Obstetric hemorrhage: • What is your obstetric hemorrhage policy and/or protocol? NYC Health + Hospitals follows the Safe Motherhood Initiative guidelines issued by the American Congress of Obstetricians and Gynecologists (ACOG), District II. NYC Health + Hospitals is the only health system or hospital in New York State identified by ACOG as a collaborator on this work. • Has this policy/protocol been updated in the last three years? When was the last update of the policy/protocol? Yes, ACOG has refined its guidelines, most recently the aspirin protocol within the past year. • What is your obstetric hemorrhage escalation policy? We follow ACOG guidelines, which address escalation when needed. • What is your massive transfusion protocol for obstetric hemorrhage? We follow ACOG guidelines. • Does your hospital have/use a hemorrhage cart? Yes. • Does your labor and delivery unit have an established hemorrhage response team? Yes. • What is the composition of your labor and delivery unit’s hemorrhage response team (including all doctors, nurses, midwives and other staff members)? All obstetrical units have emergency response teams consisting of physicians, head nurses, staff nurses, anesthesia physicians, and NICU staff. These teams may also include midwives, physician assistants, and nurse practitioners. Emergency response teams are typically called for hemorrhage, eclampsia, and other OB emergencies. Emergency blood banking services are included for hemorrhage. Additional hospital resources—including respiratory therapy, medical intensivists, surgery, and ICU care—are available. Rapid Response Teams and Code teams are in place and called upon for major medical events, including for amniotic fluid or other emboli, hypertensive crises, and other instances where critical care services are warranted. • How frequently does your staff do obstetric hemorrhage drills? All staff are drilled on hemorrhage. Supplementary training is provided for staff as they rotate through our Simulation Center. The Simulation Center offers the Obstetrics Emergency Course, which covers a range of obstetric emergencies, including all three that are specifically referenced in this document. Simulation Center training is also provided directly on the unit, which has improved staff teamwork communication and yielded a number of patient-safety benefits. • How do you measure blood loss when a patient is experiencing an obstetric hemorrhage? We calculate blood loss using visual aids and the semi-quantitative approach. • What information do you provide patients, family, and/or staff on obstetric hemorrhage? We counsel high-risk patients during pregnancy. We perform risk stratification upon admission to the hospital, and we discuss this with patients who may be at risk for hemorrhage. When hemorrhage does occur, we provide detailed disclosure to patients and their family. • Do you assess all incoming patients for their hemorrhage risk? Yes. • If yes, at what stage in the birth is the risk of hemorrhage assessed? Prenatal? During admission to hospital? During deliver? After discharge? Throughout the pregnancy, and continually, upon admission, through discharge, and after discharge. • What kind of debriefing or review process does your obstetric staff undergo following a severe obstetric hemorrhage? We debrief after an event, using the PEARLS model. We conduct quality reviews and root cause analysis when warranted. • How do you monitor outcomes and assess the hospital’s ability to respond to obstetric hemorrhage? We report adverse events to our Regional Perinatal Center, which provides quality oversight. We work closely with them in the review process, which may include evaluation of factors such as preventative efforts, risk identification, situation recognition, timeliness of treatment, and staff teamwork. • After serious events of hemorrhage, what types of review or meetings occur to assess the cascade of events and discuss prevention strategies? Answered earlier. • How often do staff meetings occur to discuss hemorrhage prevention strategies? Departmental meetings occur monthly or more frequently, at which staff review approaches to all morbidities. Severe Hypertension in Pregnancy/Labor/Delivery/Postpartum: • What is your hypertensive emergency policy and/or protocol? NYC Health + Hospitals follows the Safe Motherhood Initiative guidelines issued by the American Congress of Obstetricians and Gynecologists (ACOG), District II. • Has this policy/protocol been updated in the last three years? When was the last update of the policy/protocol? Yes, ACOG has refined its guidelines. • What is your obstetric hypertensive escalation policy? Do you use a hypertensive emergency checklist (for eclampsia or preeclampsia)? We follow ACOG guidelines, which address escalation when needed. The guidelines themselves are a checklist. • What policies do you have in place for use of antihypertensive medications during a hypertensive emergency? We follow ACOG guidelines. • Does your labor and delivery unit have an established hypertensive emergency response team? Yes. • What is the composition of your labor and delivery unit’s hypertensive emergency response team (including all doctors, nurses, midwives and other staff members)? All obstetrical units have emergency response teams consisting of physicians, head nurses, staff nurses, anesthesia physicians, and NICU staff. These teams may also include midwives, physician assistants, and nurse practitioners. Emergency response teams are typically called for hemorrhage, eclampsia, and other OB emergencies. Emergency blood banking services are included for hemorrhage. Additional hospital resources—including respiratory therapy, medical intensivists, surgery, and ICU care—are available. Rapid Response Teams and Code teams are in place and called upon for major medical events, including for amniotic fluid or other emboli, hypertensive crises, and other instances where critical care services are warranted. • How frequently does your staff do hypertensive emergency drills? In what setting do you do these drills? Staff training is ongoing, and hypertension is a topic that recurs frequently. Other obstetric emergencies frequently covered include hemorrhage, shoulder dystocia, pulmonary embolism, acute myocardial infarction, and seizure. Those trained include attending and resident physicians, nurses, midwives, and physician assistants, among others. • What information do you provide