulations of massive hemorrhages using a hemorrhage checklist; (f) evaluation of our massive transfusion protocol process; (g) establishment of standardized comprehensive hemorrhage cart for the labor and delivery unit for postpartum and antepartum care; (h) standardization of hemorrhage medication kits; and, last, (i) a novel concept of “intraoperative antibiotic timeout,” where the surgeon and anesthesiologist visually assess blood loss after hysterotomy closure before final QBL to raise awareness and determine whether redosing of prophylactic antibiotics is necessary. Chart audits showed that within 3 months of training and implementation, the staff was performing QBL at 90% of our hospital’s births. The staff now realizes that the use of innovative programs to increase the quality and safe care of our patients should be embraced by health care providers.