Maternal Patient Safety - PeriGen

Maternal Patient SafetyThe Joint Commission Makes it a Priority

ALANA MCGOLRICK, DNP RNC -OB, C-EFM

CHIEF NURSING OFFICER, PERIGEN

To learn more about PeriGen, please visit PeriGen.com

https://www.perigen.com/

DisclaimerThis presentation includes information from The Joint Commission and other sources (designated on the slides). The following studies were not conducted by PeriGen.



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About PeriGenComprehensive labor and delivery patient safety platform incorporating PeriGen’s NICHD-validated Artificial Intelligence decision support tools.

Leveraging evidence-based medicine with 50 peer-reviewed publications: American Journal of Obstetrics and Gynecology, Becker’s, Journal of Healthcare Information Management.

PeriWatch Vigilance ® is an early warning system that works with an existing EFM to quickly & consistently identify patients who may be developing a potentially worsening condition.

330 clients nationally



Our PresenterDr. Alana McGolrick

DNP, RNC-OB, C-EFM

PeriGen Chief Nursing Officer

With significant perinatal experience, Dr. McGolrick leads PeriGen's efforts to expand and enhance clinical education, customer outcomes and publishing.



Clinical ConsultantKaren Kolega (“KK”)

MSN-CNL, RNC-OB, C-EFM

PeriGen Clinical Consultant

Karen is a clinical subject matter expert for PeriGen’s obstetrical software. Her expertise in Obstetric practices, regulations and hospital operations improves prospective client engagement, adoption, and implementation.



AgendaBackground

Significance

Problem

The Joint Commission Accreditation Manual Additions

Obstetric Hemorrhage

Severe Hypertension/Pre-eclampsia

PeriWatch Vigilance® Demonstration



Objectives

At the conclusion of this program, the participant will be able to:1. Demonstrate knowledge and understanding of The Joint Commission new elements of

performance.

2. Describe the strategies to achieve compliance with the new elements of performance.

3. Identify one performance improvement opportunity that you may implement at your hospital.



Background

40-50 % of maternal deaths have been deemed potentially preventable deaths

Most preventable events are preceded by vital sign changes

Maternal morbidity rates have more than doubled in the United States since 1998

Causal factors are commonly related to a delayed response to clinical warning signs

(MacDorman et. al., 2016; Mhyre et al., 2014; Morton et al., 2019; Shields et al., 2016)To learn more about PeriGen, please visit PeriGen.com


Maternal Mortality Trends

(https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html)



Poll QuestionAre you currently participating in a local, state or national maternal safety collaborative?

1. Yes

2. No

3. Unsure

4. Plan to participate in the future



Poll QuestionIf yes, which collaborative are your partnering with?

1. AIM

2. CMQCC

3. AWHONN

4. State specific collaborative

5. Other



Significance

Medical complexity of the pregnant patient

Failure to standardize national obstetric patient safety standards

Limited research exists on maternal early warning systems

(Arora et al., 2016; Carle et al., 2013; Cole, 2014; Mhyre et al., 2014; Shields et al., 2016)



(https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm)


https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm


The Problem

Potentially preventable

maternal morbidity & mortality

Inaccurate assessment

Misinterpretation

Communication delay

Lack of standardization

Escalation of care

Complex comorbidities



Poll QuestionHave you experienced an adverse outcome that was related to any of the following causative factors? ‘check all that apply’

1. Underappreciation of patient status

2. Failure to recognize worsening condition

3. Delay in care

4. Reluctance to escalate situation



Accreditation Manual Additions

• PC.06.01.01

• Reduce the likelihood of harm related to maternal hemorrhage

• Elements of Performance 1-7

Provision of Care, Treatment, and Services

• PC.06.01.03

• Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia

• Elements of Performance 1-6

Provision of Care, Treatment, and Services

(https://www.jointcommission.org/r3_report_24_pc_standards_for_maternal_safety/)


https://www.jointcommission.org/r3_report_24_pc_standards_for_maternal_safety/


Obstetric Hemorrhage

Leading cause of maternal death worldwide

Major component of severe complications

Racial disparities indicating an alarming gap

Failure to recognize excessive blood loss

Delayed interventions

(Callaghan, Creanga, & Kuklina, 2012; CMQCC, 2015, Seachrist et al., 2019)



Elements of Performance1. Maternal hemorrhage risk assessment upon admission

2. Written procedures for stage-based maternal hemorrhage management*

3. Standardized hemorrhage supply kit

4. Staff and provider maternal hemorrhage education

5. Obstetric hemorrhage drills

6. Obstetric hemorrhage case reviews

7. Patient and family education

(https://www.jointcommission.org/r3_report_24_pc_standards_for_maternal_safety/)


https://www.jointcommission.org/r3_report_24_pc_standards_for_maternal_safety/


Obstetric Risk Assessment

(https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit)


https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit


Massive Transfusion Protocol



Obstetric Hemorrhage Supply Kit


(https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit)


https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit



Mock Drills



Case Review


(Callaghan et al., 2014, Geller et al, 2014, Kilpatrick et al., 2014)


Patient and Family Education (Suplee et al., 2016)



Hypertension Crisis & Pre-eclampsia

One of the leading causes of maternal mortality

Contributing factor to pregnancy complications

Historically focus has not been on BP control

ACOG Practice Bulletin 202, Volume 133, No. 1 January 2019

Initiate aspirin therapy for high risk maternal patients

Postpartum patients continue to be at risk

(ACOG, 2019)



Elements of Performance 1. Policy and procedure for accurate measuring and remeasuring maternal blood pressure

2. Policy and procedure for managing maternal patients with severe hypertension/preeclampsia*

3. Staff and provider maternal severe hypertension/preeclampsia education

4. Obstetric severe hypertension/preeclampsia drills

5. Obstetric severe hypertension/preeclampsia case reviews

6. Patient and family education



How to accurately

measure blood pressure

(https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit)


https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit


Policy and Procedure Designed to guide clinical practice

Provide specific steps to care for patients within the hospital

Evidenced based practice

Supported by established standards



Magnesium SulfateT W O M A I N G O A L S – M A N A G E M E N T O F P R E E C L A M P S I A A N D P R E V E N T I O N O F S E I Z U R E S





Mock Drills



Case Review

(https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit)


https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit


Patient and Family Education


(Suplee et al., 2016)


PeriWatch Vigilance® Demonstration



PeriWatch Vigilance®• PeriWatch Vigilance is an OB Early Warning System, not a documentation system

• Aggregates data from your fetal monitor and EMR, it analyzes that data and gives it back to you with actionable notifications and information

• Quality improvement tool; does not send information back to the permanent medical record

• Goal: Provide the caregivers with timely notifications of potentially worsening conditions so you can assess the patient, intervene as appropriate and potentially avoid a delay in care



Poll QuestionDo you feel that the tools and references presented today will be helpful with achieving compliance with the new elements of performance?

1. Yes

2. No

3. Not sure



SummaryUnacceptable maternal morbidity and mortality rates

One adverse outcome is too many

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Poll QuestionWould you like to chat with our team one on one?

1. Yes, I’m not a customer & would be interested learning more!

2. Yes, I am a customer & want to see what’s new!

3. Yes, I’d like to talk with the webinar speaker.

4. Thanks, but I’m good for now.



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ReferencesAvailable upon request



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Maternal Patient Safety - PeriGen