Episode #125 Maternal Safety Bundles Encore Presentation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. We have a special encore show for you today. This week, we are looking back at a very important topic: Maternal Safety Bundles. These shows first aired two years ago, Episodes 21 and 22. So, let’s head over to the labor and delivery suite or the maternity ward to discuss Maternal Patient Safety.

Before we dive into the episode today, you’ve heard me recognize our corporate supporters on this show, but there’s another supporter who is absolutely essential – YOU! Every individual donation matters so much. Please visit APSF.org and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.

Our featured articles today are from the 35th Anniversary APSF Newsletter, “National Partnership for Maternal Safety— Maternal Safety Bundles” by Jennifer Banayan and Barbara Scavone. You can find the articles at APSF.org by clicking on the Newsletter heading. Fifth one down is the Newsletter archives, then scroll down until you get to the October 2020 APSF Newsletter. Then, scroll down until you get to our featured article. At the top of the article is a link to the original article from the October 2016 APSF Newsletter that we will be reviewing as well. I will include links to both of these articles in the show notes.

Now, let’s get into our encore show featuring Maternal Safety Bundles.

[Episode #21] Before we get to the article today, I reached out to one of the authors, Jennifer Banayan, MD an associate professor of anesthesiology at Northwestern University in Chicago and she shared with us what got her interested in this important topic.

[Jennifer Banayan] “What I realized is that despite all of us living in a country with almost every healthcare luxury known to earth we are still witnessing a rising rate of maternal mortality and morbidity that is really not seen in other developed countries and this really frightened me. And so, I realized as an anesthesia provider we need to shoulder this responsibility of maternal health with our colleagues because we have the skill set and we have the expertise to contribute to better care for our pregnant patients.”

What a great way to start the show and we will be hearing more from Banayan in the next show as well.

Before we can talk about what’s happening now with maternal patient safety, we need to travel back to 2016 to look at what was happening back then.  From the October 2016 article, Banayan and Scavone start off with some staggering information since the United States is the only developed country where maternal mortality has been rising since 1990 and pregnant women in the US are three times more likely to die from pregnancy-related complications than women in Britain, Germany, and Japan.  And this is a newer trend. Before 1982, maternal mortality in the United States had been improving due to better medical care, increased hospital deliveries by physicians trained in obstetrics and utilization of aseptic technique. The most common causes for maternal mortality in the past have included hemorrhage, hypertensive disorders, thromboembolic events, and infections, but now we are seeing an increase in maternal deaths from cardiovascular disease and other significant medical comorbidities. There is some good news in that anesthesia complications associated with maternal mortality have decreased, but this is not the time to become complacent since anesthesia professionals committed to patient safety need to continue to help our patients throughout pregnancy, delivery, and postpartum.

What is happening in the United States that we are seeing this increase in maternal mortality and severe maternal morbidity? It may be due to increased parturients in the US with advanced maternal age. However, other countries with similar increases in parturients with advanced maternal age were not seeing the same trend of increased mortality. Another possible explanation is the disproportionately high cesarean section rate compared to other developed countries with associated complications including increased placental implantation abnormalities with subsequent pregnancies. Finally, the US mortality rates may be rising due to the increased rates of significant chronic health conditions seen in pregnant patients in the US including obesity, hypertension, diabetes, and chronic heart disease. There is a call to action to identity and evaluate the maternal mortality causes and look for preventable risk factors. We can look to California for an example of how to do this.  Between 2002 and 2004, there were 207 documented maternal deaths in California and 40% of these were identified as being potentially preventable.  Further evaluation revealed the three conditions that were most likely to be preventable including obstetric hemorrhage, deep venous thrombosis, and preeclampsia and eclampsia.  This information was used to create free online toolkits available to anyone by the California Maternal Quality Care Collaborative complete with articles, guidelines, implementation guides, and educational documents to help prevent maternal death. 5 years later, the maternal mortality in California decreased significantly while the national maternal mortality rate continued to increase between the years of 2008-2013.

Studies have shown that protocols are effective for improving patient outcomes, such as reducing maternal hemorrhage, by increasing education and resources and providing a toolkit.  Another example of this comes from New York State where clinician leaders in collaboration with the American Congress of Obstetricians and Gynecologists created the Safe Motherhood Initiative in 2013. This initiative included standardized risk-assessment tables, protocols, checklists, and algorithms to decrease variability in practice and improve patient safety. Three bundles were created on hemorrhage, hypertension, and venous thromboembolism. This group was committed to increasing education and resources by offering CME and bundle boxes with implementation guidance, posters, brochures, checklists, algorithms, and tables in addition to further education with PowerPoint presentations and audio recordings.

