September 21, 2018

Quantifying blood loss has taken center stage for most teams as the focus to improve readiness and response of obstetric hemorrhage is a priority to thwart maternal morbidity and mortality across North Carolina.  However, methods of quantifying blood loss across the state vary, with one team taking the leap to adopt a new technology.  UNC Rex healthcare began using a mobile app and an ipad to assist staff in capturing accurate blood loss at deliveries.  


The technology, titled the Triton system, is approved by the U.S. Food and Drug administration and is executed via an application on a tablet computer.   The program uses the tablet’s camera to capture images of surgical sponges.  “It performs colorimetric image correction and analysis and uses cloud-based machine-learning models to quantify hemoglobin (Hgb) mass on surgical sponges in real time.”  The cumulative blood loss can then be calculated “from direct extraction assays of Hgb content on surgical sponges and in suction canisters.”


Several months after implementation, the team at Rex feels the technology has improved their readiness and response to mothers who are at-risk for hemorrhage. They are able to measure blood loss quickly and provide real time volume loss updates to physicians resulting in proactive, informed clinical decisions.  Additionally, identifying accurate blood loss levels at delivery have enabled the staff to begin transfusions on the labor floor prior to transferring to postpartum.  Prior to Triton, Rex faced potential delays in discharge to provide necessary transfusions since previous practice had to rely on  hemoglobin lab results 24-48 hours after delivery.  Overall, the team feels the technology has been easy and efficient to implement.


The Duke Health System is another team taking the leap and has recently begun trialing the technology as well.  To connect with those who have embraced this method of quantification, email [email protected].

August 25, 2018

Assessing a patient’s risk for experiencing an obstetric hemorrhage after delivery can be a key component of identifying and managing a hemorrhage event quickly and effectively.  There are several factors that can increase a patient’s risk for experiencing hemorrhage.  The table below outlines what factors may define a low, medium and high risk for obstetric hemorrhage.


risk table


As teams have progressed through the AIM OBH initiative, there has been a 40% increase in the number of patients with a documented risk assessment on admission.  The goal for the initiative is to reach 98% of all patients assessed for OBH risk on admission and with a few more months ahead of us and some diligent teamwork, the goal of 98% is in sight.


Process Measure Results

July 25, 2018

One of the structure processes the Alliance for Innovation on Maternal Health hopes all teams will achieve is to integrate some of the recommended OB hemorrhage bundle processes (ie. order sets, tracking tools) into their hospita's electronic health record system.  The team at WakeMed Health and Hospitals has far exceeded this goal by creating a postpartum hemorrhage (PPH) narrator tool in their electronic medical record-EPIC.  

The narrator enables the nurse to link multiple flowsheets from one tab in the electronic record. Being able to access critical orders sets, chart medications or document vital signs rapidly, enables prompt responses to occur seamlessly.  The PPH narrator also creates a timeline of all events that have occurred from event start time to medication administration to staff arrivals, vital signs and more. (see screenshot below)  The work WakeMed has done on this documentation tool in collaboration with their IT department is commendable.  It has not only improved care for mothers at their facilities, this work has spread across the state as other health systems are looking to adopt this tool in their effort to decrease maternal morbidity and mortality. 


June 19, 2018

As the old adage says, “practice makes perfect” and AIM OBH teams have operationalized those wise words.  AIM OBH teams structure simulation practice and drills around OBH differently throughout the course of the competency year but nearly all teams have conducted some type of drill over the initiative.  In the third quarter of 2017, teams ran a total of 154 drills covering not only identification and management of OBH but also topics such as shoulder dystocia, stat Cesarean section, malignant hyperthermia, maternal code blue, and emergent maternal transfer to name a few.  In the fourth quarter of 2017, teams conducted a total of 112 drills and in the first quarter of 2018, a total of 133 drills were run.  The frequency of drills varies on each team with some teams scheduling drills once a quarter and others once a year but all teams have practiced and enhanced their skills in identification and management of OBH.

