quantification of blood loss for the obstetrical … · o: improve identification of postpartum...
TRANSCRIPT
QUANTIFICATION OF BLOOD LOSS
FOR THE OBSTETRICAL PATIENT: AN EVIDENCE-
BASED PRACTICE IMPLEMENTATION PROJECT
Susan Hale DNP, RN, C-EFM
Problem Statement and Purpose
• Leading cause of maternal death
• Occurs in 4-6% of all pregnancies
• More than 50% in first 24 hours
• 54-93% of the PPH deaths may have been preventable
• Over 90% of the preventable mortality/morbidity linked to provider related factors
Delay in treatment/diagnosis, ineffective
management, lack of proper preventative measures (ACOG, 2013)
Problem Statement and Purpose
Adopted from : Ohio Pregnancy-Associated Deaths 2008-2012. by. Ohio Department of Health, 2015. Pregnancy-Associated Mortality Review (PAMR) Data. Retrieved from https://www.odh.ohio.gov/odhprograms/cfhs/pamr/PAMR%20Data.aspx
Of the 175 injury deaths, 64.0% were unintentional, 32.6% were intentional, and 3.4% were unknown.The most common manners of death, among injury deaths, were accident (65.1%), homicide (23.4%), and suicide (8.0%).
PICOT Question
P: Obstetrical Nurses I: Use of an evidence based practice (EBP) nurse-driven
protocol for measuring blood lossC: Visual estimation of blood lossO: Improve identification of postpartum hemorrhage (PPH)T: 8-10 weeks
“In obstetrical nurses, how does an EBP nurse-driven protocol for measuring blood loss compared to physician visual estimation of blood loss affect the identification of postpartum hemorrhage (PPH) over an 8-10 week period?”
Theoretical Framework
Betty Neuman’s System Model
Focus: • Response of the individual patient to stressors and the levels of
nursing prevention interventions for attaining, retaining, and maintaining patient wellness
Nurse’s role:• Focus on the variables that may affect the person’s response to
stressors and eliminate the risk factors associated with them
Project Design -Methodology
• The Ohio State Wexner Medical Center
• Level III maternity unit
• Over 100 staff RNs
• 5,000 births/yr
• Patients - child bearing age
• Vary in ethnicity and cultural backgrounds
• Excluded STAT cesarean sections and water births
Project Design -Methodology
• Comparing visual estimation of blood loss to measured blood loss immediately following birth
• Comparison logEstimation of Blood Loss per Physician Quantification of Blood Loss per Nurse
Project Design -Methodology
Cesarean deliveries:• Surgical Technologist (ST) to set up 2 suction tubing and 2 yankauers• ST to utilize #1 suction for amniotic fluid (white tip)• ST to utilize #2 suction for post baby (blue tip)• ST to remove #1 suction tubing from field, once ALL amniotic fluid has been
suctioned (this includes amniotic fluid in the side pouches)• RN, utilizing the newborn scale, will weigh all lap sleeves and bloody sponges after
abdomen is closed and document that value in the Cesarean Section QBL Calculator• RN/ST to note amount of irrigation used and document that value in the Cesarean
Section QBL Calculator• RN to note blood loss volume in #2 canister document that value in the Cesarean
Section QBL Calculator• RN to report QBL to team before abdomen dressing applied• Anesthesia provider to document QBL in delivery summary
Project Design - Methodology
• Vaginal Deliveries• The RN to note the amount of fluid in the underbuttock drape
immediately after the delivery of the newborn and document this value in the Vaginal Delivery QBL Calculator
• The RN to note the amount of fluid volume in the underbuttock drape prior to the repositioning of the mother after the completion of the vaginal delivery document this value in the Vaginal Delivery QBL Calculator
• RN, utilizing the newborn scale, will weigh all bloody laps, sponges, linen, chux pads etc. after the mother has been repositioned and document that value in the Vaginal QBL Calculator
Project Design -Methodology
• Estimation of blood loss and QBL was compared for all vaginal and cesarean section deliveries
• Manual Comparison log was used to track visual estimated blood loss and QBL
• Comparison Log was collected daily/weekly
• Weekly results were provided via email updates
Evaluation - Analysis
• PPH definition: blood loss of ≥500 ml for a vaginal birth and ≥1000 ml for a cesarean birth (ACOG, 2006).
• Estimated blood loss per the delivering provider was compared to the QBL per the primary care nurse immediately after each delivery
• Blood loss was measured in milliliters (ml) with one gram equaling one ml
• A chi-square test of independence was used to examine for an association or dependence between two nominal variables; blood loss (EBL and QBL) and PPH (Yes or No).
Results – Cesarean Births
EBL and QBL * PPH in Cesarean Sections Crosstabulation___________________________________________________________
PPH in Cesarean Sections Total
PPH Found No PPH found___________________________________________________________
Blood Loss QBL 13 60 73EBL 8 65 73
Total 21 125 146___________________________________________________________
Results – Cesarean Births
Chi-Square Test on PPH in Cesarean Sections
_________________________________________________________Value df p
__________________________________________________________
Pearson Chi-Square 1.042 1 .307
__________________________________________________________
Results – Vaginal Births
EBL and QBL * PPH in vaginal births Crosstabulation___________________________________________________________
PPH in Vaginal Births Total
PPH Found No PPH found___________________________________________________________
Blood Loss QBL 18 155 173EBL 22 151 173
Total 40 306 346___________________________________________________________
Results – Vaginal Births
Chi-Square Test on PPH in vaginal births
_________________________________________________________Value df p
__________________________________________________________
Pearson Chi-Square .427 1 .514
__________________________________________________________
Sustainability
• Physician recommendation
• New process for determining blood loss for cesarean section births
• Vaginal birth calculator in medical record
Implications for Practice
• QBL allows for earlier identification of a PPH
• Eliminates denial and delay
Conclusion
• Early identification of PPH leads to timely intervention improving patient outcomes and decreasing maternal morbidity and mortality.
• Visual estimation of blood loss most inaccurate means and linked to underestimation of approximately 30%-50% of all deliveries (Gabel
& Weeber, 2012)
• Eliminating visual estimation of blood loss and utilizing QBL will assist in early identification of PPH and improving patient outcomes
ReferencesAmerican College of Obstetricians & Gynecologists (2013). Postpartum hemorrhage. ACOG Practice
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Association of Women’s Health, Obstetrical, and Neonatal Nursing (2014). Quantification of blood loss.Author
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Ohio Department of Health (2015). Pregnancy-Associated Mortality Review (PAMR) data. Retrieved from https://www.odh.ohio.gov/odhprograms/cfhs/pamr/PAMR%20Data.aspx
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