Académique Documents
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Elliott K. Main, MD
Medical Director, CMQCC Clinical Professor, Obstetrics and Gynecology University of California, San Francisco, and Stanford University, Medical School
Objectives:
Describe national initiatives to reduce perinatal and maternal mortality and severe morbidity Describe the California Maternal Quality Care Collaborative structure and function Describe QI approaches to Preeclampsia used by other organizations
Presenter Disclosure(s):
No conflicts to disclose Supported with grants from the California HealthCare Foundation and the CDC
: Transforming Maternity Care
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1980 2000
1990 2008
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10
Literature review and over 100 in-depth interviews and focus groups Focus on disparity (esp African American women) and on variation among the states Scathing indictment of US healthcare system for maternity care
2010
ICD-9
ICD-10
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2006. Maternal mortality for California (deaths 42 days postpartum) were calculated using the ICD -8 cause of death classification for 1970-1978, ICD-9 classification for 1979-1998 and ICD-10 for 1999 to 2006. Produced by California Department of Public Health; Maternal, Child and Adolescent Health Program, March 2010.
16.6
16.8
Year
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013.
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2006. Maternal mortality for California (deaths < 42 days postpartum) calculated beginning 1999 using ICD-10 cause of death codes A34, O00-O95, O98-O99. Maternal single race code used 1990-1999; multirace code used beginning 2000. Produced by California Department of Public Health; Maternal, Child and Adolescent Health Program, March 2010.
Mortality
Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease
Mortality
Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease
Mortality
Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease
Mortality
Cause
VTE and AFE Infection Hemorrhage Preeclampsia Cardiac Disease
Public Health
Quality
Safety
Different professional groups with different trainings and world views Different agendas and priorities Different frames and models
Far and away the greatest impact occurs when we work together!!
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= Outcomes
Reduce elective delivery at less than 39 weeks of pregnancy by 33%; Expand access to inter-conception care (between pregnancies) through Medicaid; change policy is 5-8 states; Reduce smoking among pregnant women by 3%; Increase infant safe sleep practices by 5%; Improve perinatal regionalization-- increase the number of mothers delivering at appropriate facilities by 20%
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National Maternal Health Initiative: Strategies to Improve Maternal Health And Safety
May 5th 2013 New Orleans, LA
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Council for Patient Safety in Womens Health ACOG/AWHONN/ACNM/SMFM/AAFP Washington DC, July 29, 2013 Formal Support and Endorsement of National Partnership for Maternal Safety Will coordinate dissemination and Implementation of: Three bundles, three years among the following agencies:
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Midwives (ACNM)
Maternal Safety
Direct Providers
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The Joint Commission Sentinel Event: New Criteria for OB Beginning Jan 2014 Intended not be punitive but educational Identify cases to review carefully for systems improvement opportunities For Obstetrics, they define severe maternal morbidity: All cases with 4 units of blood products All cases admitted to an ICU These cases would have a RCA. ACOG has developed a package to aid reviews
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Population (2012): 38 million >500,000 annual births (1/8 of all US births) 260+ hospitals with maternity services 125 NICUs (levels 2 and 3) Large geographic diversity: urban and rural Extensive racial/ethnic diversity
29%
of births are non-Hispanic white Language other than English spoken at home: 43.5%
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Current Collaboratives:
Prevention of Central line infections Reduction of VLBW LOS
: Transforming Maternity Care
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Offices/C linics
Hospitals
1) Engage each from the beginning 2) Evaluate the project from each viewpoint 3) Create a work plan for each stakeholder 33
MCH/Sta te
Everyones nightmare
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QI Topic 1: OB Hemorrhage
Statewide CMQCC OB Hemorrhage QI Taskforce
Large, multi-disciplinary, overlap with Maternal Mortality Review Funded by CDPH-MCAH, completed in 2009
Guidelines, protocols, checklists, sample policies, support materials Series of Best Practice discussions on all OB hemorrhage topics, from Accreta to Jehovahs Witness to Uterotonic agents www.CMQCC.org