patients, family, and/or staff on hypertensive conditions, such as eclampsia or preeclampsia? We provide patient education throughout the pregnancy, and continually, upon admission, through discharge, and after discharge. • How do you educate patients when they leave the hospital on signs of hypertensive conditions? We provide targeted patient education during the hospital stay--before and at discharge. For patients who have high blood pressure or who are at risk post-discharge, we follow up within days of discharge—either through a patient visit to their provider or through the use of home care services. • Do you assess all incoming patients for their eclampsia or preeclampsia or other hypertensive disorder risk? Yes. • If yes, at what stage in the birth is the risk of eclampsia/preeclampsia/hypertension assessed? Prenatal? During admission to hospital? During deliver? After discharge? Yes, prenatally. Yes, during admission. Yes, during delivery. Yes, after discharge. And yes, throughout the inpatient stay. • What kind of debriefing or review process does your obstetric staff undergo following a severe hypertensive event? We debrief following most clinical events, using the PEARLS model of debriefing. Our commitment to this model is shown by the publication of an article on the topic in the peerreviewed journal Academic Medicine. • How do you monitor outcomes and assess the hospital’s ability to respond to hypertensive emergencies? We report adverse events to the Regional Perinatal Center, which provides quality oversight. We work closely with them in the review process, which may include evaluation of factors such as preventative efforts, risk identification, recognition and timeliness of treatment administration, and staff teamwork. • After serious events of eclampsia/preeclampsia/other, what types of review or meetings occur to assess the cascade of events and discuss prevention strategies? Answered earlier. • How often do staff meetings occur to discuss hypertensive event prevention strategies? Departmental meetings occur monthly or more frequently, at which staff review approaches to all morbidities. Embolism Prophylaxis against obstetric emembolism and risk assessment • What is your embolism emergency policy and/or protocol? NYC Health + Hospitals follows the Safe Motherhood Initiative guidelines issued by the American Congress of Obstetricians and Gynecologists (ACOG), District II. • Has this policy/protocol been updated in the last three years? When was the last update of the policy/protocol? Yes, ACOG has refined its guidelines. • What is your obstetric embolism (thromboembolism or pulmonary embolism) escalation policy? Do you use a embolism emergency checklist? This is largely about prevention and early identification, not treatment. We conduct risk assessment upon admission, and prophylaxis is implemented when appropriate. There are only two options-- prophylaxis or a therapeutic approach—so it is not really amenable to a checklist. • What policies do you have in place for use of mechanical prophylaxis with mothers (before, during and after delivery)? We follow the ACOG guidelines. • Do you have different protocols for patients undergoing a cesarean operation versus a vaginal birth? The guidelines are different, yes. • Does your labor and delivery unit have an established embolism emergency response team? We have an emergency Rapid Response Team for all emergencies. • What is the composition of your labor and delivery unit’s embolism emergency response team (including all doctors, nurses, midwives and other staff members)? All obstetrical units have emergency response teams consisting of physicians, head nurses, staff nurses, anesthesia physicians, and NICU staff. These teams may also include midwives, physician assistants, and nurse practitioners. Emergency response teams are typically called for hemorrhage, eclampsia, and other OB emergencies. Emergency blood banking services are included for hemorrhage. Additional hospital resources—including respiratory therapy, medical intensivists, surgery, and ICU care—are available. Rapid Response Teams and Code teams are in place and called upon for major medical events, including for amniotic fluid or other emboli, hypertensive crises, and other instances where critical care services are warranted. • How frequently does your staff do embolism emergency drills? In what setting do you do these drills? Staff training is ongoing, and embolism is a topic that recurs frequently. Other obstetric emergencies frequently covered include hemorrhage, hypertension, shoulder dystocia, acute myocardial infarction, and seizure. Those trained include attending physicians, nurses, residents, midwives, and physician assistants among others. • What information do you provide patients, family, and/or staff on embolism conditions, such as thromboembolism or pulmonary embolism? We provide patient education throughout the pregnancy, and continually, upon admission, through discharge, and after discharge. • How do you educate patients when they leave the hospital on signs of embolism emergency? Patient education provided includes the signs of embolism emergency. • Do you assess all incoming patients for their embolism risk? What indicators do you use to assess the risk of patients coming in? Yes. All patients are scored, using a standardized EMR tool. • If yes, at what stage in the birth is the risk of embolism assessed? Prenatal? During admission to hospital? During deliver? After discharge? Continuous and ongoing. • What kind of debriefing or review process does your obstetric staff undergo following a severe embolism event? We debrief following most clinical events, using the PEARLS model of debriefing. • How do you monitor outcomes and assess the hospital’s ability to respond to embolism emergencies? We report adverse events to the Regional Perinatal Center, which provides quality oversight. We work closely with them in the review process, which may include factors such as preventative efforts, risk identification, recognition and timeliness of treatment administration, and staff teamwork. • After serious events of embolism, what types of review or meetings occur to assess the cascade of events and discuss prevention strategies? Answered earlier. • How often do staff meetings occur to discuss embolism event prevention strategies? Departmental meetings occur monthly or more frequently, at which staff review approaches to all morbidities.