- Email: [email protected]
Code H Obstetrical Hemorrhage: Development of a Team Approach
INNOVATIVE PROGRAMS Proceedings of the 2011 AWHONN Convention
Providing Skilled Birth Care in a Resource-Poor Setting: Training Midwives in Rural Haiti Poster Presentation
Proposed Change Nurses and midwives possess skills that can save the lives of mothers and infants and can join the e¡orts to reduce maternal mortality in the global community. The methods of caring for women and newborns in the childbearing year require adaptation when resources are limited.
This presentation will describe a training program for skilled birth attendants as de¢ned by the International Confederation of Midwives and the World Health Organization. In Haiti the challenges of providing skilled care are complicated by a lack of basic needs such as clean water, basic nutrition, and electricity. How to create a clean and safe environment in this setting and the essential medications and equipment needed will be discussed. This presentation addresses e¡orts to make skilled birth attendants an integral part of Haiti’s health care system with government recognition. This presentation also describes a mobile prenatal clinic program that uses graduate Haitian midwives and a customized vehicle to bring accessible care to hundreds of women in rural villages.
Implementation, Outcomes, and Evaluation The complications most often responsible for death or serious injury to mothers in the childbearing years in developing countries are preventable and increased in Haiti because of an insu⁄cient number of skilled birth attendants.
Implications for Nursing Practice Nurses will recognize the importance of preventative and emergency care in pregnancy regardless of where a woman lives. They will be able to adapt the high-tech skills they use now in caring for mothers and newborns to a setting with limited basic resources.
Purpose for the Program o introduce health care professionals to life-saving methods that are necessary to save the lives of mothers in childbirth in resource-poor setting.
T
Nadene Brunk, CNM, MSN, Midwives for Haiti, Richmond, VA
Keywords skilled birth attendants Haiti maternal mortality
Professional Issues
Code H Obstetrical Hemorrhage: Development of a Team Approach Poster Presentation Purpose for the Program ew York State Department of Health issued a health advisory in 2009 stating the following:
N
Maternal mortality rate is higher than the national average and hemorrhage the leading cause of mortality. Providers can prevent maternal deaths by improving recognition and response to hemorrhage. Blood loss is frequently underestimated. The causes of death are multifactorial, and prevention requires a multidisciplinary response. Hospitals with rapid and coordinated responses to extreme blood loss can limit morbidity and improve survival. Proposed Change Although we had implemented interventions to reduce the risk of morbidity and mortality secondary
S46
to maternal hemorrhage, we needed to further develop a multidisciplinary team response and identify system factors that result in delay in recognition and treatment.
Margaret T. Celenza, MS, RN,
Implementation, Outcomes, and Evaluation Step1çWe performed a needs assessment. Step 2ç How do we improve estimation of blood loss? Literature search reveals improving visual estimation and a weight-based conversion method. We also quanti¢ed the average amount of laps used in a Cesarean birth. Step 3çCollaborate with anesthesia, blood bank, maternal fetal medicine, and gynecologic oncology departments to develop guidelines for team response, a hemorrhage resource guide, and emergency equipment cart. Step 4çEliminate barriers to rapid blood access and laboratory testing. Step 5çFacilitate communication with hemorrhage team. Step 6çEducation and implementation of what we named Code H, a multidisciplinary coordinated response to maternal hemorrhage.
Mary Lynn Brassil, MS, RN,
JOGNN, 40, S2-S84; 2011. DOI: 10.1111/j.1552-6909.2011.01242.x
CNS, Obstetric Department, Winthrop University Hospital, Mineola, NY
CES, Maternal Child Nursing, Winthrop University Hospital, Mineola, NY
Keywords hemorrhage team maternal hemorrhage estimating blood loss
Professional Issues
http://jognn.awhonn.org
INNOVATIVE PROGRAMS
Chapman, M. O. and Sciba, J. C.
Proceedings of the 2011 AWHONN Convention
Simulation Lab. Nurses, physicians and nursing assistants (106) participated. Speci¢c measured quantities of simulated blood were displayed on perpads, 44 0 £oor spills, and clots in bedpans to determine the accuracy of estimating blood loss in the clinical setting. Sta¡ members estimated loss and recorded their ¢ndings. Individual results were compared with actual quantities of simulated blood. Only 1/3 in range. Clinical Setting. Direct observation during 23 Cesarean deliveries to determine average lap pad usage in order to establish a trigger point identifying hemor-
rhage; 25 saturated laps determined as trigger to alert surgeons of greater than average blood loss. Development of a task force with representatives from anesthesia, blood bank, and maternal fetal medicine departments. Code H Team implemented. Evaluation. The Code H team has enhanced a cohesive team approach to a complicated obstetric crisis. Implications for Nursing Practice Improved communication, better de¢ned roles and nursing care that is more patient-focused.
