Impact on Patient Outcomes of Implementation of Ob Hemorrhage Safety Bundle With Multidisciplinary Simulations [16J]
Authors: Binkley Shelley , Cave Christine , Baranyk Myra , Montgomery Rachel 
Published: April 2018

INTRODUCTION:
Beaumont Hospital Dearborn Labor and Delivery unit serves a diverse population of pregnant patients, delivering 4000-4500 women annually. Approximately 40% are diagnosed as “high risk” based on medical or obstetric criteria. In 2016, we implemented a national (ACOG/SMFM) Obstetric hemorrhage safety bundle at Dearborn. Obstetric hemorrhage was defined as quantitative or estimated blood loss of 500 mL or greater, during the patient's delivery stay. We performed educational presentations to all obstetric nurses, obstetric and anesthesia physicians, CRNAs, CNMs, physician assistants and residents, as well as conducted sixteen multi-disciplinary simulations over three months to implement the safety bundle. These simulations took place from June 1 through August 31, 2016 and involved physically going through an obstetric hemorrhage scenario on labor and delivery complete with model patients, simulated blood, hemorrhage cart, and all instruments and supplies needed to conduct a hemorrhage response. All participants took a required on-line course post-test on the information presented after they completed the simulation.

METHODS:
This abstract represents Phase One of a two-phase study. The methods of both phases are presented here for the sake of completion.
Phase One of the project evaluates the overall rates of obstetric hemorrhage diagnosed, the numbers of cases transfused, and the number of blood products used. This phase does not use identifiable patient data. The endpoint for Phase One is determination of the rates of diagnosis of postpartum hemorrhage and the rates of transfusion and blood products used expressed as percentages of deliveries.
Phase Two of the project evaluates in detail all patients diagnosed with obstetric hemorrhage to assess interventions. This phase is a retrospective chart review that will involve examination of patients diagnosed with hemorrhage and de-identified patient data. The interventions include quantitative measurement of blood loss, administration of uterotonics, transfusion of blood products, and surgical interventions (e.g. insertion of Bakri Balloon, uterine curettage, laparotomy, use of uterine compressions sutures, ligation of hypogastric artery, and cesarean hysterectomy). This phase will study admission and discharge hemoglobin values, as well as rates of the above-stated interventions to assess the character and quality of the institution's response to obstetric hemorrhage. The end point for phase two is to determine which interventions were assimilated most and least effectively and if changes need to be made to our implementation of the safety bundle to optimize patient care.

RESULTS:
In 2016, 4212 patients were delivered at Beaumont Dearborn Hospital. Of those, 119 were diagnosed with obstetric hemorrhage (blood loss of 500 mL or greater). Implementation of the Obstetric Hemorrhage Safety bundle did not affect the rate of diagnosis of obstetric hemorrhage that averaged 2.83% (monthly range 1.12-4.02%), consistent with published national rates for obstetric hemorrhage at similar institutions. However, the number of cases meeting criteria for transfusion, expressed as a percentage of total deliveries, increased from 0.6% to 1.0% (5/1691 to 25/2521) before and after the obstetric hemorrhage simulations started in June 2016. The overall numbers of units of blood products transfused increased from 1.0% to 3.7% (10/1691 to 93/2521) prior to and after the commencement of the simulations.

CONCLUSION:
The percentage of patients identified as needing transfusion and the total numbers of blood products transfused increased substantially following the implementation of the obstetric hemorrhage safety bundle and the commencement of the simulations. Phase two will evaluate how well the hemorrhage protocol was adhered to and whether it impacted the morbidity and rates of more dramatic interventions such as return to operating room for additional procedures such as cesarean hysterectomy. Phase two will be used to assess if there is a need to adjust our implementation of the obstetric hemorrhage safety bundle, and if so, in which aspects.