Hospitals Train to Track, React to Maternal Bleeding

ATLANTA (WOMENSENEWS)–Just as fire and police departments drill for explosions and plane crashes, Lashea Wattie, an obstetrical nurse for more than 15 years, would like to see hospital delivery teams train for their own all-too frequent and sometimes deadly emergencies.

Wattie is a clinical nurse specialist for women’s services at WellStar Kennestone Hospital in Marietta, outside Atlanta, one of the largest hospitals in the state. She works at the heart of this public health crisis.

Amnesty International ranks Georgia highest in the nation in maternal deaths and the state’s new Maternal Mortality Review Committee just revealed a shocking disparity in the much higher rate at which black women are dying from causes either related to pregnancy or associated with pregnancy.

Wattie says that simulation drills in delivery rooms have helped participants identify problems such as closed loop communication. "You have 10 people in the room, [the doctor says] ‘I need someone to call anesthesia.’ Well, who called anesthesia? Nobody called anesthesia! So now we have a stat C-section, and we don’t have anesthesia. We can’t get started. So those are the things you can identify by doing those drills."

On top of her regular nursing duties, Wattie is also the Georgia coordinator for an 18- month study of postpartum hemorrhage at the 58 hospitals that the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), a nonprofit based in Washington, D.C., launched in 2014. New Jersey and the District of Columbia are also part of the study.

Designed to identify and reduce errors by improving responses to bleeding events, it is part of a 10-year, $500 million initiative by the pharmaceutical company Merck, through its "Merck for Mothers" program, to investigate and improve maternal health in more than 30 countries.

Goals Include Recognition, Taking Action

Goals of the study include increasing recognition of women at risk for postpartum hemorrhage and taking action at the earliest possible moment when women are bleeding too much; making sure the clinical team is ready to respond; and tracking the team’s performance to help improve response to future events. One major component is collecting and weighing blood a woman loses in the birth process instead of just estimating the amount.

"This is really kind of forcing you to look at your data, trend it, identify where the holes are and fix them," said Wattie, in an interview in her office at WellStar Kennestone Regional Medical Center. "Your mom that comes in with no risk factors and ends up in an ICU. We want to look at that and say, why? What happened? Was there something we could have identified or done differently?"

Wattie is hopeful that soon after this AWHONN Quality Improvement Initiative wraps up in May 2016 it will help improve the way hospitals collect and analyze data and implement best practices.

"We are collecting this data, like how many patients this month have received transfusions? How many deaths have you had? Have you had intensive care unit admissions? Have you had ICU admissions for hemorrhage? How many days have they spent in ICU?" said Wattie.

These are simple things, Wattie said. "But if you don’t practice, you find out after the fact, when you are in this emergency and everyone again is running into each other, or you have wasted valuable time."

The message Wattie would like to send is for delivery room teams to be proactive rather than reactive. A health care team doesn’t need to be surprised to find out the patient being wheeled in is morbidly obese, almost always a risk factor. Or that she won’t take certain blood products because she’s a Jehovah’s Witness.

Over the past decade, the number of women who have died in childbirth has nearly doubled in the United States. The United States has a higher ratio of maternal deaths than at least 40 other countries, even though it spends more money per capita for maternity care than any other, according to the National Institutes of Health.

By that NIH measure, and studies from the United Nations and the World Health Organization, AWHONN says women in the U.S. have a greater risk of dying from pregnancy-related complications than women in 46 other countries, including Bosnia and Kuwait.

"It’s really astounding," said Wattie. "Not only do we rank 47th, so we are almost the poorest compared to other industrialized countries, but we also spend the most money!"

A 2013 United Nations study cited by Merck’s Dr. Priya Agrawal, ranks the U.S. even lower: 64th in maternal mortality globally–that is, higher rates of women dying as a result of a pregnancy and delivery. That’s worse than Libya, Iran and Turkey.

More Than Data Needed

Only about half the states have maternal mortality review committees and Wattie said states that have such oversight do better at lowering maternal mortality rates.

But data alone won’t turn things around in Georgia, which, like many red states, chose not to expand Medicaid eligibility under the Affordable Care Act. That means 26 percent of Georgia women between 18 and 64 have no insurance; one of the highest risk factors for maternal mortality.

In recent months, four rural Georgia hospitals have closed; more than a dozen others are considered financially fragile. Other small town hospitals have shut down their labor and delivery units.

Birth complications have many influences, ranging from a lack of insurance, a lack of prenatal care to pre-existing conditions such as high blood pressure, obesity and diabetes. Poverty and a high rate of C-sections also play a part, said Suzanne Staebler, associate professor at the Woodruff School of Nursing at Emory University, in Atlanta. She’s a neonatal nurse practitioner and serves on the board of directors of the Georgia Nurses Association.

"We are opening a mom’s abdomen, that automatically puts them at a higher risk for mortality. Because they are undergoing an abdominal surgical procedure, they have risk for deep vein thrombosis, pulmonary embolism, all of those complications related to abdominal surgery," said Staebler in an interview in her office on the Emory campus.

A recent transplant from Texas, Staebler is still learning to navigate the waters of state policies and politics regarding the protection of patients and the powers of nurses and midwives. "And much of that C-section rate, you have to wonder, because there are other countries like Britain and Canada and France, all who have modern technology health care systems, and their rates are half of what ours is."

Some C-sections are medically necessary, but many are done for the convenience of either the mom or the obstetrician. The last 10 years saw a nearly three-fold increase in the number of women who had blood transfusions around the time they gave birth.

Basic Communication

Public and private efforts are underway to reverse the devastating reality of maternal deaths and complications. It starts with something as basic as improving communication before, during and after a hospital delivery, said Wattie, who has seen plenty of problems that should have been spotted.

"You have situations," Wattie said, "where you go back through the chart after this horrific postpartum hemorrhage and you go, ‘are you kidding me?’ It says she had a previous postpartum hemorrhage? So I think, for myself, in peer review, that’s been some of the scariest things, when you see all the writing on the wall, and you are thinking, ‘Wow, we could have done better.’"

Wattie also looks forward to the arrival of clear treatment protocols at every hospital that are already followed for such life-threatening conditions as stroke. At present, Wattie said, procedures in a hospital’s labor and delivery rooms vary by such random things as geography or time of day.

The treatment of a woman having a baby in Albany, N.Y., and Albany, Ga., may be very different. "We need standard checklists. So that when nurses and physicians are moving from hospital to hospital, or are on call here or there, the steps are still very easy," said Wattie.

That uniform strategy is underway in California, through a newly formed Alliance for Innovation on Maternal Health, or AIM, made up of public and private partners. Its goal is for hospitals to implement a standard of best practices known as "maternity safety bundles."

The hemorrhage safety bundle would include equipping each hospital labor unit with a fully stocked cart for immediate hemorrhage treatment, establishing a hospital-level emergency management protocol, conducting regular staff drills and reviewing all cases to learn from past mistakes.

Having an active training program for different types of medical emergencies can really pay off, said Staebler, of Emory University’s Woodruff School of Nursing. "You will remember in the fall [of 2014] when all of the Ebola stuff was happening here, and the Emory team talked about the fact that we’ve been trained for this for 15 years, and that, you saw the results that we had. That’s what it’s about. That’s how that training and simulation system works."

Four Ebola patients treated at Emory recovered fully, and no staff members were infected.

This story is part of a larger project on African American maternal and infant health nationwide funded by the W.K. Kellogg Foundation.