Road to QBL

How to Avoid the Bumps & Potholes

Cynthia Sawyer, MSN, CNS, RNC-OB, CLE

DISCLOSURES

• No disclosures

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OBJECTIVES

• At the conclusion of this presentation the participant will be able to: – Describe the difference between estimated blood

loss and quantitative blood loss (QBL) – Verbalize the need for QBL for all vaginal and

cesarean deliveries – Identify the tools necessary for the staff to assist

them performing QBL – Evaluate the process of QBL for vaginal and

cesarean deliveries – Discuss ways to overcome obstacles and barriers

to rolling out QBL and sustaining the change

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BACKGROUND • Estimated blood loss (EBL) has been done for

post deliveries since the 1800’s

• Purpose of EBL was to determine the need for a blood transfusion

– Physicians trained to visually estimate the blood loss

• In the 1960’s researchers demonstrated that visual EBL was underestimated in large blood loss and overestimated in small blood loss

– Underestimations were by one third to one half

(AWHONN, 2014; Williams, 2014; Schorn, 2010) 4

EBL

Care provider visually estimates blood loss on laps based on saturation

Visually determines blood concentration of fluid in suction canister to determine amount

Visually estimates run off blood loss on chux under patient

Estimates total blood loss

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QBL

Weighed • For each 1 g equals 1 mL of water

Measured • Each mL approximately

equates mL blood loss

Quantified • Totals are

added cumulatively

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COMPARISON

EBL

Quick & easy

Subjective

Visual estimation

High rate of error

Not 100% accurate

QBL

Can be laborious

Objective

Quantifiably measured

Lower rate of error

Not 100% accurate

(AWHONN, 2014) 7

• Uterine atony cause in 50% of cases

• Change in practice with over use of inductions & cesarean sections

OB hemorrhage rate increased 26% from 1994-2006 in U.S.

• Quick recognition & treatment can prevent progression of blood loss

• OB hemorrhage is low volume, but high risk event

Physiological changes in pregnancy lends women capable of

losing large amounts of blood

• Denial & delay

• Under estimation of blood loss

• Lack skill in accurately assessing QBL

Problems with recognition,

treatment, & poor communication

contribute to maternal death

WHY QBL FOR ALL DELIVERIES? OB hemorrhage a leading cause of maternal mortality & morbidity, yet highly preventable

8 (Bingham, 2012; California Department of Public Health, 2015)

THE JOURNEY BEGINS

• Looking back on the road less traveled

– Two maternal deaths from a specific patient population

– High incidence of severe

obstetric hemorrhage

– Physician and office

signage instructed no tea

or vitamins after 36 weeks

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LESSONS LEARNED • Set up multidisciplinary & interdepartmental

simulations – Return demonstration of

• Blood transfusion equipment

• OB hemorrhage cart & weighing

• Uterine balloon

• CMQCC OB hemorrhage protocol

• ACLS

• Code OB

• OB Hemorrhage Order Set • Massive blood transfusion

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Low Risk Medium Risk

High Risk

No history of postpartum hemorrhage

Elective primary Cesarean section, uncomplicated

≤ 4 previous vaginal births

No previous uterine incision

No known bleeding disorder

Normal vaginal delivery

Singleton pregnancy

Prior Cesarean birth or uterine surgery

Uterine

overdistention: ▪ Multiple gestation ▪ Polyhydramnios History of previous

postpartum hemorrhage

Chorioamnionitis

Large uterine fibroids

Placenta previa, no bleeding

Oxytocin use > 18 hours

Platelets ≤ 100,000

> 4 vaginal births

≥ 3 previous Cesarean sections

Active bleeding (greater than show on admission)

Suspected placenta accrete or percreta

Platelets < 75,000 Hct ≤ 30 AND other

risk factors Placenta previa,

bleeding Known

coagulopathy

Recommended Action

Hold Clot Type & Screen Type & Cross 2 Units

OB Hemorrhage Risk Assessment

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OB HEMORRHAGE CART

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OB HEMORRHAGE CHECK LIST

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THE BACK SIDE

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NEW CODE OB SHEET

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PRACTICE MAKES PERFECT • Super User Program

– Resource person

every weekend &

every shift

– Rapid infuser

– Blood warmer

– Uterine balloon

– OB hemorrhage cart

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BEST LAID PLANS

• Demonstrate weighing laps at skills lab

– Too many new projects

– Not enough time for

demonstrations

• Should have piloted

a team of champions

— Stronger infrastructure

for roll out to support change

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MAPPING IT OUT

• Obtain buy in from key stake holders

– Anesthesiologists

– Obstetricians

– Administration

– Influential staff

– OB techs

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TOOK A WRONG TURN

• Should have’s:

– Practiced more with the OB techs

– Participated on more cases

– Really developed a core team

– Reached out to more

hospitals on workflow

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FORK IN THE ROAD

• What to do next?

