Better Health for Mothers and Babies

November 13, 2018

Agenda

Welcome

Background

Review AHA Initiative

Quality Improvement Approaches from a health system

Using data to drive improvement

Maternal Mortality Review Boards

Questions

Better Health for Mothers and Babies

Maternal Deaths largely occur outside week of birth

Caveat: Data is not complete but suggests trend

Caveat: Data is not complete but suggests trend

Partnering with AIM

https://safehealthcareforeverywoman.org/aim-program/

Improving Maternal Health

Establish or Reaffirm Commitment

DATA

Regularly review internal data with interdisciplinary team and look for improvement opportunities.

Access across continuum of care

Health Disparities

Prioritize and implement targeted strategies known to combat risk factors

Accountability

Review care protocols and discharge transitions

Advance evidence based practices

Listen to Mothers:

Engage Mothers and work with like-minded community based organizations to improve public education to lower risk

Initiative: Better Health for Mothers and Babies (BHMB)New website: https://www.aha.org/better-health-for-mothers-and-babies

Center for Health

Innovation

Field Engagement

Public Policy

Better Health for mothers

and Babies

Provide a forum for hospitals to engage in sharing leading practices through webinars like this one, case studies, and podcasts, etc.

Convene national summit of stakeholders to share leading practices and identify collaborative actions

Share quality improvement tools and facilitate QI training to address improvement and disparities

Partner with community based organizations

Urging Final Passage of S. 1112, Maternal Health Accountability Act

STRENGTH IN NUMBERS

Preventable Causes of Maternal Death: Focus on Severe Maternal Morbidity

Maternal Mortality Review Committees (MMRCs)2015: Maternal Mortality Review Information Application (MMRIA or “MARIA”)

• Supports MMRCs and provides resources to promote a standard approach to case review

• Key decisions for each death reviewed:• Was the death pregnancy-related?• Underlying cause of death?• What factors contributed to the death?• Recommendations and actions to address contributing

factors?• Anticipated impact of actions if implemented?• Was the death preventable?

Centers for Disease Control and Prevention. Report from Maternal Mortality Review Committees: a view into their critical role. https://www.cdcfoundation.org/sites/default/files/files/MMRIAReport.pdfAccessed December 20, 2017 and MMRIA. Review to Action. http://reviewtoaction.org/implement/mmria. Accessed February 20, 2018.

Preventability

63.2%

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.

• Report of 9 MMRCs in 2018 estimated that 63.2% of pregnancy-related deaths were preventable• 70% of deaths from hemorrhage

were preventable• 63.2% of deaths from cardiac

disease were preventable• Report of 4 MMRCs in 2017

determined that 59% of pregnancy-related deaths were preventable

Preventability

Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol, 2005; 106(6): 1228-34.

Review of North Carolina maternal deaths: 21% of maternal deaths could have been prevented had care conformed to nationally recognized standards

Preventability varies by cause of death

17%

22%

40%

42%

60%

89%

93%

Pulmonary embolism

Cardiomyopathy

Cardiovascular conditions

Infection

Preeclampsia

Chronic medical conditions

Hemorrhage

• What was the chance to alter outcome (good chance, some chance, no chance, unable to determine)?

• Contributing factors and description• Patient/family

• Provider

• Facility

• System

• Community

• Recommendations / specific feasible actions that if implemented should have or might have altered the course of events

Standardized Decision Form for MMRCs: Preventability

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs. Accessed 10/21/2018.

Focus on Reducing Severe Maternal Morbidity: Review by Birthing Facility

Pregnancy

complication or pre-

existing medical

condition

Potentially life-

threatening

condition with

predisposition to

end-organ injury

Survival despite

experiencing an

unanticipated event

likely to result in

death

Adapted from: Witcher PM, Lindsay MK. Maternal morbidity and mortality. In: Troiano NH, Witcher PM, Baird SM (eds). High Risk and Critical Care Obstetrics, 2019; Wolters Kluwer: Philadelphia and Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/ pregnancy-mortality-surveillance-system.htm. Accessed on 10/30/2018

0.5 -3% of pregnancies

SMM to maternal deaths: 100:1

18.0 per 100,000 live births in 2014

Continuum of Morbidity and Mortality

Severe Maternal Morbidity Review

• Purpose: identification of improvements in processes and systems

• SMM Committee• Presentation of abstracted review• Identification of opportunities to improve outcomes• Focus on systems and processes• Refer cases to peer review as indicated• Aggregate, trend and disseminate data• Sanction by facility to provide peer review protection in

accordance with state’s legislation and statutes

• Root cause analysis for sentinel events

Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: Rationale and process. Obstet Gynecol, 2014; 124(2 Pt 1): 361-6.

Severe Maternal Morbidity Review

Timing of Review

Multidisciplinary Review CommitteeReviewable Events

Review Methodology

• A peripartum event (pregnancy to first 24 hours postpartum) that requires 4 or more units RBCs

• A peripartum event that necessitates ICU admission

• Unexpected and severe event that occurs during pregnancy, peripartum, or postpartum

• OB providers• Anesthesia providers• Obstetric nurses• Quality

improvement team• Administration

• Consider patient advocate

• Scribe• Consider

partnership with regional perinatal center (small center)

• Timing of review will be determined by the severity of the event and number of events (i.e. larger birth facility may consider regularly scheduled meetings)

• Peer review protection (gather confidentiality statements from members)

• Past and current medical records

• Trained abstractor• Presentation of

primary review• Utilize standardized

format• Conclude

recommendations

Specific resources available at: https://safehealthcareforeverywoman.org/patient-safety-tools/

Debriefing

• Care providers involved in the SMM event

• Supplements standardized SMM review by multidisciplinary committee

Resources:Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity

review: Rationale and process. Obstet Gynecol, 2014; 124(2 Pt 1): 361-6.https://www.cmqcc.org/resources/1533/download

Type of event: _______________________ Date: ________________Location of event: ____________________ Members of team present: _________

Systems and processes that went well

Opportunities for improvement• Human factors (such

as communication, teamwork, situational awareness, decision making)

• Systems issues (such as availability of equipment, supplies, or medications; blood products; transport issues; staffing

IssueActions to be taken

Person responsible

Severe Maternal Morbidity, 1993-2014

Source: CDC. Severe maternal morbidity in the United States. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html. Updated on 11/27/2017. Retrieved on 2/19/2018.

