POST PARTUM

HAEMORRHAGE RISK
ASSESSMENT TOOL –
REDUCING HARM BY
REDUCING PPH
Webex 27/06/17
Dr Jenny Boyd
 Do you have a problem with pph in your unit?
 Why do you think there is a problem?
 Do all your colleagues agree that there is a
problem?
 If not, what is their reason for disagreeing?
Effective communication is the key to
all clinical care, particularly in the
maternity services, where there may
be multiple handovers of care.
Communication is effective only if the
relevant information is actually made
available to, and understood by, those
who need to act on it.
The King’s fund 2008
 EVIDENCE OF HARM

 Women who are admitted as low risk can become

higher risk as time passes
 >50% of women admitted to ITU begin their journey
as low risk
 Women have expectations about their experience
and do not expect to have complications

Dr Jenny Boyd Scottish Patient Fellowship

4
 What are we trying to
accomplish?
• Introduce a structured admission
checklist and pph risk assessment tool for
all women admitted to CLU
• To improve the quality of information
collected, to ensure better
communication, less variation in the
information about each woman. Easy to
read, easy to complete, easy to update,
identify “watchers”
STRUCTURED CHECKLIST

 Ongoing assessment of risk on admission in labour /

IOL/Augmentation
 Four hourly during 1st stage of labour –
 Hourly during second stage
 Final assessment following 3rd stage
 Discuss any issues with Midwifery Sister / Medical staff –
discuss at all handovers
PPH PREVENTION BUNDLE
 Documented
antenatal risk assessment and
management plan (where appropriate)
 Recognition and treatment of antenatal anaemia
(oral and /or IV)
 Documented reassessment of PPH risk at admission for
delivery and during the 2nd and 3rd stages of labour
 Active management of 3rd stage
 Ongoing quantitative assessment of blood loss
 Ongoing evaluation of vital signs
PRO-ACT NOT REACT

 To
actually reduce the number and volume of pph’s
we have to change our perspective
 Weare good at identifying and managing
haemorrhage
 We are good at REACTING
 We need to act earlier and be PRO-ACTIVE
RED AMBER or GREEN plan
for 3rd stage
GREEN PLAN
LESS THAN 6 POINTS

 Syntometrine IM or syntocinon IV or IM
 Repeat if necessary
 Measure blood loss
AMBER PLAN
6-9 POINTS

 Syntometrine IM / syntocinon IM or IV
 IV access and 40/500 syntocinon infusion
 Group and save and FBC
 Commence MEOWS
 WITH consideration given to administration of misoprostol or
ergometrine (if suitable)
 MORE women will have a syntocinon infusion
RED PLAN
10 OR MORE POINTS
 Syntometrine IM /syntocinon IM or IV
 IV access and 40/500 syntocinon infusion
 AND ………….PROACT………..
 2nd IV access
 Xmatch 2 units (unless suitable for electronic release)
 GIVE MISOPROSTOL pr AND EITHER ERGOMETRINE iv/im OR
HAEMABATE im
REDUCE AVOIDABLE HARM

 Ensure a plan is in place for prompt management or

3rd stage
 Identify
those whose risk changes and change the
plan accordingly
 Identify
women who are deteriorating and implement
measures early to reduce harm occurring
 A checklist with risk assessment tool will be a clear and
effective format to collect and communicate
accurate and relevant information about each woman.
 The correct information can be communicated to the
appropriate individuals and actions taken to plan the
3rd stage
 or if deterioration is noted to take action to prevent harm
occurring.
INTRODUCTION OF TOOL
number of pph's
30