Dr. Eliot Main who helped decrease maternal mortality in California worked to make similar changes across the nation. Eventually, the National Partnership for Maternal Safety was created within the Council on Patient Safety in Women’s Healthcare with the mission to “continually improve patient safety in women’s health care through multidisciplinary collaboration that drives cultural change.” And this groups stands behind collaboration because many different professional organizations are part of this coalition and it remains committed to being a multi-disciplinary group. The goal is to decease maternal morbidity and mortality in the United States by 50% through evidenced-based interventions implemented as bundles to improve patient safety. The National Partnership for Maternal Safety focused on hemorrhage, hypertension in pregnancy, and venous thromboembolism, and I will include a link to their website in the show notes. I hope that you will check it out. The information is free and available to the public.

The bundles are an important step towards improved maternal patient safety since they include a range of evidence-based recommendations that are put into an organized and accessible format with an emphasis on institution modification to meet local needs depending on available resources. The bundles include sections on Readiness, Recognition and Prevention, Response, and Reporting/system learning.

Let’s look at the first bundle called Obstetric Hemorrhage Patient Safety Bundle that was published on the website only at first and subsequently in 2015, it was published in 4 high impact journals including Anesthesia and Analgesia, Obstetrics and Gynecology, Journal of Obstetric, Gynecologic, and Neonatal Nursing, and Journal of Midwifery and Women’s Health. This is the most common maternal complication, but the related morbidity and mortality may be preventable especially when it comes to improved recognition and quantitative evaluation of blood loss, monitoring of clinical signs related to the hemorrhage, fast action to replace blood volume and improve volume status, and finally an emphasis on decisive intervention. The goals for this bundle include decreasing number of hemorrhage cases the progress to severe hemorrhage, decreasing blood transfusions, and decreasing coagulopathy associated with hemorrhage.

A closer look at the Hemorrhage bundle takes us into the Readiness section which includes supplies such as a hemorrhage cart and medications, as well as systems that need to be available to prepare for a potential hemorrhage case. The next part of the bundle involves Recognition and Prevention with patient assessments that can and should be done for every patient. An important component of the assessment is measuring total blood loss. The next section is the Response section which involves stage-based obstetric hemorrhage emergency management plans.  The last section is Reporting and System Learning which is a guide for a multidisciplinary review and debriefing after every case of severe hemorrhage so that the team can work towards improved patient safety.

Another maternal safety bundle revolves around Severe Hypertension in Pregnancy.  It is so important to recognize clinical signs of preeclampsia including hemolysis, thrombocytopenia, elevated liver enzymes, and pulmonary edema since close management can help prevent serious complications, such as stroke and maternal death. A closer look at the bundle reveals the following sections: Readiness with diagnostic criteria and antihypertensive medication dosing and administration guides; Recognition and Prevention with protocols to measure and evaluate blood pressure; Response with management plans for cases of severe hypertension and eclampsia; and Reporting and System Learning with recommendations for multidisciplinary case reviews.

The third bundle created was for venous thromboembolism in pregnancy and this was just in the draft form back in 2016, but there was promising data from the United Kingdom that incorporation of VTE prophylaxis could lead to decreased maternal mortality.

Back in 2016, the authors wrote that it was important to understand that many cases of maternal morbidity and mortality could be prevented. Anesthesia professionals are an important part of the obstetric care team and can help to manage patients with life-threatening emergencies and we should embrace the role as peripartum physicians and work with other physicians and health care professionals to improve maternal patient safety and work to help decrease the rates of maternal morbidity and mortality.

[Bechtel] It’s time to refresh your cup of coffee because we are going to take a listen to the encore of Episode #22, the Part 2 show all about Maternal Safety Bundles. Here we go.

[Episode #22] So, what has changed in the past 4 years? We can look at the October 2020 35th Anniversary APSF Newsletter to find out What’s Next. Banayan and Scavone provide this update as well.  In 2007, the US maternal mortality rate or MMR was 12.7 per 100,000.  I will warn you, the next statistic is not good news. The National Vital Statistics Report from the National Center for Health Statistics provided an updated maternal mortality rate from 2018, that was published in January 2020. We continue to have the worst rate of all the developed countries and the MMR has increased to 17.4 per 100,000. Women 40 years and older have the highest mortality rate with a rate of 81.9 per 100,000 births. In addition, African American women have a higher risk as well with an MMR of 37.1 deaths per 100,000 which is 2.5 times higher than non-Hispanic white women who have an MMR of 14.7 and it is 3 times higher than Hispanic women who have an MMR of 11.8. The highest mortality risk involves advanced age and black race and a black woman over the age of 40 has a 1 in 700 chance of dying during her delivery hospitalization. It is hard just to read these statistics aloud, but it is important because we have to figure out what happened and why maternal mortality did not improve after the bundles started to be created back in 2015. The maternal safety bundles did lead to changes across the country with the creation of hemorrhage kits, carts, protocols, checklists, response teams and participation in huddles and debriefing to improve patient care at the system level, so maybe just not enough time has passed for these changes to impact patient outcomes. But maybe it is not just the time interval since many institutions did not implement or adhere to the recommended protocols.  Places with widespread adoption of the bundles such as the state of California have seen improvements in outcomes with differences in hemorrhage severity, transfusions, and emergency hysterectomies.

