How One Team Reduced Postpartum Hemorrhage and Improved Maternity Triage
Wednesday, October 23, 2019
By Siena Davis, MPH, Project Manager, PQI
“The nurses wanted to see change.” -Terri Farrington
In January of 2018, Terri Farrington, RN, was working as the Interim Clinical Manager at Grady Memorial Hospital in Atlanta, Georgia. Grady’s providers have experience serving people with complex medical conditions. Despite this, Terri was concerned that communication issues might be interfering with quality patient management. Terri explained, “We were interested in developing QI projects that brought together physician and nursing teams, interdisciplinary teams, to better manage our patients. Grady hired consultants to assess current processes and suggest changes to improve patient experiences and outcomes.
Terri was involved with two of the QI projects that grew out of conversations with the consultants. The first project was aimed at reducing postpartum hemorrhage, and the second was aimed at improving maternity triage. Terri worked with hospital administrators and chief physicians from the affiliated schools of medicine (Morehouse and Emory) to develop QI teams for each project. Each team was guided by a physician lead and an RN lead. The teams met once a week to develop AIM statements that provided a clear summary of what the team wanted to achieve over a period of time. Each AIM statement was assigned to a member of the team.
Before the projects were implemented, the QI teams were concerned about keeping staff engaged, dealing with dissenting views, and ensuring long-term behavior change among staff. Terri felt that using the Plan-Do-Study-Act (PDSA) tool helped the teams to overcome these concerns. Terri explained, “The PDSAs were informational because they showed us where the barriers were and helped to solidify the process.” The teams used PDSA to test each change that they implemented. At the completion of each PDSA cycle, the teams decided whether they should adopt or abandon the change. The team leads worked tirelessly to keep the QI projects moving. Terri said, “They would take the PDSAs, answer the questions, disseminate the information, and help to get the teams motivated.”
The goals of the hemorrhage project were to reduce the rate of postpartum hemorrhage, and to increase knowledge of both the stages of postpartum hemorrhage and the appropriate management of each stage. The QI team has established a postpartum hemorrhage checklist, defined the stages of postpartum hemorrhage, created a medication list, ordered postpartum hemorrhage carts, educated staff on quantitative blood loss, and developed a tool to provide a visual identification of each patient’s risk within the electronic medical record (Epic).
Terri said, “Working with our team and our IT Department, we developed a tool to recognize the risk of hemorrhage for each patient that’s admitted – low, medium, or high - based on a series of questions related to the history of that patient.” As soon as the nurse completes the initial assessment on admission, a row next to the patient’s name fills in with the color that corresponds with the postpartum hemorrhage risk – green for low risk, yellow for medium risk, and red for high risk. Terri explained, “The computer calculates the hemorrhage risk based on the initial assessment… It picks up any changes in terms of orders throughout the labor process or changes in labs that would change the score.” The team also decided to provide a visual representation of postpartum hemorrhage risk on each patient’s door using a green, yellow, or red heart.
Before implementing the triage project, patients were seen on a first come, first served basis. Patients were regularly visited first by an intern or first year, followed by a third or fourth year, and finally the attending physician. The process was taking six to nine hours from registration to disposition. The goals of the triage project were to reduce the wait time and total visit time for patients, triage patients to determine acuity, and prioritize care based on acuity.
Terri introduced the Association of Women's Health, Obstetric and Neonatal Nurses' Maternal Fetal Triage Index to triage pregnant women. The QI team decided that triage would need an additional nurse to conduct the pre-assessment and assign an acuity score to each patient. Now, there is an area designated for a nurse to conduct the pre-assessment, get vital signs, labs, a urine sample, fetal heart tones, and complete a nonstress test.
Currently, the QI team is working with the IT department to develop standing order sets for the nurses. According to Terri, “The standing order sets will allow us, to do a quick assessment and then decide this is what we need to order and put it in as a nursing order that gets signed by a physician or midwife later.” The QI team is also trialing asking midwives to conduct the pre-assessment. Since midwives have been successful in reducing wait times during previous trials, hospital administrators may ask midwives to conduct all pre-assessments in the future.
As a result of the triage project, average time from registration to disposition has dropped to two to five hours. Typically, individuals who are there for five hours are admitted to the hospital.
Terri's suggestions for others who are thinking about engaging in QI:
- “I would absolutely encourage other teams to look at QI processes and pick one that works for their organization.”
- “It has been instrumental in how it has connected our teams and how it has changed our culture. It has given us better outcomes for our patients.”
- “When doing QI projects, there’s different ways to trial and test. Our hospital adopted PDSAs. That’s helped us to figure out our processes.”
- “Work through the frustration. There is that storming period, especially when you’re working with teams, and then everybody eventually comes together.”
- “You will get there. Once everyone sees what the end goal, and you get there, and you see the changes that it’s made… It’s something to be really proud of.”