25

20

15

10

number of pph's
WHAT IS GOING ON?
 Increased numbers of pph
 Retained placentas in the low risk Midwifery Led Unit
2 placenta accreta – 1 undiagnosed
1 placenta percreta – undiagnosed
 Placenta praevia
 Most haemorrhages are occurring in theatre
WHERE DO WE GO FROM HERE?
 Improved management of retained placenta –
especially in MLU
 Roll out use of checklist and risk assessment tool in MLU
 Useof checklist and risk assesment tool in theatre –
now incorporated in the checklist
 Diagnosis of abnormally adherent placentas - ? MRI
for all low lying placentas after c/s
 Renewed effort to maintain awareness
 Spread and sustain
PROBLEM
Post partum haemorrhage
Rising rates
? avoidable harm
 CHALLENGES

Culture
of “can only be
managed”
It is impossible to prevent it
Culture of acceptance
AIMS

Reduce major PPH’s by 30% by

2016
Reduce ALL PPH’s by 2016
Changingthe culture of
acceptance
 Reducing the Incidence of PPH - Driver Diagram

Outcomes Primary Drivers Secondary Drivers

Structure Checklist and Risk

Effective Risk Assessment
Effective communication of risk
Assessment
between teams
Use birth plans to discuss risk and
Reduce the care pathways with women

incidence of
Major PPH by Optimizing antenatal Hb
30% and the Early recognition and Raising awareness with women
response about Hb
incidence of all Early measurement blood loss
PPH by 15% by MOEWS
December 2016
Active Management of 3rd stage
Reliable care PPH Management Bundle
processes Report and review ALL PPH’s

Motivating and Skill training – PROMPT

engaging staff Provide feedback
 Measurement
Process Measures
• Compliance with PPH checklist and risk
assessment
• Compliance with surgical briefing
• Compliance with PPH prevention
bundle

• Target 95% compliance for each measure

 % compliance with structured checklist and PPH risk assessment

100

90
Added to surgical checklist
80

70 PROMPT training

60
% compliance

50

40

30

20
multiple testing of checklist + risk assessment tool
10

0
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
 100.00

10.00
20.00
30.00
40.00
60.00
70.00
80.00
90.00

0.00
50.00
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Apr-15
May-15
% compliance surgical briefing

Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Apr-16
May-16
Jun-16
Jul-16
Aug-16
Sep-16
 Measurement
System Measures

• % staff trained in management by

attending PROMPT

• 75% midwives
• 57% medical staff
 Measurement
Outcome Measures

• Rate of Major PPH

• Rates of all PPH
 PPH Rate blood loss >1000mls
14

12

10
rate/1000 maternities

6
Measuring bloodloss

Displaying data

4
structured checklist and pph assessment adding to surgical pause

2 PROMPT training

0
Jan Feb Mar Apr 2015 May Jun Jul 2015 Aug Sep Oct 2015 Nov Dec Jan Feb Mar Apr 2016 May Jun Jul 2016 Aug Sep-16
2015 2015 2015 2015 2015 2015 2015 2015 2015 2016 2016 2016 2016 2016 2016
 Rate per 1,000 maternities

0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
18.00

16.00
Jan 13

Feb 13
Mar 13

Apr 13
May 13

Jun 13
Jul 13

Aug 13

Sep 13
Oct 13

Nov 13
Dec 13

Jan 14

Feb 14
Mar 14

Apr 14
May 14

Jun 14
Jul 14

Aug 14

Sep 14
Oct 14

Nov 14
Dec 14

Jan 15

Feb 15
Mar 15

Apr 15
May 15

Jun 15
Jul 15

Aug 15

Sep 15
Oct 15

Nov 15
Rate of severe post-partum haemorrhage

Dec 15

Jan 16

Feb 16
Mar 16

Apr 16
May 16

Jun 16
Jul 16

Aug 16

Sep 16
Oct 16
 Lessons Learned
• No single factor makes the difference
• Whole culture shift from acceptance to prevention
• Need to engage ALL stakeholders
• The whole team must be signed up to driving
improvements locally
• Different strategies needed to engage the different
professional groups
Engaging and enabling
 Days since last event

100
120

20
40
60
80

0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Event number

32
33
34
35
36
37
38
39
40
41
42
Days between severe post-partum haemorrhage

43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
Engagement Board