Episode #21 Part 1: Maternal Safety Bundles

November 24, 2020

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Did you know that 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??

This is the first of a special two part podcast. We return to the 35th Anniversary APSF Newsletter to discuss two very important articles, “National Partnership for Maternal Safety— Maternal Safety Bundles” by Jennifer Banayan and Barbara Scavone. The first article was published in the October 2016 APSF Newsletter. We discuss the What Then on the show today and you can find the article here. https://www.apsf.org/article/national-partnership-for-maternal-safety-maternal-safety-bundles/

You can find the updated article from the Special Edition October 2020 APSF Newsletter here and we will discuss this article on the next show. https://www.apsf.org/article/national-partnership-for-maternal-safety-maternal-safety-bundles-2/

You can find the Maternal Safety Bundles that we talk about on the show today at this website:  https://safehealthcareforeverywoman.org/council/patient-safety-bundles/maternal-safety-bundles/

Figure 1: Council on Patient Safety in Women’s Health Care Maternal Safety Bundles

Obstetric Hemorrhage
Severe Hypertension in Pregnancy
Maternal Venous Thromboembolism
Obstetric Care for Women with Opioid Use Disorder
Reduction of Peripartum Racial/Ethnic Disparities
Prevention of Surgical Site Infection
Maternal Mental Health: Depression and Anxiety
Safe Reduction of Primary Cesarean Birth


A special thank you to Jennifer Banayan, MD for contributing content to the show today too.

Are you a perioperative patient safety scientist? We hope that you will consider applying for the APSF/FAER Mentored Research Training Grant. You can find more information here. https://www.apsf.org/grants-and-awards/apsf-faer-mentored-research-training-grant/

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© 2020, The Anesthesia Patient Safety Foundation

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 are venturing out side of the operating room today and up to the labor and delivery suite to discuss maternal patient safety from the perspective of what then and what now.  This is a very special 2 part show.

You’ve heard me recognize our corporate sponsors on this show, but there’s another supporter who is absolutely essential – YOU! Did you know that APSF is registered as an AmazonSmile Charitable Organization? All you have to do is select Anesthesia Patient Safety Foundation as your Amazon Smile designee and then every time you make a purchase on AmazonSmile, the AmazonSmile Foundation will donate 0.5% of the purchase price to APSF from your eligible AmazonSmile purchases. I will include a link to more information in our show notes.

We are going to return to the 35th Anniversary APSF Newsletter to discuss two very important articles, “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, first one down is the current issue. Then scroll down and you will see the article listed on the left. 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 first to cover talk about “What Then.” I will include links to both of these articles in the show notes.

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.

We have so much more to talk about when it comes to Maternal Safety Bundles especially because we haven’t even started talking about the “What Now” article from the 35th Anniversary APSF Newsletter and I am sorry to leave you in suspense, but  I wanted to leave some time to tell you about an exciting research opportunity.

The APSF is working with the Foundation for Anesthesia Education and Research or FAER to help promote the upcoming Mentored Research training grant. This is a two-year, $300,000 award that aims to help anesthesiologists develop the skills and preliminary data they need to become independent investigators in the field of anesthesia patient safety. If you are interested in pursuing the APSF/FAER mentored research training grant will need to submit a Letter of Intent prior to submitting a full application. The letter of intent submissions will open December 1, 2020 and close January 1, 2021. More information can be found on our website and I will include a link in the show notes.  https://www.apsf.org/grants-and-awards/apsf-faer-mentored-research-training-grant/

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.

© 2020, The Anesthesia Patient Safety Foundation