MHA Keystone: Obstetrics (OB)
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MHA Keystone: Obstetrics (OB)
Currently in the United States, an estimated three injuries occur for every 1,000 births, some of which
are preventable. Neonatal adverse outcomes include preventable morbidities such as respiratory
distress syndrome, sepsis, neonatal intensive care unit admission, rehospitalization, neurologic injury
and death. For the mother, obstetrical adverse events occur in approximately 9 percent of all U.S. births,
and include hemorrhage, complications of preeclampsia and death.
To ensure all babies born in Michigan come into the world in optimum health, Michigan hospitals
participating in MHA Keystone: OB implement evidence-based interventions to eliminate preventable
fetal, neonatal and maternal harm. Today, MHA Keystone: OB impacts nearly 80 percent of all births in
Michigan.
The MHA Keystone: OB collaborative integrates evidence-based clinical and science of safety
interventions that, together, support a culture of safety to prevent harmful outcomes. Strategies have
been incorporated to prevent fetal and maternal harm due to complications of labor induction and
management of the second stage of labor. In the first four years, the interventions for MHA Keystone:
OB included the Comprehensive Unit-based Safety Program (CUSP) for improving patient safety through
attitudes and practices, implementation of best practices and timely interventions to eliminate elective
induction of labor and cesarean birth prior to 39 weeks gestation, to coordinate a safe progression of
labor, and maintaining fetal wellbeing.
Continuing with the CUSP to improve unit culture and drive new patient safety initiatives, the MHA
Keystone: OB collaborative will re-launch in 2014, focused on the following aims to reduce maternal and
neonatal morbidity and mortality:
Engage and educate patients about best options for their childbirth, including labor
management, labor induction, possible cesarean birth and the potential for postpartum
hemorrhage.
Educate clinicians on current evidence and obstetrical practice professional standards, and
provide standardized tools and protocols for easier implementation in obstetrical units.
Provide feedback to clinicians and the organizations on progress and guidance on
improvement, through coaching and shared learning.
This program will be evaluated through the collection of structure, process and outcome measures,
which are collected on a monthly basis (see Appendices).
Interventions
The MHA Keystone Center will concentrate efforts in 2014 on obstetrical adverse events, including early
elective birth reduction, obstetrical hemorrhage and preeclampsia treatment, and standardization to
prevent morbidity and mortality. New interventions to prevent and manage obstetrical hemorrhage and
preeclampsia will be suggested using resources developed through the California Maternal Quality Care
Collaborative (CMQCC) to guide our activities. These interventions are considered part of the necessaryMHA Keystone: Obstetrics
March 2014
infrastructure to provide a safe environment for women giving birth. Implementation of these
interventions will be assessed as part of the project via structure measures.
2014 Timeline of activities:
Monthly webinars will be held the second Tuesday of every month for regular interaction with
participating teams.
Month Activity
January 2014 • Content Webinar – CUSP and Safety Culture Survey Results (Jan. 14)
February 2014 • Content Webinar – OB Hemorrhage Overview and Bronson Experience (Feb. 11)
March 2014 • Regional Learning Session 1
• Annual MHA Keystone: OB Workshop
April 2014 Content webinar - Data Collection Tools for Obstetrical Hemorrhage Initiative
(April 8)
May 2014 Content webinar (May 13)
June 2014 Coaching call (June 10)
July 2014 Content webinar (July 8)
August 2014 Content webinar (Aug. 12)
September 2014 Coaching call (Sept. 9)
October 2014 Regional Learning Session 2, Safe Tables
Content Webinar (Oct. 14)
November 2014 Content Webinar (Nov. 11)
December 2014 Coaching Webinar (Dec. 9)
Each hospital should form an internal improvement team/committee to guide the hospital’s
participation in this initiative. Each team should have, at a minimum, the following roles committed to
the project:
Director of obstetrics/birthing center Quality improvement and/or risk
Physician/obstetrician champion management representative
Nurse champion Data contact (responsible for data
Anesthesia provider champion collection and/or submission to the
Blood bank contact MHA Keystone Center)
Pharmacy contact Senior executive sponsor
As appropriate, teams are encouraged to include other staff members on the improvement team as well.