Optimization: An Interdisciplinary Approach to Improve Intraoperative and Postoperative Outcomes in the OB Surgical Patient Poster Presentation Montrece O. Chapman, RNC, LCCE, Birthplace/Gaston Memorial Hospital, Caromont Health, Gastonia, NC
Jennifer C. Sciba, RNC-OB, Birthplace/Gaston Memorial Hospital, Caromont Health, Gastonia, NC
Keywords optimization pre-operative screening pre-existing conditions care planning
Professional Issues
Purpose for the Program pplication of the presurgical optimization process to all surgical obstetric patients. General surgical patients have a presurgical optimization process designed to improve outcomes. Optimizing fosters a heightened awareness of pre-existing conditions in the obstetric patient, addresses them presurgically, and impacts outcomes.
A
Proposed Change Revisions to the current practice included screening by the obstetrician at the presurgical o⁄ce visit to identify pre-existing conditions and scheduling of the pre-operative visit a minimum of 5 days before surgery to allow time for optimization. The obstetrician would order any additional labs or consultations he felt were indicated at this time. The registered nurse (RN) would perform a presurgical assessment, history and physical assessment, laboratory test and review results. She would notify the primary physician of signi¢cant ¢ndings. Based on the RN assessment and ¢ndings, the physician may order a consultation with a specialty physician or anesthesia. The RN would also notify the assistant man-
JOGNN 2011; Vol. 40, Supplement 1
ager, team leader, surgical team, and neonatal intensive care unit (NICU) of any signi¢cant ¢ndings and a plan of care would be developed. Implementation, Outcomes, and Evaluation A timeline was developed that outlined recommendations for changes, target dates, and implementation. Recommendations were presented to management for approval. Education was provided to o⁄ce personnel, obstetric medical groups, anesthesia medical group, and hospital nursing sta¡. This education facilitated improved patient £ow through the presurgical process. Data were collected over an 8 month period and con¢rmed that 25% to 40% of the 20 presurgical visits completed each month had pre-existing conditions requiring optimization. As a result of optimization there were no extended stays, no complications, and outcomes were improved. Additional changes were made at this time to continue improvement. Labs would be drawn at the beginning of the visit, pre-operative orders restructured, standard tools for communication implemented. All data and recommended changes were presented to the obstetric medical committee, which approved and supported these changes. This initiative was adopted as the Birthplace Pre-Surgical Screening Process for Optimizing the OB Surgical Patient.
S47
Providing Skilled Birth Care in a Resource-Poor Setting: Training Midwives in Rural Haiti Poster Presentation
Proposed Change Nurses and midwives possess skills that can save the lives of mothers and infants and can join the e¡orts to reduce maternal mortality in the global community. The methods of caring for women and newborns in the childbearing year require adaptation when resources are limited.
This presentation will describe a training program for skilled birth attendants as de¢ned by the International Confederation of Midwives and the World Health Organization. In Haiti the challenges of providing skilled care are complicated by a lack of basic needs such as clean water, basic nutrition, and electricity. How to create a clean and safe environment in this setting and the essential medications and equipment needed will be discussed. This presentation addresses e¡orts to make skilled birth attendants an integral part of Haiti’s health care system with government recognition. This presentation also describes a mobile prenatal clinic program that uses graduate Haitian midwives and a customized vehicle to bring accessible care to hundreds of women in rural villages.
Implementation, Outcomes, and Evaluation The complications most often responsible for death or serious injury to mothers in the childbearing years in developing countries are preventable and increased in Haiti because of an insu⁄cient number of skilled birth attendants.
Implications for Nursing Practice Nurses will recognize the importance of preventative and emergency care in pregnancy regardless of where a woman lives. They will be able to adapt the high-tech skills they use now in caring for mothers and newborns to a setting with limited basic resources.
Purpose for the Program o introduce health care professionals to life-saving methods that are necessary to save the lives of mothers in childbirth in resource-poor setting.
T
Nadene Brunk, CNM, MSN, Midwives for Haiti, Richmond, VA
Keywords skilled birth attendants Haiti maternal mortality
Professional Issues
Code H Obstetrical Hemorrhage: Development of a Team Approach Poster Presentation Purpose for the Program ew York State Department of Health issued a health advisory in 2009 stating the following:
N
Maternal mortality rate is higher than the national average and hemorrhage the leading cause of mortality. Providers can prevent maternal deaths by improving recognition and response to hemorrhage. Blood loss is frequently underestimated. The causes of death are multifactorial, and prevention requires a multidisciplinary response. Hospitals with rapid and coordinated responses to extreme blood loss can limit morbidity and improve survival. Proposed Change Although we had implemented interventions to reduce the risk of morbidity and mortality secondary
S46
to maternal hemorrhage, we needed to further develop a multidisciplinary team response and identify system factors that result in delay in recognition and treatment.
