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Quantification of Blood Loss (QBL)

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How were we doing? OHI Hospitals (31 FL and 4 NC): Prior to implementation of . Phase 1 OHI initiative. 58% report use of techniques to quantify blood loss – PowerPoint PPT presentation

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Title: Quantification of Blood Loss (QBL)


1
Quantification of Blood Loss (QBL)
  • Margie Mueller Boyer, RNC, MS
  • Florida AWHONN Section OHI Representative
  • Annette Phelps, ARNP, MSN
  • FPQC Nursing Consultant

2
How were we doing?
  • OHI Hospitals (31 FL and 4 NC)
  • Prior to implementation of
  • Phase 1 OHI initiative
  • 58 report use of techniques to quantify blood
    loss
  • Only 26 quantify-only (never estimate)

3
How are we doing now? of OHI hospitals using
QBL methods for Vaginal Deliveries
3
4
How are we doing now? Cont. of OHI hospitals
using QBL methods for Cesarean Deliveries
4
5
Quantification History
  • EBL method used most often is visual estimation
  • Visual estimation is unreliable and inaccurate
  • Underestimated as much as 33 to 50
  • Institute most accurate methods Quantification
    of Blood Loss (QBL)
  • Gabel et al 2012, Patel et al 2006, Bingham et al
    2012
  • AWHONN Practice Brief www.pphproject.org

6
Weve always done it this way
  • Clinical decisions of when and if resuscitative
    efforts should begin and to notify other team
    members of hemorrhage, need to be based on
    measures and evidence
  • It is a matter of patient safety!
  • Gabel, K. T., Weeber, T. A. (2012)

7
QBL Benefits
  • QBL prompts the Nurse on critical actions
  • No longer rely on flawed, imprecise visual
    estimation
  • Timely recognition of excessive blood loss leads
    to initiation blood transfusions and other
    maternal resuscitative efforts
  • Overestimation can be costly--unnecessary
    treatments like transfusions
  • Underestimation can delay life saving hemorrhage
    interventions

8
Recommendations
  • AWHONN now recommends QBL at every birth
  • The process is intentionala formal effort!
  • No more vague Guesstimates
  • Continues until the patient is stable and is
    cumulative with hand-off reporting

9
QBL is More Accurate
  • The goal is not a perfect, precise number.
  • There may be some discrepancies from mixing with
    amniotic fluid, urine, irrigant, etc.
  • However it is more accurate to do some
    measurements than to rely solely on visual
    estimates.

10
Who should determine QBL?
It is a team effort and needs to be
standardized. Some teams designate one member as
responsible to measure, orally report, and
record. We will discuss 2 methods. We should be
able to answer How much blood is in the
suction canister (after amniotic fluid)? How much
blood is on sponges? How much blood is on the
floor/on the table? At regular intervals and
cumulatively until the patient is stable (2 to 4
hours post delivery) CMQCC 2010
10
11
Methods
  • Weigh Blood soaked pads, chux
  • Direct Measure Collect blood in graduated
    measurement containers and/or under buttocks
    drapes
  • Account for other fluids(amniotic fluid,
    irrigation)
  • AWHONN Practice Brief, Quantification of Blood
    Loss May 2014

12
Recommendations
  • Weigh wet materials (with known dry weight) may
    be done by gathering a group of pads and weighing
    them all together
  • TIP A practical way of measuring blood in laps
    is to weigh them in groups of 5.
  • Calculate the gram weight and convert to
    milliliters.
  • One gram One milliliter
  • AWHONN Practice Brief, Quantification of Blood
    Loss May 2014

Jennifer McNulty MD and Amy Scott MSN
13
FPQC QBL Calculation Poster
Created by Tricia Walton, RNC,BSN, Hedy Edmund,
RNC,BSN and the FPQC Available upon Request
from the FPQC
14
Recommendations cont.
  • Use calibrated under-buttock drapes (at vaginal
    birth, note the volume of amniotic fluid, urine
    and stool after birth but before the placenta)
  • Measure what can be suctioned at CS (less
    irrigation AF)

15
Direct Measure
Under Buttocks Drapes
275 mL
16
Cesarean Sections
Shared by Jennifer McNulty MD and Amy Scott MSN
and available in the OHI Toolbox
17
AWHONNs tips for Where Do We Begin?
  • Start by teaching the process that is common for
    most cases.
  • Begin with vaginal births then scheduled
    cesareans.
  • Be willing to modify and tweak the process to
    meet the particular logistics of your facility.
  • Have team meeting to determine how to manage
    e.g., the STAT cesarean.