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These are open access tools being utilized in many : Transforming Maternity Carestates
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STAGE 1: OB Hemorrhage
Cumulative Blood Loss >500ml vaginal birth or >1000ml C/S -ORVital signs >15% change or HR 110, BP 85/45, O2 sat <95% -ORIncreased bleeding during recovery or postpartum
MOBILIZE ACT THINK
Primary nurse, Physician or Midwife to: Activate OB Hemorrhage Protocol and Checklist Primary nurse to: Notify obstetrician (in-house and attending) Notify charge nurse Notify anesthesiologist
Primary nurse: Establish IV access if not present, at least 18 gauge Increase IV fluids rates (Lactated Ringers preferred) and increase Oxytocin rate (500 mL/hour of 10-40 units/1000mL solution); Titrate Oxytocin infusion rate to uterine tone Continue vigorous fundal massage Administer Methergine 0.2 mg IM per protocol (if not hypertensive); give once, if no response, move to alternate agent; if good response, may give additional doses q 2 hr Vital Signs, including O2 sat & level of consciousness (LOC) q 5 minutes Weigh materials, calculate and record cumulative blood loss q 5-15 minutes Administer oxygen to maintain O2 sats at >95% Empty bladder: straight cath or place Foley with urimeter Type and Crossmatch for 2 units Red Blood Cells STAT (if not already done) Keep patient warm Physician or midwife: Rule out retained Products of Conception, laceration, hematoma Surgeon (if cesarean birth and still open) Inspect for uncontrolled bleeding at all levels, esp. broad ligament, posterior uterus, and retained placenta
Consider potential etiology: Uterine atony Trauma/Laceration Retained placenta Amniotic Fluid Embolism Uterine Inversion Coagulopathy Placenta Accreta Uterine Rupture
If: Continued bleeding or Continued Vital Sign instability, and <1500 mL cumulative blood loss proceed to STAGE 2
Dose
10-40 units per 1000 ml, rate titrated to uterine tone
Route
IV infusion
Frequency
Continuous
Side Effects
Usually none Nausea, vomiting, hyponatremia (water intoxication) with prolonged IV admin. BP and HR with high doses, esp IV push Nausea, vomiting Severe hypertension, esp. with rapid administration or in patients with HTN or PIH
Contraindications
Hypersensitivity to drug Hypertension, PIH, Heart disease Hypersensitivity to drug Caution if multiple doses of ephedrine have been used, may exaggerate hypertensive response w/possible cerebral hemorrhage Caution in women with hepatic disease, asthma, hypertension, active cardiac or pulmonary disease Hypersensitivity to drug Rare Known allergy to prostaglandin Hypersensitivity to drug
Storage
Room temp
Methergine (Methylergonivine)
0.2mg/ml
0.2 mg
-Q 2-4 hours -If no response after first dose, it is unlikely that additional doses will be of benefit -Q 15-90 min -Not to exceed 8 doses/24 hrs -If no response after 3 doses, it is unlikely that additional doses will be of benefit. One time
250 mcg
Nausea, vomiting, Diarrhea Fever (transient), Headache Chills, shivering Hypertension Bronchospasm Nausea, vomiting, diarrhea Shivering, Fever (transient) Headache
Refrigerate
Cytotec (Misoprostol)
100 or 200mcg tablets
800-1000mcg
Room temp
California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
Prevention:
Active Management of 3rd Stage: oxytocin after delivery
Readiness:
Partnership with Transfusion Service (aka Blood Bank) for un-crossmatched and
massive transfusion protocols and timely availability Other resources (including surgery, MFM, higher level facility referrals, social work) Hemorrhage Cart / with Procedural Instructions (balloons, compression stitches) Education (RN, OB, Anesthesia, and Emergency Room physicians) including didactic training and drills
Recognition/Response:
Endorse a unit-standard stage-based hemorrhage protocol with a task checklist Systematic and semi-quantitative approach to CUMMULATIVE blood loss
Process: Risk assessment done on every patient? (sample) Outcome 1: Total number of units of blood products per 100 mothers giving birth Outcome 2: Number mothers giving birth who received 4 units of blood products per 1,000 births (massive transfusion)
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QI Topic 2: Preeclampsia
Quality Improvement Opportunity Examples from PAMR:
Missed triggers: high BP (systolic and diastolic), pain, altered mental status, O2 saturation, fetal distress Underutilization of Magnesium SO4 and anti-hypertensive medications Difficulties getting physician to the bedside, and obtaining consultations Location of care issues involving Postpartum, ED and PACU
Key Supports:
The Joint Commission Sentinel Alert #44: Preventing Maternal Death (2010) ACOG Committee Opinion #514: Emergent Therapy for AcuteOnset, Severe Hypertension with Preeclampsia or Eclampsia (Dec 2011)
Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received.
Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received.
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Forty percent of patients with new onset hypertension or new onset proteinuria will develop classic preeclampsia.
Barton JR, Sibai BM. Prediction and prevention of recurrent preeclampsia. Obstet Gynecol. 2008;112(2 PART 1): 359-372.
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ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514, 2012; Tuffnell D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880.
%
64.0% (87.5%) (12.5%)
16.0% 8.0% 4.0%
Rate/100,000 1.0
.25
1 1 1
4.0% 4.0%
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Key Clinical Pearl Controlling blood pressure is the optimal intervention to prevent deaths due to stroke in women with preeclampsia.
Over the last decade, the UK has focused QI efforts on aggressive treatment of both systolic and diastolic blood pressure and has demonstrated a reduction in deaths.
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The overall mortality rate for preeclampsia in California is greater than 2 times that of the UK, largely due to differences in deaths caused by stroke.
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The critical initial step in decreasing maternal morbidity and mortality is to administer anti-hypertensive medications within 60 minutes of documentation of persistent (retested within 15 minutes) BP 160 systolic, and/or >105-110 diastolic. Ideally, antihypertensive medications should be administered as soon as possible, and availability of a preeclampsia box will facilitate rapid treatment. In Martin et al., stroke occurred in: 23/24 (95.8%) women with systolic BP > 160mm Hg 24/24 (100%) had a BP 155 mm Hg
3/24 (12.5%) women with diastolic BP > 110mm Hg 5/28 (20.8%) women with diastolic BP > 105mm Hg
Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia and Eclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, Obstet Gynecol 2005;105-246.
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Adapted from Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia and Eclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, OG 2005;105-246.
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OR
Switch TO:
Adapted from ACOG Commi ee Opinion #514; (1) MFM, Cri cal Care, Anesthesia, Internal Medicine; (2) Raheem I, Saaid R, Omar S, Tan P. Oral nifedipine versus intravenous labetalol for acute blood pressure control in hypertensive emergencies of pregnancy: a randomised trial. BJOG. 2012;119:78-85.
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ACOG Commi ee Opinion #514, 2011; ACOG Prac ce Bulle n #33. Reaffirmed 2012.
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Eclampsia
Eclampsia is defined as NEW ONSET grand mal seizures in a woman with preeclampsia Incidence is 1 in 1,000 deliveries in U.S.
Mortality from eclampsia ranges from approximately 1% in the developed world, to as high as 15% in the developing world
Ghulmiyyah L, Sabai BM. Maternal Mortality from Preeclampsia/Eclampsia. Semin Perinatol 2012;36:56-59.
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3,267 deliveries and 46 cases of eclampsia (1.4%) Most common prodromal neurological symptoms (regardless of the degree of hypertension OR whether the seizure occurred antepartum or postpartum):
Headaches
20% of women with eclampsia reported no neurologic symptoms before the seizure
Cooray SD, Edmonds SM, Tong S, et al. Characterization of Symptoms Immediately Preceding Eclampsia. Obstetrics & Gynecology, 118(5):1000-1004, November 2011.
