| Abstract |
Hemorrhage is a leading cause of morbidity and mortality in an otherwise healthy parturient. A national effort, led by the Council on Patient Safety for Women’s Health, is underway to address this patient safety concern. This partnership has developed evidence-based guidelines to improve the safety of obstetric care, and these “bundles” are provided for implementation across the country. This EBP Implementation effort is a novel collaboration of staff at the Ft. Belvoir Community Hospital and faculty from the Uniformed Services University (USU) to implement all of the recommendations of the bundle. The collaboration is a multidisciplinary group that included over 200 members from OB/GYN, nurse midwifery, anesthesia, blood bank, laboratory and administration. The project included phases of EBP implementation including Plan-Do-Check-Act (PDSA) cycles. There were four separate teams corresponding to the components of the bundle: Readiness, Recognition, Response, and Reporting. A coordinated, swift response by the hemorrhage response team can be lifesaving, so an emphasis of this project was to provide a sustainable method for team building. The debriefing process for the drills was used to facilitate team building and communication. Hemorrhage drills were used to identify systems-problems that delayed treatment. High fidelity simulation is an important means of providing education for OB care staff. It can also be a method of accurately assessing the changes in processes. Monthly high-fidelity simulation drills were used to evaluate processes at a community-sized facility. Notable improvements were made in the efficiency of recognition and response, speed of obtaining blood products from Transfusion Services, and overall team functioning. The DoD Perinatal Quality and Safety Workgroup has recommended the implementation of this patient safety bundle at all military hospitals. The implementation is complex and the PDSA cycles serve as a method of assessing the implementation, and simulation provides a means of assessing the team functioning. |
