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Institute for Healthcare Improvement (IHI)

Perinatal Improvement Community Special Webinar

"VENOUS THROMBOEMBOLISM (VTE) SAFETY RECOMMENDATIONS: TARGETING MATERNAL

PATIENTS”January 22, 2014

IHI Perinatal Improvement Community in continuous existence since 2005

Speakers

Sue Gullo, DirectorPIC

Peter Cherouny, Faculty Chair

PIC

Michael Wong, FounderPPAHS

Objectives of Today’s Webinar1. Discuss the most up to date data that supports VTE as

a leading cause of maternal morbidity and mortality.

2. Describe the development of the VTE Safety Checklist.

3. Identify specific components of the care process that have been identified as problem prone and unreliable.

4. Identify opportunities to be involved in testing.

VENOUS THROMBOEMBOLISM (VTE):

SAFETY RECOMMENDATIONSTARGETING MATERNAL PATIENTS

Maternal Death Rate Has More Than DoubledNo. of pregnancy-related deaths per

100,000 live births per year

http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

Maternal Death Rate Has More Than Doubled

“These statistics may represent a conservative estimate of the problem. Why? Not all pregnancy-related deaths are accurately identified and reported. Hence, pregnancy-related deaths identified at the national level likely undercount the true number.”

William M. Callaghan, MD, MPH Chief, Maternal and Infant Health Branch

Division of Reproductive HealthNational Center for Chronic Disease Prevention and

Health Promotion Centers for Disease Control and Prevention

US Maternal Death Rate Compared to Other Countrieshttps://www.cia.gov/library/publications/the-world-factbook/rankorder/2223rank.html

RANK COUNTRY (DEATHS/100,000 LIVE BIRTHS 2010)

1 Estonia 2

2 Greece 3

3 Singapore 3

4 Italy 4

5 Sweden 4

6 Austria 4

7 Iceland 5

8 Japan 5

9 Poland 5

10 Finland 5

11 Czech Republic 5

12 Slovakia 6

13 Netherlands 6

14 Spain 6

15 Ireland 6

16 Israel 7

17 Norway 7

18 Qatar 7

19 Germany 7

20 Australia 7

21 Lithuania 8

22 Portugal 8

23 Malta 8

24 Montenegro 8

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2223rank.html

US Maternal Death Rate Compared to Other Countries

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:1

•Venous thromboembolism costs the health care system more than $1.5 billion/year2

•Cost of managing an initial episode:2-deep vein thrombosis $7,712-$10,804 (est.)-pulmonary embolism $9,566-$16,644 (est.)

US Spending More, Getting Poorer Results

1. Ina May Gaskin, CPM, MA, “Maternal Death in the United States: A Problem Solved or a Problem Ignored?” Journal of Perinatal Education, 2008 Spring; 17(2): 9–13

2. Dobesh PP (2009) “Economic burden of venous thromboembolism in hospitalized patients.” Pharmacotherapy 29 (8): 943-53

Why Focus on VTE Pregnancy is a major risk factor for developing venous thrombosis and pulmonary embolism, especially following cesarean delivery and up to one month post partum.1“For pregnant women, the risks of VTE is 4-5 times higher than women who are not pregnant. Moreover, this risk is at least twice as much following cesarean delivery.” 2

Dr. Andra James Professor of Obstetrics & Gynecology,

Division of Maternal Fetal MedicineUniversity of Virginia School of Medicine

1. “Pregnancy-Related Mortality Surveillance” – Centers for Disease Control & Prevention, Feb. 21, 20132. http://ppahs.org/2013/05/02/preventing-death-following-cesarean-delivery/

VTE Risk for Maternal Patients

To ensure VTE Prevention is maximally used, harm reduction strategies should be used:

•consistently by clinicians •effectively with hand off communications

One Patient is One Too Many: The True Reason for OB VTE Prevention

Amber Scott: •On May 22, 2012, husband came home from work and found her unresponsive. •After determining that Amber had a blood clot in her brain, doctors performed an emergency caesarian section.

http://www.thedoctorweighsin.com/amber-scotts-story-spotlights-risk-blood-clots-new-expectant-mothers/

•Adeline was born, 6.5 pounds, healthy and beautiful

•While Adeline was thriving, Amber was fighting for her life:

- lay in a coma as doctors performed a series of surgeries to remove the clot in her brain.

