Quantitative blood loss measurement remains largely a subjective process in many healthcare organizations. This is an issue for many different types of patients, but it is an especially acute problem in labor and delivery. Between 2014 and 2017, postpartum hemorrhage accounted for 10.7 percent of pregnancy-related deaths.
Becker's Hospital Review recently spoke with three experts about the challenges associated with quantitative blood loss measurement and opportunities for improvement:
- Imana Mo Minard, MSN-Ed, RN, Director of Nursing, Emergency Center, Beaumont Farmington Hills (Mich.)
- Deborah Mordecai, DNP, MS, MA, BSN, CNM, CENP, Assistant Chief Nursing Officer and Director of Patient Care Services, Women's, Infants' and Children's Division, University of Texas Medical Branch in Galveston
- Lisa Spencer, MBA-NM, BSN, RNC-OB, Nurse Manager, Labor and Delivery/High Risk Obstetrics, University of Texas Medical Branch
These nursing leaders shared insights about the products, processes and change management approaches their organizations have adopted to improve quantitative blood loss measurement.
Solving the blood loss estimation puzzle
Leading healthcare organizations have recognized quantitative blood loss measurement is a competency that needs greater attention in the clinical setting, as well as in nursing and medical schools.
"My team just completed a large project on estimating blood loss in the emergency center. One of the big findings was the lack of formal training in this area," Ms. Minard said. "Clinicians, nurses, physicians and techs aren't formally trained on this as part of their education. Blood loss comes up in the context of different disorders and patients who need blood transfusions, but the estimating piece isn't there."
In labor and delivery, early recognition of postpartum hemorrhage is critical. Two key challenges in this area are human error and the subjective assessment of blood loss.
"In earlier years when I worked at the bedside, I can remember coming out of ORs or deliveries. These were procedures where patients lost blood," Dr. Mordecai said. "Many times, I'd look at an EBL that documented the patient lost 250 milliliters and I'd think it was at least 450 or 500."
Teams find it both challenging and frustrating to essentially guess how much blood a patient has lost. In the emergency setting, clinicians often have to evaluate the blood on a patient's clothing or on the floor and try to determine the volume.
"When we have women who present in the emergency center with heavy abnormal bleeding, whether it's from a miscarriage or issues with their menstrual cycle, we may have to transfuse," Ms. Minard said. "Once again, we are stuck, trying to figure out how many pads they filled up. It really is kind of a big puzzle. That's the best way to describe it."
The journey to more accurate blood loss measurement
Clinicians have turned to different visual and measurement techniques to estimate patient blood loss, such as visual aids that show blood measurement on laps and pads, graduated drapes and weighing laps and pads. For patients with a gastrointestinal bleed, teams may quantify blood loss by measuring the fluids that the nasogastric tube has suctioned into a canister.
The University of Texas Medical Branch recently conducted a blood loss estimation research study on 242 women who underwent scheduled Cesarean sections.[1] The study conducted was to compare subjective estimated blood loss estimated by the surgeons to the Triton quantitative system.
"We used Triton, which is a Gauss Surgical system for quantitatively measuring blood loss," Ms. Spencer said. "Clinicians used an iPad app to take pictures of laps and 4x4s. Based on the photos, the app measures the blood lost. For heavier laps, we put them in a bowl, and it weighed them. We found that the quantitative blood loss estimates correlated with post op hemoglobin. However, we do not feel that it adds to us clinically. The main reason it that we overestimate rather than underestimate blood loss. I think people want quantitative blood loss because they are worried that we underestimate blood loss, but we did not find that."
If a health system introduces new approaches for quantitative blood loss measurement, change management is essential. "Weighing pads is a little different than just cleaning up the room and walking out," Dr. Mordecai said. "As we evaluate new systems, we consider their accuracy, how important they will be and how much time it will take to complete tasks."
To reduce postpartum hemorrhages, The University of Texas Medical Branch's Labor and Delivery team has developed a comprehensive portfolio of tools and processes, including frequent postpartum hemorrhage emergency drills with the labor and delivery team.
Risk assessments are integrated into the Epic system and visual aids are posted outside the rooms of patients at risk. When these patients are ready to deliver, the team places the postpartum hemorrhage cart nearby. If there is a postpartum hemorrhage, tranexamic acid and initiation of the massive transfusion protocol is available.
How to bring the best tools to the bedside
Healthcare leaders with limited resources recognize partnerships with staff are the key to deploying the best tools at the patient bedside. "In situations like quantitative blood loss estimation, I want to hear from the staff," Ms. Minard said. "I want them to try different products and to tell me which one will work best and meet the needs of our department. They are the end users and the feedback they give me is critically important. Shared governance with the staff and letting them make the decisions that control their practice will guarantee success every time for the patient."
Dr. Mordecai echoed those sentiments. "Employees have a multiplicity of support," she said. "We work from our end to facilitate and give them the right equipment. But the way the team implements it and puts it together is up to them. Part of the success is not only having the resources, but how the team uses those resources, their attention to detail and their focus on the patient, quality and safety."
Collaborative programs create best practices
The TexasAIM initiative is an example of a collaborative program created by the Department of State Health Services, the Alliance for Innovation on Maternal Health (AIM) and the Texas Hospital Association. Its goal is to help hospitals and clinics carry out maternal safety projects to end preventable maternal death and severe maternal morbidity. Hospitals and communities nationwide participate in the AIM program and use its maternal safety bundles to improve patient well-being. AIM partners with state teams and health systems to achieve its objectives.
The University of Texas Medical Branch partnered with TexasAIM in the postpartum hemorrhage bundle. TexasAIM launched this project in 2018, with a mission to reduce maternal morbidity and mortality across the state. The program has run side by side with The Joint Commission requirements on postpartum hemorrhage. The University of Texas Medical Branch team submitted data quarterly over the past two years, reflecting multiple quality projects implemented while working with different patient teams.
"If you want to move forward and try new things, you need physicians, nurses and leadership to be on the same page," Dr. Mordecai said. "They need to be open to new ideas and collaborative processes. You might go into a project thinking that it will make a difference, but sometimes it doesn't. The key is to be open to learning that your hypothesis isn't correct, then adjusting and seeing where you need to go from there.
The University of Texas Medical Branch team has found it very helpful to have collaborators from outside the hospital. Through the AIM process, the group has learned about other hospitals' quantitative blood loss initiatives, including how they started, what they implemented and the lessons they learned.
Conclusion
Health systems continue to pursue new and better ways to quantify blood loss estimation. "After our emergency center study, our unit practice council gathered education for new graduate nurses on estimating blood loss. I think we've gotten better in healthcare, but I definitely don't think we're where we want to be," said Ms. Minard.
Better techniques for quantifying blood loss will benefit patients across the board. "Not only are women at great risk during pregnancy, childbirth and postpartum, but racial disparities have come even more to light in the past year," Dr. Mordecai said. "Women of color have higher rates of material complications that result in sickness and death. This work is designed to help all women. The hope is that we can increase safety for women across the nation during childbirth and beyond."
[1] “Validation of a New Method to Assess Estimated Blood Loss in the Obstetric Population Undergoing Cesarean Delivery,” by Fawzi Saoud et al., 2019, American Journal of Obstetrics & Gynecology, Vol. 221 (3), p. 267.E1-267.E6.