Figures & Tables
Figures
- FIGURE 1
The “4 Rs” Flowchart for Sepsis and Hypertensive Disorders of Pregnancy (A) and for Hemorrhage (B)
Abbreviations: C-section: cesarean delivery; MEOWS: Modified Early Obstetric Warning Score; QBL, quantity blood loss.
- FIGURE 2
Correlation Between Implementation of MEOWS and the iMMR From Life-Threatening Conditions, June 2019 to March 2021
Abbreviations: iMMR, institutional maternal mortality ratio; LTC, life-threatening condition; MEOWS, Modified Early Obstetric Warning Score.
- FIGURE 3
Run Chart of the Aggregated iMMR From All Causes of Death in the 19 Participating Hospitals, January 2018 to September 2021a
a December 2019 to March 2021 represents the implementation period of the quality improvement initiative.
Abbreviations: iMMR, institutional maternal mortality ratio.
- FIGURE 4
Run Chart of the Aggregated iMMR Due to Life-Threatening Conditionsa in the 19 Participating Hospitals, January 2018 to September 2021b
a Life-threatening conditions comprised postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy.
b December 2019 to March 2021 represents the implementation period of the quality improvement initiative while April to September 2021included the post-implementation period.
Abbreviations: iMMR, institutional maternal mortality ratio.
Tables
- TABLE 1.
Primary Drivers of Improved Women’s Survival Around Birth and Associated Changes the Participating Hospitals Tested
Primary Driver (what to do) Changes (how to do) Create a reliable process to identify patients with suspected LTCs. Use MEOWS in addition to the standard screening tool for all patients (MEOWS + screening tool). Add 2 questions for women with MEOWS (MEOWS ≥ 4 or a single parameter score of 3):
Can the patient have an infection (suspicion of sepsis)?
Can the patient have HDP?
Create alert systems for the entire team when suspected LTC is identified through MEOWS ≥ 4 or a score of 3 on any parameter + yes in 1 of the 3 questions or blood loss ≥500 mL vaginal birth or ≥1,000 mL for cesarean delivery. Provide safe, reliable, and equitable care for all patients at admission, antepartum, postpartum, and discharge. Ensure the timely rescue of all patients with suspected LTC by competent and trained teams to apply the care bundles. Reassess all patients according to bundle recommendations using MEOWS. Ensure to escalate the care of all patients with any LTC. Train teams to adapt the care considering social and racial inequalities. Develop engaged care teams with knowledge of how to deal with LTCs, considering social and racial inequalities. Train teams from all departments to provide clinical assistance to patients with LTCs. Promote training in the Model for Improvement. Build capacity (process/people) in the organization to collect and publish measures disaggregated by race reliably. Develop a culture of safety and continuous improvement. Create highly effective interdisciplinary teams (huddles, SBAR for communication, adverse events analysis). Engage leaders to promote transparency, fair culture, and quality of care as a high organizational priority. Ensure that service is co-designed with patients, families, and community. Engage patients/family/community to co-design care processes. Improve transparency in communication with patients/family/community. Abbreviations: LTCs, life-threatening conditions; MEOWS, Modified Early Obstetric Warning Score; HDP, hypertensive disorders of pregnancy; SBAR: Situation, Background, Assessment, Recommendation.
- TABLE 2.
Care Bundles for Postpartum Hemorrhage, Sepsis, and Hypertensive Diseases of Pregnancy
Care Bundle Items in the Care Bundle PPH first response care bundlea TROM: Tranexamic Acid, Reposição volêmica (IV fluids), Oxytocic drugs, and Massage (uterine)b
Treat each of the 4 “Ts” accordingly (tone, trauma, tissue, and thrombin)
PPH second response care bundlec Calculate shock index
Move patient to operation room
Treat each of the 4 “Ts” accordingly
Consider blood transfusion
HDPs care bundle Collect laboratory tests for preeclampsia
Magnesium sulfate loading dose
Magnesium sulfate maintenance dose
Control of blood pressure and respiratory rate
Recalculate MEOWS
Treat high blood pressure
Sepsis care bundle Measure lactate level
Obtain blood cultures prior to administration of antibiotics
Administrate antibiotics
Rapidly administer 500 mL IV solution
Apply vasopressor after IV fluid to maintain mean arterial pressure ≥65 mmHg
↵a For blood loss ≥500 mL (vaginal birth) or ≥1,000 mL (cesarean delivery), regardless of altered vital signs.
↵b After this BTS, a group or researchers published an article proposing E-MOTIVE36 instead of TROM. The elements of the bundle are the same, but arranged in a different order, which changes the acronym.
↵c After applying the first response bundle and blood loss persists.
Abbreviations: BTS, Breakthrough Series; HDPs, hypertensive disorders of pregnancy; MEOWS, Modified Early Obstetric Warning Score; PPH, postpartum hemorrhage.
- TABLE 3.