- weeks later, came out of the coma, when Amber held up two fingers after being shown a picture of Adeline.



Amber’s progress:•Continues with rehabilitation more than a year after delivery.

•Amber continues to make great progress in her daily outpatient therapy sessions.

•She is now able to pull herself up and stand on her own as she steadily regains strength in both the left and right side of her body.



Amee VanTassellDied of blood clot just four days after cesarean delivery of healthy daughter

http://www.poughkeepsiejournal.com/article/20130802/SPORTS12/308020050/D-C-Am-Jim-Hamburger-dedicating-tournament-his-late-

daughter?gcheck=1&nclick_check=1

Jim Hamburger poses with his daughter, Amee VanTassell. VanTassell died on April 1, four days after giving birth, at the

age of 36.

One Patient is One Too Many: Preventable Deaths

Eleven days after undergoing what she thought was “an uncomplicated C-section,” Samara McAuliffe developed a blood clot in her lungs.

Jessica Phillips surived a life-theatening blood clot right after giving birth by C-section.

Lisa Boyd suffered a blood clot in her leg a week after giving birth to her second child. She nearly died.

One Patient is One Too Many: Many Faces Impacted by Preventable VTE

VENOUS THROMBOEMBOLISM (VTE) SAFETY RECOMMENDATIONS :

TARGETING MATERNAL PATIENTS

PeterCherouny,M.D.EmeritusProfessor,Obstetrics,GynecologyandReproductiveSciences,UniversityofVermontChairandLeadFaculty:IHIPerinatal ImprovementCommunity

VENOUS THROMBOEMBOLISM (VTE) SAFETY RECOMMENDATIONS: TARGETING MATERNAL PATIENTS

Joint Commission Sentinel Event Alert Issue #44

Relationship between route of delivery and maternal death

Vaginal 1.7Primary Cesarean 16.3Repeat Cesarean 7.4Total Cesarean 12.7Totals 6.5

Clark et al. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. AJOG;199:36.

MMWR Pregnancy Related Mortality

All Causes by pregnancy outcome and PRMR%

Embolism 20Hemorrhage 17Preeclampsi/Eclampsia 16Infection 13Cardiomyopathy 8

Chang J, et al. Pregnancy-Related Mortality Surveillance. United States, 1991—1999. MMWR. Surveillance Summaries. February 21, 2003 / 52(SS02);1-8.

Maternal Death NYS

All Causes%

Embolism 24PIH 24Hemorrhage 15Infection 15

New York State Department of Health


Causal relationship between route of delivery and maternal death

Vaginal 0.2Primary Cesarean 2.5*Repeat Cesarean 1.1Total Cesarean 2.0*Totals 1.4*p<0.001 for VD



Causal relationship between route of delivery and maternal death excluding PE

Vaginal 0.2Primary Cesarean 2.5Repeat Cesarean 1.1Total Cesarean 2.0Totals 1.4


P=0.07

P=0.38

P=0.08

4.0 million USA deliveriesX 33.7% cesarean =

1.34 million Cesarean Sections– Even low incidence outcomes become

important


Definitions– Deep VenousThrombosis -DVT– Pulmonary Embolism –PE– DVT + PE = VTE– Thromboembolic disease


Incidence– 1-2/1000 pregnancies– 4-5 fold relative risk in pregnancy– ½ during pregnancy and ½

postpartum– >1/100,000 maternal deaths (10%)


Risk Factors– Prior history VTE– Thrombophilias– Bed rest– Obesity– Smoking– Operative delivery


Although bed rest and hydration have been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects, such as loss of employment, should not be underestimated.