Margaret T. Celenza, MS, RN,
Implementation, Outcomes, and Evaluation Step1çWe performed a needs assessment. Step 2ç How do we improve estimation of blood loss? Literature search reveals improving visual estimation and a weight-based conversion method. We also quanti¢ed the average amount of laps used in a Cesarean birth. Step 3çCollaborate with anesthesia, blood bank, maternal fetal medicine, and gynecologic oncology departments to develop guidelines for team response, a hemorrhage resource guide, and emergency equipment cart. Step 4çEliminate barriers to rapid blood access and laboratory testing. Step 5çFacilitate communication with hemorrhage team. Step 6çEducation and implementation of what we named Code H, a multidisciplinary coordinated response to maternal hemorrhage.
Mary Lynn Brassil, MS, RN,
JOGNN, 40, S2-S84; 2011. DOI: 10.1111/j.1552-6909.2011.01242.x
CNS, Obstetric Department, Winthrop University Hospital, Mineola, NY
CES, Maternal Child Nursing, Winthrop University Hospital, Mineola, NY
Keywords hemorrhage team maternal hemorrhage estimating blood loss
Professional Issues
http://jognn.awhonn.org
INNOVATIVE PROGRAMS
Chapman, M. O. and Sciba, J. C.
Proceedings of the 2011 AWHONN Convention
Simulation Lab. Nurses, physicians and nursing assistants (106) participated. Speci¢c measured quantities of simulated blood were displayed on perpads, 44 0 £oor spills, and clots in bedpans to determine the accuracy of estimating blood loss in the clinical setting. Sta¡ members estimated loss and recorded their ¢ndings. Individual results were compared with actual quantities of simulated blood. Only 1/3 in range. Clinical Setting. Direct observation during 23 Cesarean deliveries to determine average lap pad usage in order to establish a trigger point identifying hemor-
rhage; 25 saturated laps determined as trigger to alert surgeons of greater than average blood loss. Development of a task force with representatives from anesthesia, blood bank, and maternal fetal medicine departments. Code H Team implemented. Evaluation. The Code H team has enhanced a cohesive team approach to a complicated obstetric crisis. Implications for Nursing Practice Improved communication, better de¢ned roles and nursing care that is more patient-focused.
Optimization: An Interdisciplinary Approach to Improve Intraoperative and Postoperative Outcomes in the OB Surgical Patient Poster Presentation Montrece O. Chapman, RNC, LCCE, Birthplace/Gaston Memorial Hospital, Caromont Health, Gastonia, NC
Jennifer C. Sciba, RNC-OB, Birthplace/Gaston Memorial Hospital, Caromont Health, Gastonia, NC
Keywords optimization pre-operative screening pre-existing conditions care planning
Professional Issues
Purpose for the Program pplication of the presurgical optimization process to all surgical obstetric patients. General surgical patients have a presurgical optimization process designed to improve outcomes. Optimizing fosters a heightened awareness of pre-existing conditions in the obstetric patient, addresses them presurgically, and impacts outcomes.
A
Proposed Change Revisions to the current practice included screening by the obstetrician at the presurgical o⁄ce visit to identify pre-existing conditions and scheduling of the pre-operative visit a minimum of 5 days before surgery to allow time for optimization. The obstetrician would order any additional labs or consultations he felt were indicated at this time. The registered nurse (RN) would perform a presurgical assessment, history and physical assessment, laboratory test and review results. She would notify the primary physician of signi¢cant ¢ndings. Based on the RN assessment and ¢ndings, the physician may order a consultation with a specialty physician or anesthesia. The RN would also notify the assistant man-
JOGNN 2011; Vol. 40, Supplement 1
ager, team leader, surgical team, and neonatal intensive care unit (NICU) of any signi¢cant ¢ndings and a plan of care would be developed. Implementation, Outcomes, and Evaluation A timeline was developed that outlined recommendations for changes, target dates, and implementation. Recommendations were presented to management for approval. Education was provided to o⁄ce personnel, obstetric medical groups, anesthesia medical group, and hospital nursing sta¡. This education facilitated improved patient £ow through the presurgical process. Data were collected over an 8 month period and con¢rmed that 25% to 40% of the 20 presurgical visits completed each month had pre-existing conditions requiring optimization. As a result of optimization there were no extended stays, no complications, and outcomes were improved. Additional changes were made at this time to continue improvement. Labs would be drawn at the beginning of the visit, pre-operative orders restructured, standard tools for communication implemented. All data and recommended changes were presented to the obstetric medical committee, which approved and supported these changes. This initiative was adopted as the Birthplace Pre-Surgical Screening Process for Optimizing the OB Surgical Patient.
S47