2MHA Keystone: Obstetrics
March 2014
MHA Keystone: OB Enrollment Form
Our organization has received the overview provided about the new MHA Keystone: OB initiatives and
would like to be included as a participant, understanding that work of this nature is not without great
effort. We agree to commit to the following to achieve success:
Participating Hospital Commitment
Hospital will designate a “project champion” to lead this initiative locally. The project
champion can be any number of roles including nurse, obstetrician, anesthesiologist or quality
improvement specialist. This individual will be the primary contact responsible for deploying the
interventions, collecting data and sharing their findings with the team. It is essential that this
individual be engaged and motivated to improve patient care, and adept at encouraging and
enabling faculty to contribute.
Improvement team members will be expected to participate in educational activities for the
duration of the project. Each month there will be a webinar for content presentation, coaching
and problem solving, in addition to an annual statewide conference.
All teams will be expected to implement each intervention during the course of the initiative.
Teams will also be expected to collect data and report on specific measures throughout the
duration of the project. The MHA Keystone Center’s standard of rigorous measurement and
reporting will be a hallmark of this project. The MHA Keystone Center will strive to minimize the
burden of data collection by using data that is already collected where feasible, to focus on
methods to improve performance and commit to the philosophy that harm is not tenable.
Names and titles of key contacts to which the MHA Keystone Center will direct messages and
information should be provided below. Please print neatly.
Hospital Name:
Project champion (primary contact): Title & Email:
Physician champion: Title & Email:
Anesthesia provider champion: Title & Email:
Data contact: Title & Email:
Other: Title & Email:
Other: Title & Email:
The MHA Keystone: OB initiative is subject to institutional review board (IRB) oversight. Each
participating hospital must indicate whether it will be using the central IRB offered by the MHA
Keystone Center or whether it will use its own individual IRB to gain approval for this project. Please
check the box below indicating your decision.
Hospital wishes to use a central IRB coordinated by the MHA Keystone Center
Hospital wishes to use its own individual IRB.
Please fax the completed form to (517) 703-0605 or email to Tammy Nault at tnault@mha.org.
3MHA Keystone: Obstetrics
March 2014
APPENDIX A:
Obstetrical Hemorrhage
According to a study by the Centers for Disease Control and Prevention on pregnancy-related mortality
in the United States between 1998 and 2005, hemorrhage is one of the leading causes of maternal
death (Berg et al., 2010). The incidence of maternal hemorrhage has been increasing in the United
States (Dildy, 2012). Callaghan et al (2010) found a 26 percent increase in the incidence of postpartum
hemorrhage (PPH) between 1994 and 2006. This increase was attributed primarily to higher rates of
uterine atony (from 1.6 percent of births to 2.4 percent of births) rather than changes in rates of
cesarean birth, vaginal birth after cesarean, maternal age, multiples, hypertensive disorders or diabetes
mellitus. Severe maternal morbidity is also on the rise in the United States; the three most common
diagnoses are blood transfusion, hysterectomy and eclampsia (Callaghan et al., 2008). These data
represent a significant number of childbearing women; severe maternal morbidity is 50 times more
common than maternal death.
Postpartum hemorrhage is defined as excessive bleeding (> 500 mL) following vaginal birth, and (> 1000
mL) following cesarean birth. Approximately four to six percent of women have primary postpartum
hemorrhage. The Centers for Medicare & Medicaid Services has specifically identified obstetrical
hemorrhage as a priority for Hospital Engagement Networks (HENs) to address through the Partnership
for Patients initiative in 2014, and the MHA Keystone HEN will align its metrics with other HENs so that
there is national comparison data available.
The MHA Keystone Center suggests the following interventions to prevent and manage obstetrical
hemorrhage, and will use resources developed through the California Maternal Quality Care
Collaborative (CMQCC) to guide our activities. These interventions are considered part of the necessary
infrastructure to provide a safe environment for women giving birth. Implementation of these
interventions will be assessed as part of the project via structure measures.
