How One Perinatal Educator Implemented Quantitative Blood Loss in Texas
Wednesday, September 30, 2020
By Siena Davis, MPH, Project Manager, PQI
“As a result of implementing QBL at our facility, we are able to better recognize and plan preemptively for patients that are at significant risk for severe blood loss.” –Jessica McNeil
Jessica McNeil, DNP, APRN, CNM, RNC-OB, C-EFM, is a certified nurse midwife and clinical educator in Dallas, Texas. Jessica conducts QI projects, implements evidence-based practices, and oversees research projects. In addition, Jessica implements maternal safety initiatives mandated by the Texas Alliance for Innovation on Maternal Health (TexasAIM).
In 2019, TexasAIM asked participating hospitals to implement Quantitative Blood Loss (QBL). Jessica explained, “QBL has been recognized as a best practice to improve maternal outcomes. When you have a better understanding of how much blood a woman has truly lost then you can preemptively respond appropriately.” The goals of the QI project were to use QBL on all vaginal and cesarean deliveries, conduct a risk assessment on each patient, and institute interventions for patients at high-risk of hemorrhage at Texas Health Presbyterian Hospital Flower Mound.
Before starting the project, Jessica along with Loren Blair, MSN, RN conducted an assessment to make sure all the necessary equipment was available. They also got buy-in from staff. During her meetings with staff, they shared national, state, and hospital level data. They provided staff with resources and e-learning materials developed by TexasAIM.
Next, they gathered a group of stakeholders together. Jessica explained, “We started off with a narrow viewpoint of who our stakeholders were. We had to go back and say, ‘Wait a minute. We need help from IT. The nurses can’t chart this. It's not in our electronic medical record. We need blood bank at the table. We need the midwives at the table.’” The stakeholders started meeting together twice a month. They used materials provided by TexasAIM to track their progress.
The stakeholders selected individuals to be change champions for the project. Jessica said, “The individuals that were selected were recognized leaders within the department who voiced support for the change and believed in what we were doing. They were also respected by their peers and in good standing within the unit so they could model good behavior.”
As soon as the project started, the stakeholders began running Plan-Do-Study-Act (PDSA) cycles. “After each PDSA cycle, we would evaluate what went right and what went wrong. Then we would go back to the drawing table and run another one,” said Jessica. During project implementation, they realized that many of the staff did not have a strong understanding of QI. Jessica stated, “As educators, it’s our job to continually reinforce QI concepts. What is a PDSA cycle? Why are we doing that? What does it mean to continually reevaluate and improve? What does that look like tangibly?” Throughout the project, they educated staff at Texas Health Presbyterian Hospital Flower Mound on the importance of QI.
Texas Health Presbyterian Hospital Flower Mound
When asked what parts of the project went well, Jessica replied, “I think actually performing the QBL, weighing the items, went well. Once they understood and they had the tools in place, I think they adapted to that really well and were able to very easily get that number.” One of the challenges they faced with implementing QBL was getting all the doctors onboard. While reviewing audits, Jessica would see notes saying certain doctors did not want to perform or chart QBL. Jessica said, “Before we started our PDSA cycles we told the doctors we would be implementing QBL, but I don’t think it truly got across. That set us back a little bit. We had other providers that really championed the change, and were instrumental in moving things forward. I think as a team we were able to change course and get on track.”
As a result of the project, staff are better able to recognize patients who are at risk for hemorrhage and respond appropriately when hemorrhage occurs. Staff are implementing QBL in about 96-100% of vaginal and cesarean deliveries. Jessica explained, “A lot of months we’re at 100%. We’ve seen some really positive rapid improvement. Hopefully that decreases our severe morbidity and mortality rates overall.”
Jessica's advice for others considering engaging in QI:
- “I think that every single team that is going into a QI project really should start with the education. What is QI? Why do we care? Why do we do it? How does it differ from research?”
- “IHI does a really good job of explaining QI and starting with the why. Their open school modules are free.”
- “Get your stakeholders. Get provider input. Make sure nursing has a voice as well.”
- “Sit down and really think about every single person that you interact with when your patient is bleeding (or even before). For every action, there is a reaction. Think about how these actions will impact the service line.”
- “Evaluate your EMR. Make sure you have the tools to chart things and run reports. If you have a data analyst, use them. They become your best friend. If you don’t have a data analyst, consider making a proposal for your hospital to get one.”
- “Attend PQI’s Implementing Perinatal Quality Improvement Conference, PQI Champions Webinars, and review PQI’s Obstetric Hemorrhage Action Brief to help get more insights into how to use QI tools and methods.”
- “Don’t be afraid to reach out to other facilities to get feedback and ideas from them. Ultimately, it’s about safe outcomes for patients. It’s not a competition between hospitals. If one hospital has a really great system, then why not reach out and share that information instead of recreating the wheel?”