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The Safe Motherhood InitiativePeter Bernstein, MD, MPH, FACOG

Professor of Obstetrics & Gynecology and Women’s Health

Maternal Fetal Medicine Division Director

Department of Obstetrics & Gynecology and Women’s HealthAlbert Einstein College of Medicine

Montefiore Health SystemBronx, NY

Disclosure, Objectives, etc.

● Disclosure: I have nothing to disclose.

● Educational Need/Practice Gap: ○ The majority of maternal mortalities are preventable.○ Compliance with standardized OB patient safety bundles can reduce the rate of maternal

mortality

● Objectives:○ Describe the leading causes of maternal mortality in the United States.○ Discuss the key elements of a maternal safety bundle.○ Develop a maternal safety bundle for their practice setting.

● Expected Outcome: Improved compliance with OB patient safety bundles

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Source: Creanga et al., 2017

Source: NYS MMR Report, 2017

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Safe Motherhood Initiative: History

● Began in 2001 as a voluntary review program to examine reported cases of hospital-based maternal deaths

● Collaborative effort between ACOG & NYSDOH

● Assisted hospitals in making protocol changes to improve patient safety and raise awareness of risk factors that can contribute to serious morbidity

● Timely recognition and intervention could have prevented many of the deaths reviewed

● De-funded in Executive Budget proposal in 2010

Safe Motherhood Initiative: History

Since 2013, the Safe Motherhood Initiative has been working with obstetric hospitals inNew York State to develop and implement standard approaches for handling obstetric

emergencies associated with maternal mortality and morbidity. The Safe Motherhood Initiative focuses on the four leading causes of maternal death: maternal sepsis, obstetric hemorrhage,

venous thromboembolism, and severe hypertension in pregnancy.

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Safe Motherhood Initiative: Overview

● Develop standard approaches for managing obstetric emergencies associated with maternal mortality and morbidity

● Focuses on the leading causes of maternal death –obstetric hemorrhage, venous thromboembolism, and severe hypertension in pregnancy. Maternal sepsis is the SMI’s 4th bundle (released May 2020).

● 117 obstetric hospitals engaged

● On-site implementation visits to assist with QI efforts

SMI in person meeting w/ in situ simulation, 2018

SMI in person meeting w/ CME offered

Safe Motherhood Initiative: Overview

● Founded in evidence-based best practices

● Delineation of standard of care

● Minimization of variability

● Decreased reliance on memory

● Emphasized patient safety

● Reduction in redundant efforts

READINESS

RECOGNITION

RESPONSE

REPORTING

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Safe Motherhood Initiative: Overview

Bundles:

● Obstetric Hemorrhage

● Severe Hypertension

● Prevention of Venous Thromboembolism

● Maternal Early Warning Signs

● Sepsis in Pregnancy

READINESS

RECOGNITION

RESPONSE

REPORTING

Safe Motherhood Initiative: Overview

Tangible tools hospitals can use to implement directives

● PowerPoint slide sets

● Visual aids posters

● Checklists

● Algorithms

● Risk assessment tables

● Medication dosing tables

● Debriefing forms

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Safe Motherhood Initiative:Maternal Early Warning System (MEWS)

• Definition: Set of specific vital sign and physical exam findings  that prompt a bedside evaluation and/or work‐up

• Action: Positive MEWS screen  Prompt provider bedside  evaluation  clinical judgement, differential diagnosis leads  provider to implement appropriate bundle(s)

• Goal: Prompt and timely identification and treatment of women  developing critical illness

“An effective early‐warning system should facilitate timely diagnosis and  treatment, and thereby limit the severity of any morbidity.”