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Magnesium Sulfate
Primary effect is via CNS depression Improves blood flow to CNS via small vessel vasodilation Blood pressure after magnesium infusion:
sBP dBP dBP dBP 120 min mm Hg 30 min 120 min 141 14 87 10 79 9 82 9
Mild Group
145 10
Belfort M, Allred J, Dildy G. Magnesium sulfate decreases cerebral perfusion pressure in preeclampsia.Hypertens Pregnancy. 2008;27(4):315-27.
58% reduction in seizures 45% reduction in maternal death* 33% reduction in placental abruption
*The 45% reduction in maternal death is not statistically significant but clinically important.
Altman D, Carroli G, Duley L, et al. The Magpie Trial: a randomized placebo-controlled trial; Lancet 2002;359:187790.
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Severe Preeclampsia X X X X X
Eclampsia
** X* X* X
X X X X X
**ACOG Executive Summary, 2013: for preeclampsia without severe features, it is suggested that magnesium sulfate not be administered universally for the prevention of eclampsia.
* Should be considered: Numbers needed to treat (NNT) = 109 for mild, 63 for severe 56
Magnesium sulfate therapy for seizure prophylaxis should be administered to any patients with:
Severe
Preeclampsia
Preeclampsia
with severe features i.e., subjective neurological symptoms (headache or blurry vision), abdominal pain, epigastric pain AND
be considered in patients with mild preeclampsia (preeclampsia without severe features)
should
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63% 87%
17 7
89%
20
10 0 0
1 6+
68%
96%
40
30 20 10 0 0
88%
8% 12% 4%
2 3
0%
5
4%
6+
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>48 hours following delivery, up to 4 weeks PP Accounts for approximately 15% of cases of eclampsia 63% had no antepartum hypertensive diagnosis The magnitude of blood pressure elevation does not appear to be predictive of eclampsia The most common presenting symptom was headache, which occurred in about 70% of patients; other prodromal symptoms included shortness of breath, blurry vision, nausea or vomiting, edema, neurological deficit, and epigastric pain
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Al-Safi Z, Imudia A, Filetti L, et al. Delayed Postpartum Preeclampsia and Eclampsia. Obstet Gynecol. 2011;118(5):1102-1107.
Early post-discharge follow-up recommended for all patients diagnosed with preeclampsia/eclampsia Preeclampsia Toolkit recommends post-discharge follow-up:
within
3-7 days if medication was used during labor and delivery OR postpartum within 7-14 days if no medication was used
Postpartum patients presenting to the ED with hypertension, preeclampsia or eclampsia should either be assessed by or admitted to an obstetrical service
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This and many other patient education materials can be ordered from www.preeclampsia.or g/market-place
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Use of preeclampsia-specific checklists, team training and communication strategies, and continuous process improvement strategies will likely reduce hypertensive related morbidity.
Use of patient education strategies, targeted to the educational level of the patients, is essential for increasing patient awareness of signs and symptoms of preeclampsia.
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Process: Treatment within 60 minutes per 100 mothers with preeclampsia and severe hypertension (either sBP 160 OR dBP110) Outcome: Number of days of ICU care per 100 mothers with preeclampsia
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Offices/C linics
Hospitals
MCH/Sta te
16.6
16.8
Year
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. United States data and HP2020 Objective were calculated using the same methods. U.S. maternal mortality rates are published by the National Center for Health Statistics (NCHS) through 2007 only. Rates for 2008-2010 were calculated using NCHS Final Birth Data (denominator) and CDC Wonder Online Database for maternal deaths (numerator). Accessed at http://wonder.cdc.gov/ucd-icd10.html on Apr 17, 2013 8:00:39 PM. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, April, 2013.
Thank You!
Visit: CMQCC.org