NEW ORLEANS — The following is the LSU Health Center New Orleans' list of initiatives supported to fight maternal mortality
"Addressing Maternal Morbidity and Mortality
LSU Health New Orleans School of Medicine’s Obstetrics and Gynecology faculty have been leading efforts to prevent maternal morbidity and mortality both on the state and local levels.
AT THE STATE LEVEL
Louisiana Pregnancy-Associated Mortality Review
The Louisiana Pregnancy-Associated Mortality Review (LA-PAMR) works to quantify and understand pregnancy-related and pregnancy-associated deaths in order to create actionable, comprehensive recommendations to prevent future deaths. This is accomplished through epidemiological surveillance and multidisciplinary case review. LA-PAMR is an official activity of the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality (Louisiana Perinatal Commission).
Dr. Robert Maupin, Professor of Obstetrics and Gynecology specializing in Maternal/Fetal Medicine at LSU Health New Orleans School of Medicine, led the effort to initiate the State of Louisiana’s Maternal Mortality Review. He has served as Maternity Program Medical Director in the Bureau of Family Health Program of the Louisiana Department of Health’s (LDH) Office of Public Health and on LDH’s Commission on Perinatal Care and Prevention of Infant Mortality.
Louisiana Perinatal Quality Collaborative
Dr. Pooja Mehta, LSU Health New Orleans assistant professor of OB/GYN, is helping lead state quality efforts as medical director of the Louisiana Perinatal Quality Collaborative. Another LSU Health New Orleans OB/GYN faculty member, Dr. Stacey Holman, serves as a physician advisor.
The Collaborative is committed to implementing specific best practices to every woman, every time, driving systemic change that doesn’t leave anyone behind, no matter who they are.
Factors affecting severe maternal morbidity are thought to be a mix of social determinants, issues with quality of medical care, and increased level and complexity of illness in people giving birth.
SMM trends may, in part, be driven by patient mix and facility level of care (i.e. whether or not a facility has required services to take care of mothers and newborns who meet criteria to require greater intensity of medical services, like an intensive care unit, or a maternal/fetal medicine specialist).
The aim of the Collaborative responds directly to Louisiana data and is twofold: to reduce severe maternal morbidity in birthing people who experience hemorrhage and high blood pressure by 20% in participating facilities and to reduce the black-white disparity in this outcome in participating facilities. To achieve this, the Collaborative is focusing on implementing best practices recommended by the Alliance for Innovation on Maternal Health (AIM) and the Institute for Healthcare Improvement (IHI):
• Partnering with patients and their families;
• Quantifying blood loss;
• Debriefs following severe maternal morbidity events;
• Team huddles and OB unit drills
• Timely treatment of severe hypertension;
• Assessing patient risk and team readiness at important points in care.
The LaPQC’s Reducing Maternal Morbidity Initiative is informed by the Institute for Healthcare Improvement’s evidence-based Breakthrough Series collaborative improvement model.
The Collaborative will support quality improvement activities in birth facilities including strategies to reduce racial bias and components of the AIM bundle to reduce racial disparities. It has recruited key faculty representing community perspectives and expertise on racial equity in order to achieve this goal, including leaders from Louisiana-based organizations: Sista Midwife, the Birthmark Doula Collective, and the Institute for Women and Ethnic Studies.
A total of 31 Louisiana birthing facilities are participating in the Reducing Maternal Morbidity Initiative
Healthy Moms, Healthy Babies Advisory Council
An initiative that Governor John Bel Edwards included in his legislative agenda for 2018 resulted in a bill passed by the Louisiana Legislature establishing the Healthy Moms, Health Babies Advisory Council. The Council’s charges are to:
· Evaluate functions and activities of existing groups focused on maternal mortality in order to collaborate with and engage stakeholders.
· Support and contextualize reporting of maternal outcomes data disaggregated by race and ethnicity where possible.