• Acute MI• Aneurysm• Acute renal failure• ARDS• Cardiac arrest / v-fib• Conversion of cardiac

rhythm• DIC• Eclampsia• Heart failure / arrest

during procedure• Puerperal cerebral

disorders• Pulmonary edema• Sepsis• Shock• SCD• Air & thrombotic

embolism• Blood transfusion• Hysterectomy• Temporary

tracheostomy• Ventilation

SMM indicators and corresponding ICD codes during delivery hospitalization

SMM in 25 US Hospitals2008 - 2011

Grobman WA, Bailit JL, Rice MM, et al. Frequency of and factors associated with severe maternal morbidity. ObstetGynecol, 2014; 123(4): 804-10.

Secondary analysis of Eunice Kennedy Shriver NICHD MFMU Network cohort of women and neonates in 25 US hospitals

Obstetric Hemorrhage: Prioritization for Improving Quality of Care

Report and review:• Post-event debriefs• Multidisciplinary review • Monitor outcomes• Use data to guide

quality improvement initiatives

Systematic review of deliveries that require 4 or more units RBC

Target: 20-30% reduction in use of blood products

• Total number of transfusions in deliveries > 20 weeks

• Number of massive transfusions in deliveries > 20 weeks

http://www.jointcommission.org/sentinel_event _policy_and_procedures/

Main E. OB hemorrhage measures for hospital QI projects. CMQCC. Available at: https://www.cmqcc.org/resource/ob-hem-hemorrhage-measures-hospital-qi-projects. Published 3/24/2015. Accessed 2/20/2018

Council on Patient Safety in Women’s Health Care. http://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Obstetric-Hemorrhage-Bundle.pdf. Accessed 2/20/2018.

SMM Review: Other Priorities

• Appropriate and timely recognition of hypertensive disorder?

• Appropriate magnesium sulfate prophylaxis?

• Timely and appropriate recognition and treatment of severe hypertension?

• Appropriate timing of delivery• Appropriate management of

complicationsExample quality metrics• Cases admitted to ICU due to systems

issues• Elapsed time from onset of confirmed,

severe hypertension to initiation of antihypertensive therapy

• Total number of women with severe features of preeclampsia who receive magnesium sulfate for seizure prophylaxis

Hypertensive Disorders of Pregnancy

• Appropriate thromboprophylaxis?• Timely diagnosis of VTE?• Recognition of risk factors for VTE?

Venous Thromboembolism

• Timely diagnosis of sepsis or infection• Appropriate timing and selection of

antibiotics?• Appropriate (adequate) IVF volume• Identification of risk factors?

Infection / Sepsis

• Appropriate and timely diagnosis and management?

• Were risk factors recognized?• Appropriate consultation?

Cardiac Disease / Cardiomyopathy

https://safehealthcareforeverywoman.org/patient-safety-tools/severe-maternal-morbidity-review/

Maternal Safety Toolkits

Organization

Patient Safety Toolkits

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ACOG District II Safe Motherhood Initiative

Council on Patient Safety in Women’s Healthcare

+AIM

+AIM

+AIM

+AIM

+AIM

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CMQCC

PEC

Safe Motherhood Initiative (SMI)ACOG District II

• May, 2013• Standardized review and reporting of maternal

deaths in NY• Standardized practices for obstetric emergencies

associated with maternal mortality and morbidity• Education/engagement

Safety bundles

https://www.acog.org/About-ACOG/ACOG-Districts/District-II/Safe-Motherhood-Initiative. Accessed 2/20/2018

OB Hemorrhage

Severe Hypertension

VTE

• Maternal health initiative• Alliance for Innovation on Maternal Health (AIM)

• September, 2014• National data-driven maternal safety and quality

improvement initiative• Funded through MCHB

OB Hemorrhage

Maternal VTE

Severe hypertension

Maternal mental health-depression and

anxiety

Opioid use disorder

Postpartum basics

Prevention of retained vaginal sponge

Peripartumracial/ethnic disparities

Safe in primary C/S

Support after severe maternal event

Maternal early warning criteria

Severe maternal morbidity review

Toolkits for Quality Improvement

Safety bundles Safety tools

http://safehealthcareforeverywoman.org/. Accessed 2/20/2018

Som

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AHA Member Advisory – November 6, 2018

Heart Safe Motherhood: Innovation to Improve Maternal Outcomes, Experience and Cost Wednesday, November 28, at 2 p.m. ET

Meeting the Challenges to Reduce Maternal Risk: A Dialogue with Neel Shah, MDWednesday, December 5, at 12 p.m. ET

Reducing Maternal Morbidity and Mortality: The Providence Oregon ApproachThursday, December 13, at 12 p.m. ET

Upcoming Webinars

QUESTIONS?

Robyn Begley, DNP, R.N.AHA Senior Vice President and Chief Nursing Officer & CEO, American Organization of Nurse Executivesrbegley@aha.org

Jay Bhatt, D.O.AHA Senior Vice President and Chief Medical Officerjbhatt@aha.org

Patricia (Trish) M. Witcher, MSN, RNC-OBClinical Outcomes Manager, Northside Hospital Trish.Witcher@Northside.com