– Mhyre et al., 2014

EXAMPLE

Safe Motherhood Initiative:  Maternal Early Warning System

Systolic BP (mmHg)Diastolic BP (mmHg)  Heart Rate  RespiratoryRate

<90 or >160>100

<50 or >120

<10 or >24

O2 Sat on room air;% <95Oliguria, mL/hr x 2hrs <35Temperature <36 C or >38 CWBC <4,000 or

>15,000

*Mhyre et al., 2014, National Partnership for Maternal Safety

EXAMPLE

Recommended MEWS Option: ModifiedMEWC(MEWC = Maternal Early Warning Criteria*)

Positive screen

1 abnormal criteria,sustained for >20 min

Maternal agitation, confusion, or unresponsiveness; patientwith hypertension reporting a non‐remitting headache or shortness of breath requires immediate attention

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Safe Motherhood Initiative:Clinical Significance of Sensitivity & Specificity

Higher Sensitivity Lower Sensitivity

Identifies most relevant cases

‐Many cases to be evaluated‐ Costly; difficult to maintain‐ Alert fatigue

Misses some relevant cases

‐ Fewer cases to be evaluated‐ Easier to maintain

EXAMPLE

No likely illness/

OB emergency

Continue to  monitor VS,  

clinical status per  unit standard

SMISepsis Bundle

SMIHemorrhage  

Bundle

SMIVTE Bundle

SMISevere HTN  Bundle

Sources: ACOG DII SMI Bundles

Maternal Early Warning SystemPositive Screen

Prompt Bedside Evaluation

‐Specific MEWS abnormality‐Clinical presentation‐Presence of Risk Factors‐Additional tests

Most likely etiology:

Other

EXAMPLE

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Safe Motherhood Initiative: VTE Prevention

Source: Friedman et al., 2015

UNDERUSE  OF POST‐ CESAREAN THROMBOEMBOLIC PROPHYLAXIS

Characteristic None Mechanical Pharmacologic Combination

955,787 (75.7) 278,669 (22.1) 16,639 (1.3) 12,110 (1.0)

Year of Surgery

2003 115,663 (91.6) 8,717 (6.9) 1,274 (1.0) 664 (0.5)

2004 124,230 (87.4) 15,674 (11.0) 1,319 (0.9) 923 (0.7)

2005 131,220 (84.6) 21,013 (13.5) 1,889 (1.2) 1,051 (0.7)

2006 154,876 (81.0) 32,302 (16.9) 2,413 (1.3) 1,608 (0.8)

2007 145,589 (74.7) 44,842 (23.0) 2,451 (1.3) 2,053 (1.1)

2008 131,250 (66.0) 62,545 (31.4) 2,852 (1.4) 2,294 (1.2)

2009 125,096 (60.5) 75,315 (36.4) 3,609 (1.8) 2,753 (1.3)

2010 27,863 (58.4) 18,261 (38.3) 832 (1.7) 764 (1.6)

(cohort includes cesarean delivery hospitalizations in the US between 2003‐2010)

Venous Thromboembolism Prevention  Safety Bundle

READINESS (Every Unit)•Use a standardized thromboembolism risk assessment tool for VTE during:

•Outpatient prenatal care

•Antepartum hospitalization

•Hospitalization after cesarean or vaginal deliveries

• Postpartum period (up to 6 weeks after delivery)

RECOGNITION (Every Patient)

•Apply standardized tool to all patients to assess VTE risk at time points designated under “Readiness”

•Apply standardized tool to identify appropriate patients for thromboprophylaxis

• Provide patient education

•Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis

RESPONSE (Every Unit)

•Use standardized recommendations for mechanical thromboprophylaxis

•Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation

•Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia

REPORTING/SYSTEMS LEARNING (Every Unit)

•Review all thromboembolism events for systems issues and compliance with protocols

•Monitor process metrics and outcomes in a standardized fashion•Assess for complications of pharmacologic thromboprophylaxis

EXAMPLE

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Safe Motherhood Initiative: OB HEM Project

● Improve READINESS to respond to an obstetric hemorrhage by implementing standardized policies and procedures and developing rapid response teams;

● Improve RECOGNITION of obstetric hemorrhage by performing ongoing objective quantification of actual blood loss and triggers of maternal deterioration during and after all births;

● Improve RESPONSE to hemorrhage by performing regular on-site, multidisciplinary hemorrhage drills; and

● Improve REPORTING of obstetric hemorrhage using standardized definitions resulting in consistent coding.

