Texas Children’s Hospital (TCH) is a large, stand-alone pediatric and women’s hospital that is self-insured and funds quality improvement efforts to improve outcomes and reduce patient risk throughout the institution. The Pavilion for Women (PFW) at Texas Children’s Hospital opened in 2012, with the transfer of an existing obstetric service from a small nearby medical center program.
The PFW is a level IV designated high-risk delivery service, with 17 labor and delivery recovery rooms and a 4-bed intensive care unit, 11 triage beds, 6 operating rooms, and 70 inpatient beds for antepartum and mother-baby couplet care. The PFW is attached to the 610-bed children’s hospital, which includes a 168-bed Level IV Newborn Center.
To reduce the incidence of obstetric adverse events (OBAE) and improve patient outcomes, the PFW undertook a multipronged improvement initiative to increase the readiness, recognition, and effective and efficient management of obstetric hemorrhage (OH).
While addressing the opportunity to reduce OBAEs, the PFW was met with the added challenge of a rapidly growing delivery rate and case mix index.
Between 2012–2015 the number of deliveries at the PFW more than doubled, from approximately 250 per month in 2012 to more than 500 per month in 2015. This rapid growth in delivery volume coupled with the increase in
case mix index required aggressive expansion of the clinician workforce. In one year, for example, more than 100 registered nurses were hired to meet patient care demands. The growth in case volume and acuity and staff initially outpaced the ability to meet clinician education and practice needs.
To improve the clinical management of OH at the PFW, an interprofessional team planned and implemented several interventions, including:
- development of clinical protocols
- didactic and online education (Relias OB, formerly GNOSIS™)
- hands-on skills stations
- interprofessional simulation team training (STT)
Underpinning this quality and patient safety initiative was the standardization of clinical processes and reductions in care variation. Standardization and reduction in process and care delivery variation was facilitated
initially through the iterative development and adoption of two evidence-based clinical practice algorithms addressing management of OH due to uterine atony, and massive transfusion. Once the protocols for OH and massive transfusion (MTP) were developed and approved, layered educational and practice initiatives were undertaken in two waves: didactic, hands-on skills stations and online education (Relias OB), followed by interprofessional STT.
An initial overview of Relias OB was provided for all interdisciplinary obstetric clinicians, and Relias OB Peer Mentors (TCH staff trained on Relias OB) were educated to facilitate its implementation. Every member of the obstetrics team (providers and nurses) were given access to a standardized Relias OB for OH assessment that then provided analytics on the team variation of the national evidence- based guidelines and protocols for postpartum hemorrhage and hemorrhage events during pregnancy. Clinical leaders followed up with obstetric staff to encourage completion of each component.
Initial Obstetric Hemorrhage Results
Out of 18,342 total deliveries between March 2012 and September 2015, 65 mothers who experienced OH required ≥4 units of PRBCs (0.35%).
- 26% reduction rate of OH requiring ≥4 units of PRBCs
- 50% reduction deliveries requiring activation of the MTP
Additionally, the total units of blood products transfused during OH requiring the activation of the MTP decreased significantly. Not only did the proportion of total number of units of blood products transfused during OH requiring an MTP decrease over time, the proportion of types of blood products transfused also changed.
The PFW continued utilization of Relias OB and maintained its focus on reducing preventable harm by improving care coordination between teams, improving data transparency (pushing data to internal and external stakeholders) and sharing provider metrics on learning outcomes.
Since 2018, PFW included the use of Relias OB into the labor and delivery department’s bylaws, incorporating the solution’s obstetrical hemorrhage course into the hospital’s bundle for OH prevention. Prompted from changes to the definition for obstetrical hemorrhage and ICD10 code changes from 2017, new measures included OH assessment on admission, at least once during delivery, and the true quantification of estimated blood loss for all deliveries.
While PFW’s obstetrical hemorrhage rate has fluctuated by 6–7%, the hospital’s transfusion and MTP rates continue to remain low, as their good work continues. Additionally, the expansion of Relias OB has influenced the hospital’s outcome metrics overall.
FY18 results achieved:
- 64% decrease in obstetric adverse events (since FY12)
- 51% decrease in umbilical cord PH <7.0 rate (since FY13)
- 30% decrease in OH transfusion rate (since FY15)
- 82% decrease in APGAR ≤3 at 5 minutes of life rate (since FY17)
- 36% rate of overall OH transfusion rate (June 2017-May 2018)
The Future State of Texas: Designation Requirements
To address Texas’ high rate of harmful maternal and neonatal outcomes, the state legislature passed a bill creating a Perinatal Advisory Council to develop and recommend criteria for designating levels of neonatal and maternal care, including specifying the minimum requirements supporting qualification at each level. The council also develops a process for the assignment of care levels and makes recommendations for organizing the state into neonatal and maternal care regions and examines utilization trends and makes recommendations to improve outcomes.
While the designation rule went into effect on March 1, 2018, beginning September 1, 2020, Texas will require the maternal level of care designation for all hospital providers that render neonatal/maternal inpatient services and receive Medicaid reimbursement for obstetrical services.
It’s important to note that 54% of births in Texas were associated with Medicaid patients in 2014, making the designation rule incredibly significant to the state’s labor and delivery hospitals.
The new ruling leaves hospitals providing labor and delivery services in rapid preparation for the September 2020 deadline to ensure their Medicaid reimbursement is not at risk.
Texas Children’s Hospital was one of the first three facilities in the state to earn designation as a level IV facility.
Relias OB helped the hospital meet the education component of the recent designation criteria. The solution also further improves patient safety by promoting teamwork, communication and a culture of safety through interdisciplinary standardized and validated evidence-based framework to reduce variation and move towards high reliability.
Lynda Tyer-Viola, the Vice President of Women’s Services and for the Pavilion for Women and Nursing Research at Texas Children’s Hospital, noted, “Texas Children’s Hospital uses Relias OB for its interdisciplinary education, which I’m confident is why we meet the criteria for interprofessional education, as confirmed during our 2018 survey…. Quality is a moving target, and Relias OB’s provider education enables our team to keep the eye on the ball.”