18
Vaginal Births Keep it Simple
  • For Vaginal Births, begin right after the
    infants birth
  • Note amniotic fluid, urine, etc. in the
    under-buttocks bag prior to birth. (Applicable if
    SROM occurs close to birth or amnioinfusion
    performed.)
  • RN looks at the bag as soon as OB/CNM has
    completed the delivery to communicate the amount
    of blood in the calibrated drape as QBL.
  • AWHONN Practice Brief, Quantification of Blood
    Loss May 2014

19
Quantification Tips from AWHONN
  • Assess amount of fluid in the under buttocks
    drape prior to delivery of placenta - mark drape
    or state amount
  • Begin QBL immediately after the infants birth
    PRIOR to delivery of the placenta.
  • Record the amount of fluid collected
  • Most of the fluid collected prior to birth of the
    placenta is amniotic fluid, urine, and feces. If
    irrigation is used, deduct the amount of
    irrigation from the total fluid that was
    collected.
  • Subtract the pre-placenta fluid volume from the
    post-placenta fluid.   Most of the fluid
    collected after delivery of placenta is blood.
  • Continue QBL 2-4 hrs postpartum

20
Resources
  • FPQC OHI Toolkit and Materials for QBL

http//health.usf.edu/publichealth/chiles/fpqc/OHI
.htm
21
Resources
  • Available at www.pphproject.org

22
Frequently Encountered Clinical Issues and
Responses (adapted from Bingham Main 2012 and
AWHONN 2014)
  • Issue
  • AWHONN Response
  • Providers believe that their patients are unique
    thus, the research does not apply to their
    specific group of patients.
  • Many physicians and nurses have only performed
    EBL. They are not familiar with how to QBL.
  • Distribute key peer-reviewed literature related
    to the measurement of blood loss to every nurse
    and physician.
  • The lack of experience indicates that there is a
    need for more education tactics with QBL details.

23
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • The providers are concerned, on the basis of
    their training and experience, that if they begin
    quantifying blood loss they will have higher
    blood loss levels which might reflect negatively
    on their practices putting their reputations in
    jeopardy.
  • Track the number of births quantified and their
    relationship to early recognition of PPH. Report
    facts and QBL trends to the physicians and
    nurses.

24
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • Measurement of cumulative blood loss is the goal.
    Often it is too late when we recognize that the
    woman has lost too much blood. Perform regular
    quantification in non- emergency situations to
    prepare the team for the actual PPH event.
  • QBL is only needed for cases where a hemorrhage
    is identified.

25
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • The goal is not a perfect, precise number.
    There may be some discrepancies from mixing with
    amniotic fluid, urine, irrigation, etc. and this
    can be measured to some degree. It is more
    accurate to do some measurements than to rely
    solely on visual estimates.
  • QBL is not exact and therefore it is not worth
    doing.

26
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • Since irrigation is usually done after the major
    bleeding is controlled, it may be best to connect
    to another canister BEFORE irrigating to capture
    this fluid separately. With continued use,
    documenting the measures at birth and then
    ongoing becomes routine practice and there is
    less forgetting to document.
  • There was fluid already in the canister, just
    estimating, we forgot it and so its just an
    estimate.

27
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • Shared responsibility and accountability is
    critical to quality patient outcomes. A shared
    team awareness is needed. It is no one persons
    responsibility. It is a TEAM responsibility.
  • With QBL, it is now my responsibility to get it
    right.
  • I used to be in charge and still want the
    responsibility.

28
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • Teams that do QBL report that it becomes routine
    and takes very little additional time. Have QBL
    nurse and physician experts showcase doability of
    QBL and describe how they successfully performed
    QBL.
  • QBL takes a lot of time.

29
Issues and Responses cont. (adapted from Bingham
Main 2012 and AWHONN 2014)
  • Issue
  • AWHONN Response
  • Have scales and dry item lists readily available
    in every OR. Develop quick methods for
    totaling/calculating in EMR. Think of the time
    that will be saved by avoiding a hemorrhage
    event. 
  • Its going to slow down OR room turnover.