· Incorporate an ongoing community advisory process into existing state committees and collaboratives that generate data, recommendations, and proposals for health system changes relevant to maternal mortality and morbidity, prioritizing representation from organizations led by members of affected, historically marginalized communities.
· Establish guidelines for specific data components relevant to birth equity to be included in state and agency reports on maternal mortality and morbidity, including a plan for timely dissemination of reports on maternal mortality, morbidity, and related disparities to legislators, healthcare organizations, and other keystakeholders.
· Make recommendations on further policy options to ensure that the state establishes ongoing public health monitoring and activated response to eliminate cases of and disparities in maternal mortality and morbidity.
· Issue a report of its findings and recommendations on or before February 1, 2020, to the Commission on Perinatal Care and Prevention of Infant Mortality, the governor, the speaker of the House of Representatives, and the president of the Senate.
· Issue research findings, reports, and recommendations for legislation at the discretion of the council.
LSU Health’s Drs. Maupin and Mehta are members of the Healthy Moms, Health Babies Advisory Council.
AT THE LOCAL LEVEL
In New Orleans, LSU Health faculty worked to create and are actively involved with an Obstetric Quality Committee at the partner private hospital where they deliver babies. LSU Health New Orleans OB/GYN faculty serve a high-risk population and consider these patients to be their highest priority.
The Obstetric Quality Committee is responsible for revising policies and procedures, designing patient safety tools for standardization of processes, and formulating educational plans for nurses and physicians. The Committee determined that the greatest impacts for change are obstetric hemorrhage and hypertension in the peripartum period. To address these:
HEMORRHAGE
- A risk assessment tool was included in the admit process more than two years ago to prospectively identify patients with high risk for hemorrhage. This risk assessment triggers additional patient safety actions including blood product availability, notification of high risk on the patient dashboard, and increased communication among nurses and physicians in preparation for delivery.
- A hemorrhage cart was created on Labor & Delivery to greatly reduce response time in emergency situations. The cart contains supplies, surgical instruments, and medications needed in the event of a hemorrhage. That cart can simply be pulled into a labor room or operating room if needed.
- An education plan was developed and implemented about the Quantification of Blood Loss (QBL). By developing a standard process of objective blood loss quantification, all members of the healthcare team are speaking the same language. Using a standard process to quantify blood loss allows providers to have a more accurate measurement and use this data point as a clinical indicator for determination of blood product replacement or other targeted strategy for treatment of hemorrhage.
- The transfusion policy was completely revised. The hospital now has a highly functioning Massive Transfusion Protocol, developed with input from blood bank experts. The design was implemented in similar fashion to a trauma protocol and supports recent patient safety literature on the importance of transfusion policies in Labor & Delivery.
HYPERTENSION
- A policy was written and implemented to decrease time from BP measurement to provider notification.
- A review of the intrapartum/postpartum management of hypertension was also provided to nurses and physicians.
- The Committee is currently working on the next stage of this patient safety initiative in which they look at reduction in time to medication administration for severe hypertensive disease. In addition, they are reviewing all postpartum discharges to assure that proper education was given to the patient as well as access to short-term outpatient follow-up. They have created a structure by which discharge education is standardized to include information about recognition of critical Post Birth Warning Signs.
- Over the past two years, unanticipated obstetric hemorrhage cases have decreased, the risk assessment tool has had 100% compliance, and nurses and providers have actively participated in the QBL process.
A multidisciplinary patient simulation education structure was developed by which nurses and physicians are able to practice critical obstetric scenarios in situ within the delivery unit. LSU Health faculty members lead the debriefing and LSU resident teams are present for every simulation case.
COMMUNICATION & TRANSITION
Closed loop communication techniques strengthen the patient care model between nurse, provider, patient, and family. Transitions of care, equally important to patient safety, have been part of the daily routine with LSU Health resident service for years. The entire Obstetrics team, including the attending physicians, review the entire census of their service at least twice per 24-hour period. A safety huddle also occurs daily on L&D that includes a multidisciplinary approach."