Interventions
Intervention 1: Continuation of the Comprehensive Unit Based Safety Project (CUSP). CUSP follows a six
step iterative process to improve patient safety and the culture that drives safety attitudes and
practices. Culture is a major focus because it is the set of shared attitudes, values, goals and practices
that characterize an organization (or unit/clinical area). CUSP is continuous and should be a part of daily
activities in each unit or clinical area.
Intervention 2: Identification and management of patients at risk for obstetrical hemorrhage using a
standardized risk assessment tool.
Intervention 3: Establishment and implementation of an active management of third stage labor
protocol that includes routine administration of oxytocin with shoulder delivery, cord traction and
uterine massage.
Intervention 4: Establishment and implementation of an obstetrical hemorrhage policy, based on
recommendations from the CMQCC, including a standardized protocol for massive transfusions
necessitated by obstetrical hemorrhage and an obstetrical hemorrhage kit or cart that has appropriate
medications and equipment that may be needed for this emergency.
4MHA Keystone: Obstetrics
March 2014
Recommended Intervention 5: Conduct interdisciplinary OB hemorrhage drills at least twice annually;
include a post-drill debrief as part of the process. Consider videotaping the drill to be used for the
debriefing.
Process Measures:
Risk assessment for obstetric hemorrhage documented upon admission
o Numerator: number of audited charts with risk assessments completed and
documented upon admission
o Denominator: total number of charts audited
o Instructions: Audit 20 randomly selected charts per month (10 vaginal, 10 cesarean); all
charts if less than 20 per month
Women receiving all elements of active management of third stage of labor
o Numerator: number of audited charts with documentation that a woman received all
elements of active management of third stage labor (active management of third stage
of labor for all vaginal births includes routine administration of IM or IV oxytocin with
shoulder delivery or placental delivery, gentle cord traction and uterine fundal massage
for at least 15 seconds; must perform all three interventions to be considered active
management of third stage labor).
o Denominator: total number of charts audited
o Instructions: Audit 20 randomly selected charts per month (10 vaginal, 10 cesarean); all
charts if less than 20 per month.
Process Measure Recommended
Debrief sessions:
o Numerator: number of debrief forms completed
o Denominator: number of hemorrhages each month that required interventions,
treatments, procedures outlined in Stage two or three of the CMQCC PPH Protocol (See
Appendix B).
Outcome measures:
Total number of blood products transfused per 1,000 women who gave birth > 20 0/7 weeks
gestation during birth admission
o Numerator: total number of units of any blood product* (RBCs, FFP, Plt packs, Cryo)
transfused during the birth admission (women giving birth >20 0/7 weeks gestation)
o Denominator: total number of women giving birth (>20 0/7 weeks gestation)
Number of women (who gave birth > 20 0/7 weeks gestation) who were transfused with ≥4
units of any blood product during the birth admission per 1,000 women
o Numerator: number of women (who gave birth > 20 0/7 weeks gestation) who were
transfused with ≥4 units** any blood product* during the birth admission
o Denominator: total number of women giving birth (>20 0/7 weeks gestation)
*The numerators identify all blood products rather than just RBCs. This is the definition used by the Joint
Commission and supported by an ACOG/CDC/SMFM consensus committee.
**The definition of an obstetric sentinel event including transfusion of ≥4 units of blood products is currently in
consideration by The Joint Commission.
5MHA Keystone: Obstetrics
March 2014
APPENDIX B:
Early Elective Deliveries
Process Measures
Process measure data will be collected on a monthly basis.
1. Elective deliveries before 39 completed weeks of gestation (Joint Commission Perinatal Care -01)
Outcome Measures
Outcome measure data will be collected on a monthly basis.
3. Babies (> 37 wks/0 days gestation to 37 and < All births > 37 and < Use Joint % of elective
induction before 39 39 completed weeks 39 completed Commission PC- births in sample
completed wks of gestation (per the Joint weeks gestation 01Sampling that were < 39
gestation Commission PC-01 criteria) (per the Joint Guidelines completed wks of
Commission PC-01 gestation (> 37
criteria) wks/0 days
gestation to 37 wks/0 all babies > 37 wks/0 days all babies > 37 all babies > 37 % of babies (> 37
days gestation toYou can also read
