Dr. David C. Lagrew Jr.
It’s critical that all members of the multidisciplinary team are involved during the planning phase, otherwise the emergency response can be hindered, according to Dr. David C. Lagrew Jr., chief integration and accountability officer at MemorialCare Health System in California. For instance, he worked with a hospital that recounted to him having failed to inform the blood bank that they had renovated their operating room and renumbered the doors. The result was that the blood bank staff person was delayed in finding the correct operating room.
“When someone is bleeding to death, minutes matter,” said Dr. Lagrew.
Once protocols and supplies are in place, units need to educate their staff about the new procedures and run drills.
“I’m a proponent of drills for this kind of response,” said Dr. Main. While simulations are effective for technical work, drills are essential when dealing with emergency responses so that staff on the unit know whom to call, when to call, and what to do, he said.
But Dr. Main said he expects that drills will be a challenge for hospitals because they involve an investment of time and money. Another challenge, he said, is getting private practice physicians to participate in the hospital unit drills. “It’s about their time and money,” Dr. Main said.
As part of the response to hemorrhage, the safety bundle also calls for a more standardized approach to assessing blood loss, as well as “universal vigilance,” since about 40% of postpartum hemorrhages occur in low-risk women.
Dr. Elliott K. Main
Physicians are encouraged to directly measure cumulative blood loss using methods such as collecting blood in calibrated, under-buttocks drapes during vaginal birth or in calibrated canisters during cesarean delivery. Another measurement approach is to weigh blood-soaked items, such as sponges.
This type of quantitative approach is superior to traditional methods of “eye balling” the amount of bleeding, waiting for lab results, or monitoring vital signs, said Dr. Lagrew. “We are absolutely miserable at estimating blood loss,” he said, noting that frequently the obstetrician will give one number for blood loss, while the anesthesiologist and the nurse offer different numbers.
And lab results often take too long, while vital signs don’t offer an early enough warning that blood loss is severe since women often have to lose 1.5 L of blood before there are any changes in their vital signs.
“The bottom line is, you don’t want to wait that long to intervene,” Dr. Lagrew said. “By doing this, it allows us to have a more timely response.”
The safety bundle also calls on hospital teams to engage in debriefings and monitor outcomes to improve their response to obstetric hemorrhage, said Dr. Goffman, who has been working with hospitals in New York as part of the American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative.
“It’s this move to a culture of safety that may be the most difficult change for some hospitals,” she said. “That culture change takes time.”
mschneider@frontlinemedcom.com
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