Management of preterm labor. ACOG Practice bulletin 43. May 2003


Cesarean delivery– All in moderate risk unless surgery is

less than 30 minutes and patient under 40 without other risk factors


PreventionRecognitionTreatment


Prevention–Risk assessment–Risk appropriate prophylaxis–REPEAT


Effective Risk Assessment– Initial visit–During pregnancy–Admission for delivery


Effective Risk Assessment– Low risk (surgery less than 30’, patient

<40yo)– Moderate risk– High risk– Highest risk


Effective Prophylaxis Assessment– Risk-based– All patients having a cesarean

delivery should have PCD (pneumatic compression devises) placed


Prevention– Risk assessment– Risk appropriate prophylaxis– REPEAT


PPAHS VTE Checklist Group: Health Expert PanelRose Mary Ainsworth, RN, MSN Mother/Baby UnitHuntsville Hospital for Women and ChildrenRichard Berkowitz, MD Quality Assurance DirectorColumbia University Medical CenterWilliam M. Callaghan, MD, MPH Chief, Maternal & Infant Health Branch Division of Reproductive Health National Center Centers for Disease Control and PreventionPeter Cherouny, MD Lead Faculty, Perinatal Community, Institute for Healthcare ImprovementNancy Chescheir, MDClinical Professor, Maternal-Fetal MedicineObstetrics and Gynecology,UNC School of MedicineSteven Clark, MD Medical Director, Women & Newborns Clinical ServicesHospital Corporation of AmericaMichèle G. Curtis, MD, MPH, MML CeeShell Consultingeditor of “Glass’ Office Gynecology”Raiyomand Dalal, FRANZCOG, MD, DNB, FCPS, DGO, DFP, MNAMSSenior LecturerSchool of Medicine, University of Western SydneyMary D’Alton, MD Chair, Department of Obstetrics & GynecologyMaternal-Fetal MedicineColumbia University Medical CenterLisa J. Enslow, MSN, RN-BC Nurse EducatorWomen's Health and Ambulatory Care ServicesHartford HospitalFrank Federico, RPh Patient Safety Advisory Group, The Joint CommissionExecutive Director, Institute for Healthcare Improvement

Sue Gullo, MS, RN Director, Perinatal Improvement CommunityInstitute for Healthcare ImprovementRoy Jackson, MD, B.Sc., MB.BCh., F.R.C.SSouthern Health CentreAndra James, MD John M. Nokes Professor of Obstetrics & GynecologyDivision of Maternal-Fetal MedicineUniversity of VirginiaBetty Janey Project Manager, Perinatal CommunityInstitute for Healthcare Improvement)Deborah Karsnitz, DNP, CNM, FACNM Nurse Educator, Frontier Nursing UniversityJohn Keats, MDPresident and Medical Director, California HealthFirst Physiciansmember, ACOG’s Patient Safety & Quality Improvement CommitteeColleen Lee MS, RN Maternal/Perinatal Patient Safety OfficerMontefiore Medical Center Michael Paidas, MD Co-Director, Yale Women and Children’s Center for Blood DisordersDepartment of Obstetrics, Gynecology and Reproductive Sciences Yale University School of MedicineJody PaxtonCoordinator, Statewide Intensive Care Clinical NetworkDepartment of Health, Queensland, AustraliaJanet N. Press, RNC, MS, CT Perinatal/Obstetrical CoordinatorC.N.Y.Regional Perinatal ProgramPerinatal Bereavement Services CoordinatorCrouse HospitalPeter Pronovost, MD, PhD, FCCMProfessor, Depts. of Anesthesiology/Critical Care Medicine & SurgeryThe Johns Hopkins University School of Medicine Richard Smiley, MD Chief, Obstetric AnesthesiaColumbia University Medical Center

“Ensuring the identification of pregnant women at-risk for VTE and applying measures to reduce VTE risks would assist in reducing blood clots, particularly for women following cesarean delivery.”

Dr. John Keats (ex-officio member of ACOG’s Patient

Safety and Quality Improvement Committee)

Simple, Cost-Effective Solutions: Easily Adopted and Ensures Maximal VTE Prevention

“Fortunately, risk factors for VTE can be reduced by simple and cost-effective measures, such as fitting inflatable compression devices on a woman’s legs before cesarean delivery and using inflatable compression sleeves until the woman is able to walk after delivery.”

Dr. Andra James (Professor of Obstetrics & Gynecology,

Division of Maternal Fetal Medicine, University of Virginia School of Medicine)

http://ppahs.org/2013/05/02/preventing-death-following-cesarean-delivery/

Questions/Discussion

Sue Gullo - [email protected]

Pete Cherouny –[email protected]

Michael Wong - [email protected]

Interested in the IHI Perinatal Improvement Community?

Please visit us on our website today to learn more!

http://www.ihi.org/offerings/MembershipsNetworks/collaboratives/PerinatalImprovementCommunity/Pages/default.aspx

Please email PIC Project Coordinator Evan Bittel at [email protected] if you have any questions or would like additional information.

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