The American Hospital Association and healthcare software company Epic are rolling out a new toolkit to better address postpartum hemorrhages. The toolkit is already being used at hospitals around Arkansas and making an impact on maternal health outcomes. Ozarks at Large's Daniel Caruth reports.
For many expecting mothers, giving birth rarely follows an exact plan. And at hospitals in Arkansas, the number of women who died during childbirth is nearly 44 out of every 100,000—one of the highest maternal mortality rates in the nation, according to numbers from the Arkansas Center for Health Improvement.
“There are a few things more tragic than seeing a mother die in the process of childbirth, and both Jackie and I have seen that firsthand. And I mean, just the, like, the feelings that I have even speaking about that right now—like, that's a feeling that never goes away,” said Dr. Chris DeRienzo, a neonatologist and the senior vice president and chief physician executive for the American Hospital Association, or AHA.Recently, the AHA and the electronic health record system Epic have teamed up to roll out a free toolkit for hospitals around the country to help improve maternal healthcare outcomes.
Dr. Jackie Gerhart is a family medicine physician and a chief medical officer with Epic. She says the most common cause of death during childbirth is postpartum hemorrhage, and the biggest issue for many labor and delivery doctors and nurses is not having adequate information about the patients or the resources to address hemorrhage ahead of time.
“The feeling you have is: what else could I have possibly done? And if even this toolkit brings one more thing to the table that clinicians will be able to do faster, that might potentially save one life—I think it's worth it.”Postpartum hemorrhage is defined as blood loss after childbirth of 500 milliliters following a vaginal birth or 1,000 milliliters after a cesarean section. DeRienzo says the average person has around four to five liters of blood, but that number increases for pregnant women.
“A severe postpartum hemorrhage is about one liter of blood loss. And so what we're really talking about is losing nearly 20 percent of your total blood volume, which is pretty significant.”There are actually two kinds of postpartum hemorrhage. Women are at risk of postpartum hemorrhage for a number of weeks after delivery. But the kind that we are working with this toolkit to prevent, manage, treat, and then measure is the kind that happens in that immediate post-delivery several-hour period.
Nikki Knowles is a registered nurse and director for Women and Children's Services at Baptist Health in Little Rock and says postpartum hemorrhage is, unfortunately, something she and other nurses at her hospital see too often.
“Well, it is fairly common. And so what we do is—what Epic has built into our documentation is we have a postpartum hemorrhage staging guideline that breaks down a hemorrhage into three different stages based on the amount of blood loss.So the staging guidelines, they provide, like, clear assessment interventions such as labs and medications to be ordered and implemented by the providers and by the bedside nurses.”Baptist Health is the state's largest healthcare system and operates eight hospitals, including in Fort Smith and in Van Buren. And Dr. Gerhart says they have actually been using parts of this toolkit from Epic for a few years now.
“Yeah, and I do know that they have had a strong vision and focus on this. And they've even looked at some of the tools even before the toolkit was all put together to try to determine what they could turn on. So yeah, I just appreciate their partnership and also their commitment to trying to improve the health outcomes of mothers.”According to the AHA, postpartum hemorrhage affects 3 to 5 percent of all deliveries and is responsible for 11 percent of all childbirth-related deaths in the U.S.
Gerhart says finding ways to identify those risks and prevent hemorrhage is the first step in curbing these deaths.
“There's a checklist that every doc that's caring for women in labor and delivery goes through, and it's the preventive—so how do I know if this person has any of the risks?And frankly, about 40 percent of the time, we don't even have a specific risk. It's a surprise to us. And so how can we help at least tackle the ones where there is some kind of a risk that we can assess and have it in the forefront of our mind to make sure that we're taking all of the measures even before hemorrhage might occur?”She says the toolkit focuses on five different components—prevention being the first. And Gerhart says the electronic health record from Epic can now calculate a score for the patient during childbirth and postpartum based on medical history and risk factors to alert physicians and nurses of a possible hemorrhage threat.
“And so that's an initial guide. But then if a hemorrhage does happen, then you need to work to order the correct things.So it's ordering transfusion protocol. It's ordering different medications. It's making sure that you have the right people in the room. And all of that coordination, again, can be done and organized in the EHR through something we call an order set or a postpartum hemorrhage order set.And it's essentially a checklist that, in the moment, allows you to have all the things ordered at once. And that can be done in the background while you're caring for the patient.And then after having those orders, we then try to figure out, okay, is there something that we can do in the moment to try to quantify if we're getting improvement?And so there's a QBL—or a quantitative, quantifiable blood loss—calculator that allows us to figure out: is it a liter? Is it not a liter? It's very hard to tell when the woman’s in labor. You're not able to always easily measure it.And so having a standard by which to measure—and that's built out in your EHR—is really important.”She says the last two parts of the toolkit focus on outcomes and training for hospital staff. And DeRienzo says the toolkit is novel because it helps to standardize protocol for staff during an emergency situation.
“And in the middle of an emergency is not the time to try to learn new things. You have to execute.There's a reason that, as we were preparing for this call, Jackie and I were remembering our days of all of the advanced CPR-type training—it's called ACLS and PALS and NRP—and also, you rehearse and you practice over and over and over again because you need those tools to be immediately available, and it needs to effectively become muscle memory.So the ability to bring this toolkit live into your platform—I think, Jackie, you said it really well—it brings all of the things that a clinician and a clinical team needs in the moment to execute in order to have the best chance at saving a mom's life.”And Nikki Knowles says Baptist Health has seen measurable impacts from utilizing this toolkit. The Little Rock campus saw a 5 percent reduction in postpartum hemorrhage rates for all C-section deliveries and a 2 percent decrease for vaginal deliveries since 2021.
And Knowles says the quantitative blood loss calculator has been the most impactful piece of the toolkit for her staff.
“So you have to actually measure every pad, every towel, everything to get an accurate blood count.So implementing that was probably the biggest change for us and the most beneficial. Because before then, the physicians and the nurses would just give an estimate of the average blood loss. It was not truly identified.And so this right here was eye-opening—saying, ‘Oh, well, her blood loss was really 1,200.’And two years prior we might have guessed that it was, ‘Oh, maybe 500.’”Baptist Health, which delivers around 6,800 babies a year, implemented this program across all of its hospitals in three phases beginning in 2021, and also has staff participate in drills to better understand the tools when treating a hemorrhaging patient.
Knowles says before the toolkit, the biggest barriers to addressing postpartum hemorrhage were education and communication.
“The toolkit's really kind of broken down those barriers for us because everybody's on the same page. They speak the same language.So the physicians, when the nurse calls and says, ‘Hey, I have a QBL of 1,000. Her baby weighed nine pounds. We're having trouble getting the uterus to be really firm.’So everybody's speaking the same language whenever we are calling it in report.”DeRienzo and Gerhart say getting this free toolkit into more hospitals is a significant step, but there's still more to be done in tackling the country's maternal health care crisis.
“We understand that this is a problem that has been existing for many, many years. And it just feels—it feels in our bones—that this is something we should be able to help manage.It can't just be, do we have the right treatment or not? Because clearly, many different places across the country are having multiple different outcomes.And so there are other things to the equation of what causes these outcomes. And things like this toolkit can at least get us one step closer to standardizing how care is being given across the country, so that we can then look at the other pockets of areas that might be affecting it.”
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