Characteristics of the Participating Institutions, by the Life-Threatening Condition Chosen for Improvement
Life-Threatening Condition to Improve No. of Institutions Type of Administrationa Median Live Births Between April 2018 and March 2021 (Range) Postpartum Hemorrhage 7 3 public (1 teaching)
3 philanthropic
1 social organization
11,813 (3,814–19,377) Hypertensive Diseases of Pregnancy 8 4 public (1 teaching)
2 philanthropic
2 social organization
7,055.5 (3,903–12,528) Sepsis 4 4 public (1 teaching)
14,269 (5,828–27,597) ↵a Public hospital: Health care facility that is owned, funded, and operated by the government or a government agency at the local, regional, or national level; Teaching hospital: a medical facility that is affiliated with a medical school or university and is actively involved in the training and education of medical students, interns, residents, and other health care professionals; Philanthropic hospital: health care institution that operates with a primary focus on providing medical services and care as part of its charitable mission; Social organization: health care institution managed by an organized group of individuals who come together to pursue common goals, share values, and establish structured relationships to achieve specific purposes.
- TABLE 4.
Changes Documented in the Hospitals Before and After the BTS, by the “4Rs” Clinical Steps
Clinical Step (The 4Rs) Before the BTS After 17 months of the BTS Recognize MEOWS not included in existing tools and protocols for triage and vital signs monitoring in most participating hospitals MEOWS was adopted across the hospitals. Inconsistency among HCWs in interpreting the urgency to act when faced with abnormal vital signs and managing clinical situations The HCW team is well-trained on tools and protocols using Job Instruction/TWI methods. Delayed critical interventions and compromised patient safety due to absence of a clear threshold for action A clear threshold to act: if MEOWS score of 4 or greater, or a score of 3 in any single parameter, the HCW needs to ask if there is suspicion of sepsis or preeclampsia. With hemorrhage, the threshold is blood loss. Rescue Predominant obstetrician-based decision-making Team-based care and standardized. Decision-making variable depending on HCW background experience and preferences Leadership and frontline team trained in using data for decision-making and rapid cycle improvement. No QI capability to reflect on performance and improve systems of care HCWs use improvement sciences to systematically improve the quality of care. Significant variations in clinical care due to unclear protocols and clinical decision-making Collaborative agreement on best practices and evidence-based interventions reduces care variation. Reassess No standard tools or process to reassess the patients after interventions MEOWS is the gold standard for reassessing patients after implementing care bundles or clinical interventions. There is a clear process for communicating patient status to the care team. Refer No explicit standard tool during the transition of care MEOWS is undertaken for all patients requiring care transitions with a clear recommendation to act. No standard referral pathways Streamlined referral pathways to ensure optimal patient care. Abbreviations: BTS, Breakthrough Series; HCW, health care worker; MEOWS, Modified Early Obstetric Warning Score; QI, quality improvement; TWI, Training Within Industry.
- TABLE 5.
Number of Deaths per Period and the Estimated Number of Deaths Prevented, by Cause of Death
Number of Deaths per Period Estimated Number of Deaths Preventeda Cause of Death Baseline:
January 2018 to November 2019
Implementation:
December 2019 to March 2021
Post-Implementation:
April 2021 to September 2021
During and After Implementation: December 2019 to September 2021 Hypertensive Disorders of Pregnancy 15 11 5 0 Postpartum hemorrhage 15 3 1 11 Sepsis 26 8 0 18 Others (all causes except the 3 analyzed life-threating conditions) 46 31 10 5 Total (3 life-threating conditions and other, except COVID-19) 102 53 16 4 Live Births 133,471 120,916 ↵a To estimate the number of deaths averted, we employed the following method: initially, we established a baseline by gathering data on maternal mortality within a defined timeframe preceding the intervention. Subsequently, we calculated the baseline maternal mortality rate by dividing the number of maternal deaths by the number of live births during that period. Using this rate, we projected the anticipated number of maternal deaths, multiplying the rate by the number of live births each month, commencing with the first month after the baseline period. This projection illustrated the expected number of maternal deaths had the intervention not been implemented. Throughout the project, we meticulously collected the actual number of maternal deaths each month. By subtracting the actual number of deaths from the projected number, we determined the difference, representing the number of deaths averted.
- TABLE 6.
Variations in Care Bundle Practices Among Participating Hospitals, May 2019 to October 2021
Care Bundle Items in the Care Bundle Reporting Hospitals (N) Initial Control-Line (%) Final Control-Line (%) Variation (percentage points) MEOWS N/A 19 78 98 +20 PPH prevention actions Assess hemorrhage risk 16 of 19b 92 92 0 Quantify blood loss 57 90 +33 10 IU oxytocin after delivery 80 99 +19 PPH first response care bundle Tranexamic acid 6 of 7 63 90 +27 IV fluids 76 84 +8 Oxytocic drugs (higher dose) 76 87 +11 Uterine massage 74 89 +15 HDP care bundle Magnesium sulfate (loading dose) 4 of 8 86 86 0 Magnesium sulfate (maintenance dose) 54 75 +21 Treat high blood pressurea 87 87 0 Sepsis care bundle Measure lactate level 3 of 4 42 88 +46 Obtain blood cultures prior to administration of antibiotics 84 84 0 Administer antibiotic 92 92 0 Rapidly administer 500 ml IV solution 53 93 +40 Apply vasopressor after IV fluid to maintain mean arterial pressure ≥ 65 mmHg 91 91 0 Abbreviations: HDP, hypertensive disorders of pregnancy; MEOWS, Modified Early Obstetric Warning Score; N/A, not applicable; PPH, postpartum hemorrhage.
a Hydralazine was the antihypertensive/vasodilator available in the participating hospitals.
↵b The reporting hospitals varied from 5 to 16, reaching 16 in the last 3 months of the BTS.
Supplemental material
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