May 30, 2018

One goal of our obstetric hemorrhage initiative is to decrease, by 33%, the total units of packed red blood cells transfused to patients who experience a hemorrhage - and North Carolina perinatal quality improvement teams are getting close to achieving it! The key to this success is a dedicated effort to implement a staged-based protocol, ensure risk assessments are completed on admission, throughout delivery and during the postpartum period, as well as ensuring vital structure measures are in place, such as a hemorrhage cart. 

The graph below represents the progress teams across the state have achieved as they continue to thwart maternal morbidity and mortality in North Carolina.

OBH Progress

April 13, 2018

Over 35 perinatal teams came together last month for PQCNC’s face to face learning session to collaborate and share their experiences related to implementation of the AIM hemorrhage bundle.  The day was full of education focused on specific bundle elements ranging from risk assessment, patient engagement, debriefs and an interactive EBL station which garnered lots of discussion and information sharing.  Teams were fortunate to have Gene Hobbs, a Certified Healthcare Simulation Educator (CHSE) from the University of North Carolina, conduct an actual obstetric hemorrhage simulation using audience participants including the role of patient and family member.  Providing an immediate debrief with the participants and the audience allowed Gene to share his expertise regarding various ways to tailor simulations to any environment.  He highlighted how education through simulation can occur anywhere, at any time, and high fidelity equipment is not necessary to be successful.  Attendees were given resources outlining a myriad of quick, easy drills to perform each month that enhance simulation and communication techniques for teams as well as a step-by-step guide on how best to support and partner with family members during the crisis of their loved one. 

Simulation Learning Session

March 12, 2018

Lake Norman Regional Medical Center is a true leader in patient and family engagement.  The leadership of Women’s Services hosted a patient panel for the staff and administration from labor and delivery, postpartum and nursery units.  The three patient panel willingly shared their powerful birth experiences and offered meaningful feedback to the staff.  Responding to a need in the community, Lake Norman is also hosting a support group for all women who did not have the birth experience they were expecting and who have experienced the loss of an infant or child.  This exemplary work in patient engagement will enhance the care provided by the staff at Lake Norman and provide a needed service to women in the Mooresville area.

January 21, 2018

Many times, quality improvement in the perinatal setting has a clinical focus. Yet clinical improvements are not optimized without the partnership of patients and their families. Columbus Regional Healthcare System embraces this concept and is focusing their obstetric hemorrhage improvement efforts on the patient and family experience. In September 2017, after hearing from an expert panel of post-partum hemorrhage (PPH) survivors at PQCNC’s AIM Obstetric Hemorrhage kickoff meeting, the team from Columbus Regional Healthcare System was inspired to improve their understanding of the patient and family experience. In particular, by learning from women about how their staff can best support patients' and families’ emotional recovery following a severe maternal event. Using feedback from PPH survivors, the team has recently implemented an educational resource for women outlining important physical and emotional signs and symptoms to be aware of, and discuss with their doctor, following discharge from the hospital. Additionally, in order to address support needs during the hospital stay, Columbus Regional Healthcare System is implementing changes that will ensure support of the patient and family during the event.

PQCNC OBH Discharge Education

Life After Postpartum Hemorrhage available here for your use...

December 18, 2017

One of the process measures that PQCNC AIM OBH teams are reporting as they work to improve identification and management of obstetric hemorrhage is the percentage of women with a formal measure of quantitative blood loss (QBL).  Successful implementation and sustainment of the practice of measuring QBL for both vaginal and Cesearean section deliveries has been demonstrated by a local North Carolina hospital, CaroMont Regional Medical Center.  The team from CaroMont paired up with PQCNC to share their expertise via recorded webinar on the steps they utilized for successful implementation of QBL measurement.  This webinar is available to all PQCNC AIM OBH teams to view at any time and to learn from the success of one of their neighboring hospitals.

November 7, 2017

Teams are beginning to meet this month to organize their first small test of change.   The majority of teams are putting their efforts to work by updating or creating a postpartum hemorrhage policy, establishing a standard workflow to quantify blood loss at every delivery or construct designated hemorrhage carts or bags for staff to quickly utilize if needed - all focused on improving their readiness, recognition and response to postpartum hemorrhage patients as a means of reducing maternal mortality.