A new study in the February 2022 issue of The Joint Commission Journal on Quality and Patient Safety, “Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit,” details how a labor and delivery (L&D) unit implemented these two interventions to reduce the time and distance traveled to obtain materials necessary to treat PPH.

The researchers created a simulation dictating the collection of a prespecified list of supplies commonly used in response to PPH. Baseline data were collected, and then Lean Six Sigma tools were used to construct a process map, including recording times and cumulative distance traveled to collect each item.

The simulation was repeated after developing, creating and deploying two interventions:

• Intervention 1: A cart containing the supplies most used in response to PPH.
• Intervention 2: A medication kit with a refrigerated box of all medications typically administered during PPH.

The average time to collect a prespecified list of supplies and medication in response to a PPH scenario was 11 minutes 5 seconds, with an average cumulative distance traveled of 4,092 feet. Following Intervention 1, the time decreased to 4 minutes with 918 feet traveled; and following Intervention 2, the time further decreased to 2 minutes 14 seconds with 462 feet traveled. This represents a 79.8% reduction in time and an 88.7% reduction in distance from baseline to postintervention – optimizing the ability to efficiently treat PPH.

“Designation and maintenance of a hemorrhage cart or kit is one recommended measure that should be part of a larger comprehensive institutional obstetric hemorrhage protocol,” note Gabriela Dellapiana, MD, and Kimberly D. Gregory, MD, MPH, in an accompanying editorial. “Rapid access to the contents of the kit should go a long way toward decreasing maternal morbidity and mortality from hemorrhage.”

Also, to address maternal health, The Joint Commission implemented 13 new elements of performance to improve the quality and safety of care of women during all stages of pregnancy and postpartum. The Joint Commission also began publicly reporting hospital performance on two perinatal care measures last year.

Also featured in the February issue:

• Harnessing Event Report Data to Identify Diagnostic Error During the COVID-19 Pandemic (Brigham and Women’s Hospital, Boston)
• Improving Diagnostic Error Detection and Analysis: The First Step on a Long Path to Diagnostic Error Prevention (editorial)
• A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU (Northwestern University Feinberg School of Medicine, Chicago)
• Meds to Beds: A Quality Improvement Approach to Optimizing the Discharge Medication Process for Pediatric Patients (NYU Langone Health, New York)
• ICU Volunteer “Transition Guides”: A Prospective Study on Improving the Patient Transfer Experience (Beth Israel Deaconess Medical Center, Boston)
• Conversion of a Skilled Nursing and Rehabilitation Facility into a Satellite Hospital in Response to a COVID-19 Surge (Maimonides Medical Center, New York)
• Building a Targeted Automatic e-Consult (TACo) Program (University of California, San Francisco)

For more information, visit The Joint Commission Journal on Quality and Patient Safety website. 

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Note for editors    
The article is “Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit” by Benjamin K. Kogutt, MD; Julia M. Kim, MD, MPH; Susan E. Will, MS, RNC; and Jeanne S. Sheffield, MD. The article appears in The Joint Commission Journal on Quality and Patient Safety, volume 48, number 2 (February 2022), published by Elsevier.