Let’s take a look at the Center for Disease Control and Prevention’s Pregnancy Mortality Surveillance System which reveals that minority groups including non-Hispanic black and non-Hispanic American Indian Alaska native women have significantly higher mortality rates than all other racial and ethnic groups. Even when controlling for education and socioeconomic status, Black women have a higher mortality rate so that African American women with relative social and economic advantages, such as a college degree, have higher risks for morbidity and mortality in pregnancy than white women who do not have these relative social and economic advantages. This is a significant healthcare disparity for Black Women. It may be due to chronic stress due to unrelenting systemic racism experiences by black women in this country leading to physiological strain and higher rates of hypertension and pre-eclampsia and higher rates of maternal deaths. The authors tells us that “In other words, the everyday stressors experienced simply by being a Black woman in America increases the likelihood of experiencing illness and dying from it, and this extends to the pregnancy and postpartum periods.” In addition, healthcare workers may fail to recognize and act on important concerns and symptoms reported by black patients due to racism and implicit bias. In order to prevent maternal death, health care workers must recognize and act early even though symptoms may be vague. The racial disparity for maternal patient safety is very concerning.

Another threat to maternal patient safety involves opioid-use disorders and mental health and suicide-related deaths. Pregnant women may be at increased risk for opioid overdose and we have seen the rate of pregnancy-associated mortality related to medication overdose double between 2007 and 2016. In 2019, a retrospective, population-based cohort study  of over one million women who delivered a live-born infant in California revealed that deaths due to drugs was the 2nd highest cause of death and deaths from suicide was the 7th leading cause during the postpartum time period. This is not a unique finding in the United States as Japan and the United Kingdom have also reported high rates for postpartum suicide and mental health disorders for postpartum women.

Obstetric patients with opioid dependency who have developed tolerance and hyperalgesia are likely to report higher postpartum pain scores. These patients may require higher doses for opioids for pain control but care must be taken to monitor for the sedative and respiratory depressive effects as well. In the past 4 years, we have seen that women with substance abuse are more likely to need a cesarean delivery and a blood transfusion during delivery. They also have an increased risk of death. Patient who present for delivery and are opioid-naïve are not exempt from risk since women who are opioid-naïve are at risk for developing an opioid dependence if they are prescribed opioids at the time of discharge. Risk factors for this include patients with a history of psychiatric illness, use of other illicit substances, and patients with chronic pain disorders. Multimodal pain management is an important strategy to help decrease opioid administration. Going forward, it will be important to evaluate pregnancy-associated deaths from opioid-use disorders and suicide along with other causes of maternal death so that we can work towards improved prevention of these deaths in the future. More work is definitely needed to address maternal mental health and substance abuse in obstetric patients.

But let’s not wait, anesthesia professionals have an important part in helping to implement these bundles to help make obstetric care safer for our patients. Our scope of practice is not limited to spinal and epidural procedures. The authors remind the readers that anesthesia professionals must act as peripartum clinicians and work on multidisciplinary teams to help improve maternal safety.

Before we wrap up for today, Banayan leaves us with some final thoughts. I asked her what does she envision for the future with regards to maternal safety and anesthesia care.

[Jennifer Banayan] “I’m actually really optimistic about the future. I think that we’ve done a really good job of getting out the message that we need to focus on maternal care in this country. We’ve done a really good job of hemorrhage protocols and incorporating hemorrhage kits and bundles into all the birthing centers in this country and I think it is just going to take more.”

Thank you for sharing your thoughts with us and we are looking forward to seeing improved and safer maternal care going forward.

[Bechtel] If you have any questions or comments from today’s show, please email us at [email protected]. Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. We hope that you will tell your colleagues about this podcast as we work to spread the word about improving anesthesia patient safety. For more anesthesia patient safety tweets and posts, please follow us and like us on twitter and Instagram!

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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