Hospital implementation visit, 2019

Safe Motherhood Initiative: Severe Hypertension

When to Treat:SEVERE HYPERTENSION

SBP ≥ 160 or DBP ≥ 110

HYPERTENSIVE EMERGENCYPersistent, severe hypertension that can occur antepartum, intrapartum, or postpartum  Two severe BP values (≥ 160/110) taken 15‐60 minutes apart

Severe values do not need to be consecutive

o Repeat BP every 5 min for 15 min

o Notify physician after one severe BP value is obtained

o If severe BP elevations persist for 15 min or more, begin treatment  

ASAP. Preferably within 60 min of the second elevatedvalue.

o If two severe BPs are obtained within 15 min, treatment may be  

initiated if clinically indicated

Standardize Care

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EXAMPLE10

Safe Motherhood Initiative: Sepsis Bundle

Readiness & Recognition*

• Utilization of maternal early  warning system

• Education of patient &  provider

• Standardized sepsis work‐up  criteria

• Standardized sepsis diagnostic  tool

Response & Reporting

• Standardized sepsis  management algorithm

• Consultation

• Consideration of obtaining  higher level care

• Case debriefing

• Multidisciplinary reviews

* For the purposes of this bundle, “readiness” includes the development of preparedness tools & “recognition” is  loosely defined as the use of these tools in the evaluation and diagnosis of maternal sepsis.

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Maternal Sepsis Management

• Initial Sepsis Management Triad:

1. Antibiotics

2. Fluid management

3. Call appropriate consultants as per institutional protocol• Consults may include OB/MFM/Medicine/Anesthesia/Critical Care/Surgery

• Followed by:

• Consider transfer to higher level care

• Source control

• Vasopressors as needed

• Consider antenatal steroids as appropriate for fetal lung maturity

• Consider magnesium sulfate for neuroprotection

• VTE prophylaxis

• Evaluate need for delivery

Sources: ACOG Committee Opinion #455; SMI VTE Bundle

EXAMPLE

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Maternal Sepsis Management

Antibiotics:

• Start within 1 hour of sepsis suspicion

• Broad spectrum

• Narrow and focus antibiotics once pathogen and sensitivities  are identified

Delayed antibiotics > 1 hour = increased mortality

Sources: Bauer et al., 2018; Padilla & Palanisamy, 2017; Rhodes et al., 2017

EXAMPLE

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Safe Motherhood Initiative: Overview

FREE

Available for Apple & Android devices

Continually updated to reflect latest guidance

For providers

New interactive features just launched in September

Safe Motherhood Initiative: Overview

www.acogny.org

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Safe Motherhood Initiative: Additional NYS Initiatives

NYS Perinatal Quality Collaborative (NYSPQC)

Statewide partners:● ACOG District II● NYSDOH● Greater NY Hospital Association● Healthcare Association of NYS

Activities:● Learning sessions● Coaching calls● Data collection● Project manager support w/PDSA cycle reviews● Clinical expert advice on implementation & QI

Safe Motherhood Initiative: OB HEM Project

● Goal: To reduce maternal morbidity and mortality statewide by translating evidence-based guidelines into clinical practice to improve the assessment and management of obstetric hemorrhage.

● Activities:

○ Learning sessions

○ Coaching calls

○ Data collection

○ Project manager support

○ Clinical expert advice on implementation & QI

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Safe Motherhood Initiative: Health Equity Subcommittee

● Evaluation of all patient safety bundles in SMI (hemorrhage, hypertension, VTE, sepsis)

● Equity lens

● Multidisciplinary team

● Addressing respectful care as it relates to quality improvement

Safe Motherhood Initiative: Additional NYS Initiatives

NYS Maternal Mortality Review Board

Multidisciplinary review of each death with a more complete assessment of:● Causes of death● Factors leading to death● Preventability● Opportunities for intervention● Translate trends & issues to action● Collaborate to develop issue briefs, grand rounds● QI projects with partners, including ACOG● Issue maternal mortality report

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The American College of Obstetricians & Gynecologists (ACOG), District II100 Great Oaks Boulevard, Suite 109Albany, NY 12203518-436-3461info@ny.acog.orgwww.acogny.org

@ACOGNY@acogd2@acogd2

Safe Motherhood Initiative contact:

Kristin DeVries, MA. MPPACOG District IIkdevries@ny.acog.org

QUESTIONS?