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OVERCOMING OBSTACLES

• Alleviating frustrated staff

– Labor intensive at time of delivery

• Instituted buddy program

• Marking pen attached to suction canister

– Developed QBL scratch sheet

– Calculator attached to scale

– Preweights on scale

– Practicing doing mock QBL

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RECYCLE YOUR OLD STUFF

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TAKING THE SHOW ON THE ROAD

• Remediation

• Winning them over

• Justification

– Best practice

– Examples of how

EBL didn’t work

– Know how to do

it in an emergency

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ALONG FOR THE RIDE • Make them sign it!

– Ward conference

– Log book

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QBL FOR VAGINAL DELIVERY

After delivery of infant the OB notes amount of amniotic fluid

At the end of the delivery procedure OB notes level of graduated bag and subtracts amniotic fluid for QBL

If blue towels, gauze, or pads are soaked with blood, they will be weighed, dry weights subtracted, and added to total

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GOT AMNIOTIC FLUID?

• RN prompts OB to look at amniotic fluid level

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GOT IT IN THE BAG

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After Delivery of Infant After Delivery of Placenta

QBL FOR CESAREAN Blood loss from suction canister

Mark amount after tech has suction

gutters after delivery of baby

Note total amount of fluid before

irrigation

Subtract amniotic fluid from total

Blood loss from laps

Before closing add up preweights –

wet & dry

Weigh entire holder of laps

Subtract preweights from lap holder weight

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WHAT IS WHAT?

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IT WEIGHS HOW MUCH?

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WEIGH THAT LAP

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MATH IS NOT EASY FOR MOST

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ADD IT ALL TOGETHER

QBL

Blood loss from

under patient

Blood loss from

canister

Blood loss from laps

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ONE STEP AT A TIME

• Debriefing with tool

• Social work consults added

to order sets

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MAKE LEARNING FUN

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BRIBERY NEVER HURTS

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JOURNEY STILL AHEAD

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COMING SOON

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SMOOTH OUT THE ROAD

• Working with IT to develop

– E-calculator

– OB hemorrhage pick list

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DO NOT REINVENT THE WHEEL

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ONE SIZE FITS MOST

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KEEP IT SIMPLE

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SUSTAINABILITY • PACU log audits

• Simulations

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AWHONN VIDEO

• Quantification of Blood Loss

44 (AWHONN, 2014)

Questions?

Thank you

REFERENCES

Association of Women’s Health, Obstetric and Neonatal Nurses. (2014). Quantification of blood loss: AWHONN practice brief

number 1. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 00, 1–3. DOI: 10.1111/1552-6909.12519. Retrieved from:

http://www.pphproject.org/downloads/awhonn_qbl.pdf

Association of Women’s Health, Obstetric and Neonatal Nurses. (2014). How to quantify blood loss. Retrieved from:

https://www.youtube.com/watch?v=F_ac-aCbEn0

Bingham, D. (2012). Obstetric hemorrhage-related maternal mortality and morbidity. Journal of Women’s Health, 21(9), 901-902.

doi: 10.1089/jwh.2012.3873.

California Department of Public Health. (2015). OB hemorrhage toolkit. California Maternal Quality Care Collaborative. Retrieved

from: https://www.cmqcc.org/resource/obstetric-hemorrhage-20-toolkit

Schorn, M. N. (2010). Measurement of blood loss: Review of the literature. Journal of Midwifery & Women’s Health, 55(1), 20-27.

Retrieved from: http://www.medscape.com/viewarticle/716622_4

Williams Obstetrics, 24th (ed.) (2014). Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Dashe, J. S., Hoffman, B. L., Casey,

B. M., and Sheffield, J. S . (Eds.). New York, NY: Mc Graw Hill Education

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