30
Testimonial
  • AWHONN recommends measuring blood loss for every
    woman who gives births in order to reduce denial
    that leads to delays in women receiving
    lifesaving treatments.  Measuring blood loss
    makes a un-reliable subjective process much more
    reliable.

Debra Bingham, DrPH, RN, AWHONN Vice President of
Nursing Research, Education, and Practice
31
Testimonial
  • Why do Quantification of Blood Loss in
    Obstetrics?
  • When I was practicing in Ohio, a quality
    improvement project was initiated for reduction
    of obstetric hemorrhage.  I was skeptical about
    some of the components and somewhat taken aback
    to having anesthesiologists or nurses telling me
    what the blood loss amount was. I had been
    estimating blood loss for years without any
    problems and did not see the value for the added
    time and attention that it would take.  That is,
    until the consistent measurements indicated that
    estimation was not as safe for my patients as
    measured quantification.
  • Over time, I learned from the literature that
    estimations were often as much as 50 inaccurate,
    usually underestimating the true loss.  I have
    heard from nurses, that on day 2 the hematocrit
    is sometimes low and the patient symptomatic when
    estimations are used and quantifications
    ignored.  This has made a believer out of me and
    now, I consistently want to have quantified
    measurement of blood loss for vaginal and
    Caesarean deliveries.  Quantification is not a
    perfect measurement but is more accurate than
    guessing, and with the new tools offered to make
    the measures more accurate, it is getting better
    and better.
  • Many of our national organizations are strongly
    encouraging us to use the most accurate
    quantifications we can.  Recent recommendations
    have come from working groups comprised of ACOG,
    CDC, SMFM, and AWHONN, as well as, multiple state
    perinatal collaboratives that quantitative
    measures are safer for patients. I think we need
    to have a culture change in the delivery suite. 
    We have the evidence that early recognition of
    significant blood loss and early intervention is
    safer for our patients. 
  • We need to get over the old thinking that we are
    not good at our jobs if there is blood loss and
    move to the evidence based model that says we are
    best at our work if we recognize and respond
    appropriately.
  • Judette Louis, MD, MPH
  • Assistant Professor, Department of Obstetrics and
    Gynecology
  • Morsani College of Medicine
  • FPQC Clinical Advisor

32
Testimonial
  • When it comes to obstetric hemorrhage, denial and
    delay in recognition can equal maternal death. 
    The uterus can bleed 500-800 cc/minute and within
    5 minutes of unrecognized hemorrhage a patient
    can suffer loss of an entire blood volume along
    with valuable clotting factors.    Signs of
    hypotension are often masked in healthy patients
    due to increases in cardiac output and
    vasoconstriction. Quantification of blood loss in
    the operating room and labor and delivery room is
    vital to providing early intervention in
    recognition and treatment of obstetric
    hemorrhage. 
  • As medical providers, we need to join together in
    accurately measuring blood loss as part of the
    multidisciplinary approach to obstetric
    hemorrhage.  By putting the ego aside and letting
    go of estimates, we can move towards evidenced
    based quantification of blood loss to help
    providers overcome the denial and delay in
    treatment of maternal hemorrhage.
  • Jean Miles, MD
  • Chief of Obstetric Anesthesia
  • Memorial Healthcare System
  • Patient Safety Committee for the Society of
    Obstetric Anesthesia and Perinatology

33
Testimonial
  • When implementing any new initiative among
    nursing staff it is essential to understand the
    why behind the purpose of implementing the new
    process/procedure.   QBL allows us to have a more
    accurate clinical picture of blood loss so we can
    proactively manage our patients rather than
    reactively manage their symptoms after they are
    already occurring.   Even the most experienced
    clinicians can have a difference of opinion when
    it comes to subjective assessment.   QBL is the
    closest we can come to objectively assessing the
    blood loss post-delivery so we can improve
    clinical outcomes for our patients.
  •  

Marie Sakowski, MSN, RNC Nurse Manager,
Perinatal, Labor and Delivery Womens Health
Pavilion Florida Hospital Tampa
34
Summary
  • For EVERY birth, begin QBL immediately after the
    infants delivery and continue ongoing QBL
    measurement until bleeding is stable.
  • Cumulative measurement of blood loss is key to
    early recognition of excessive blood loss for
    timely initiation of life saving interventions.
  • QBL for all births reduces the incidence of
    denial of significant blood loss and delayed
    recognition and initiation of treatment.
  • Adapted from AWHONN.

35
QBL Exercise
36
Questions?
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