SAN DIEGO – Utah hospitals reported improved implementation of an obstetrics hemorrhage bundle following a series of teleconferencing sessions.

“There is an increasing body of evidence to support the use of protocols and bundles in obstetrics to improve outcomes for pregnant women and their babies,” Brett D. Einerson, MD, MPH, lead study author, said in an interview. “In Utah and throughout the Mountain West, we face the unique challenge of disseminating information and education on the latest evidence-based treatments to smaller rural hospitals that still need to be prepared for events like severe postpartum hemorrhage but do not have the volume, or sometime the resources, to be adequately prepared.”

Telehealth, or the use of audio-visual technology in medicine, has been used to connect health care providers to patients in need of specialized medical care in the United States – particularly in states like Utah with low population density, said Dr. Einerson, a clinical fellow in the division of maternal-fetal medicine at the University of Utah Health Sciences Center, Salt Lake City. He and his associates set out to use telehealth for another purpose: to train health care providers in the use of obstetric bundles with twice-monthly telehealth trainings. He presented their findings at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Telehealth allowed us to reach providers who otherwise could not travel the distance to attend frequent training sessions and gave the whole state access to expertise at the region’s large tertiary care hospitals,” Dr. Einerson said. “As far as we know, this is one of the first uses of telehealth as a tool for disseminating patient safety and quality improvement education for health care providers on a statewide scale.”

Dr. Einerson and his associates invited all Utah hospitals to participate in the Obstetric Hemorrhage Collaborative, an evidence-based educational program aimed at facilitating implementation of the obstetric hemorrhage bundle. The program involved two in-person training meetings and twice-monthly teleconferencing with expert mentorship over 6 months. In-person sessions consisted of hands-on training and strategy building, while telehealth sessions were led by regional and national leaders in the field of obstetric hemorrhage.

A statewide self-assessment survey of 38 bundle elements was administered before initiation of the project and after completion. The researchers used modified Likert scales to describe participant responses. Means and proportions were compared before and after the training.

Of Utah’s obstetric hospitals, representing every hospital system in the state, 27 (61%) completed the needs-assessment survey, and 15 (34%) participated in the Obstetric Hemorrhage Collaborative, which included four bundle domains:

Recognition and Prevention: Conducting a risk assessment and active management of the Third Stage of labor.
Response: Creating a checklist and a rapid response team.
Readiness: Establishing a blood bank, hemorrhage cart, and conducting simulation/team drills.
Reporting and Learning: Fostering a culture of debriefing, conducting a multidisciplinary review, and measuring outcomes and processes.

Hospitals reported implementation, or progress toward implementation, of significantly more elements of the bundle after the educational program, compared with before the collaborative (a mean of 33.3 vs. 19 bundle elements; P less than 0.001). Hospitals reported increased implementation of elements in all four bundle domains. All participants (100%) reported that teleconferencing sessions were “very helpful,” and 14 (93%) said that they were “very satisfied” with the collaborative.

“Hospitals in the state of Utah generally had the right tools to treat and prevent obstetric hemorrhage but did not have the systems in place to be sure that the tools were used correctly,” Dr. Einerson said. “For instance, 80% of hospitals had access to a cart with supplies for treating bleeding, but less than 15% were systematically measuring blood loss after delivery. What surprised me most, however, was that most hospitals did not track their rates of postpartum bleeding. In my mind, you can’t set goals for treatment until you know how good – or bad – you are doing. Knowing your baseline rate of outcomes can help set goals and measure progress toward achieving them. Before training, less than 50% of Utah hospitals knew their own rate of hemorrhage, but all participating hospitals reported tracking their rates after the intervention.”

He acknowledged certain limitations of the study, including the fact that it did not measure obstetric outcomes. “We are in the process of measuring the effectiveness of our telehealth intervention by monitoring hemorrhage rates and complications over time,” Dr. Einerson said. “This survey of participants in the statewide telehealth bundle program is the first step.”

Dr. Einerson reported having no financial disclosures.

dbrunk@frontlinemedcom.com

Using telemedicine to improve maternal safety