Obstetric Hemorrhage Initiative
The Florida Perinatal Quality Collaborative, in partnership with the District XII American College of Obstetricians and Gynecologists (ACOG), Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Florida Council of Nurse Midwives, Florida Hospital Association, and the Florida Department of Health, has developed this Obstetric Hemorrhage Initiative (OHI).
Read our publications on the OHI:
In the Maternal and Child Health Journal: The Obstetric Hemorrhage Initiative (OHI) in Florida: The Role of Intervention Characteristics in Influencing Implementation Experiences among Multidisciplinary Hospital Staff (2016)
In the Journal of Perinatology: Contextual factors influencing the implementation of the Obstetrics Hemorrhage Initiative in Florida (2017)
Florida's Pregnancy Associated Mortality Review (PAMR) committee released a 2016 Urgent Maternal Mortality Message to Providers on Hemorrhage and Placental Disorders
- A data collection and display spreadsheet is available for download by hospitals who want to track their own OH data. See resources below.
Florida hospitals are encouraged to continue to work on obstetric hemorrhage using the tools, resources, and lessons learned from the FPQC's OH Initiative.
Suggested commitment length: Spend 1 year instituting recommendations and 6 months institutionalizing changes.
After a successful Round 1, FPQC launched a Round 2 for hospitals who missed the first round to lead their own initiative in their hospital with FPQC technical assistance and support. See below for resources.
Data Collection and Display Spreadsheet:
OHI Round 2 Data Entry and Display Spreadsheet Instructions
OHI Hospital Data Entry and Display Spreadsheet.xlsx
Round 2 kicked off with an Orientation Webinar in February 2016.
In June of 2016 we held a Collaboration Webinar, where hospitals shared their challenge and successes in working on OHI:
Resources and Tool Box
- Florida Obstetric Hemorrhage Initiative (OHI) Toolkit updated October 2015
- OHI Hospital Data Entry and Display Spreadsheet
- OHI Hospital Data Entry Spreadsheet Instructions and Questions
- OHI Key Driver Diagram
OHI Hospital and Patient Success Stories
Addtional Resources are available in the OHI Tool Box.
Click here to view the OHI Tool Box for Hospital Implementation
If you cannot access Box on your hospital campus, please contact us to request files.
Printed materials available for OHI hospitals upon request from Florida hosptials:
- Florida's Obstetric Hemorrhage Initiative Toolkit
- OB Hemorrhage Stages Algorithm Poster
- Quantification of Blood Loss Poster
- "Have you Q.B.L.ed Today?" sticky note pads
- Archived Safety Action Series webinars from the Council on Patient Safety in Women's Health Care
- OB Harm Reduction Checklist and OB Hemorrhage Checklist from HRET
- Florida PAMR Urgent Message for Maternity Care Providers
- View AWHONN's video on How to Quantify of Blood Loss
- View Lee Memorial Health System's Tips and Tricks on Quantification of Blood Loss After Vaginal Birth video
- Free Online course: Quality Improvement in Obstetric Hemorrhage Management. 1 CME / 1.25 AMA PRA
- VHA network's Partnership for Patients Education Series recorded webcast with a focus on the Florida OHI and Baptist Hospital of Miami: Improving Maternal Outcomes of Obstetric Hemorrhage
OHI Round 1 Webinars
Webinar recordings and slides are archived on Box Cloud Storage. This site has been approved by USF Health as HIPAA compliant.
6.4.2015: Sustainability of OB Hemorrhage Projects
5.14.2015: End of Initiative Celebration
12.4.2014: OHI Success Stories
9.11.2014: Physician Champion Panel
6.12.2014: OHI 6-Month Check In and Progress Report
5.8.2014: Team Communication and Debriefing
4.10.2014: Quantification of Blood Loss
3.13.2014: OB Hemorrhage Simulation Drills
2.13.2014: Physician Engagement and Data Reports
1.16.2014: Massive Transfusion Protocols
12.5.2013: Data Collection and Hospital Implementation
OHI Round 1 Results31 Florida hospitals and 4 North Carolina hospitals participated in the OHI pilot phase from 2013-2015. Download the report below to view results of the initiative.
OHI Round 1 Final Data Report
Hemorrhage, or severe bleeding, is the leading cause of pregnancy-related mortality worldwide and in the United States (Bingham et al, 2011; American College of Obstetricians and Gynecologists (ACOG) 2006). Postpartum hemorrhage has been defined as blood loss in excess of 500 mL following a vaginal birth or more than 1,000 mL following a cesarean birth (ACOG, 2006). It is estimated that one woman dies every four minutes from postpartum hemorrhage worldwide (ACOG, 2006). The pregnancy-related mortality ratio in the United States has increased to its highest levels in decades from 11.1 to 15.7 deaths per 100,000 live births from 1993 to 2006 (Creanga, 2012). Further, between 1994 and 2004 there was a 27.5% increase in postpartum hemorrhage deaths, primarily due to uterine atony, and a 92% increase in maternal blood transfusions (Bingham et al, 2011; Callaghan et al, 2010). Recent research indicates that “54 to 93% of these hemorrhage deaths may have been preventable” (Bingham and Jones, 2012).
Maternal hemorrhage is considered to be the most preventable cause of maternal mortality (Burke, 2010). Improved quality of medical care is the most important factor for the prevention of mortality due to obstetric hemorrhage. More than 90% of the potentially preventable morbidity and mortality due to hemorrhage is because of provider-related factors, notably incomplete or inappropriate management (Della Torre, et al, 2011). A 2011 study found that delay in treatment or diagnosis, ineffective management, and lack of proper preventive measures for hemorrhage led to preventable pregnancy-related deaths and extreme morbidity (Della Torre et al, 2011).
Although there is no clear trend, the pregnancy-related mortality ratio (PRMR) in Florida fluctuated from 13.3 in 2005 to 26.2 in 2009. Hemorrhage was one of the top three causes of maternal mortality, accounting for 15% of deaths during this time period. Most maternal deaths from hemorrhage were caused by ruptured ectopic pregnancy, uterine atony/postpartum bleeding, placenta accreta, percreta, or increta, and retained placenta (FL PAMR). Risk factors associated with deaths due to hemorrhage in Florida included lack of prenatal care, non-Hispanic Black race; having a cesarean delivery and advanced maternal age (FL PAMR).
In order to address Florida’s pregnancy-related mortality, the Florida Department of Health contracted with the Florida Perinatal Quality Collaborative (FPQC) to convene a group of maternal health, public health, and quality improvement leaders to work on a Maternal Mortality Prevention Initiative. The FPQC maternal mortality workgroup reached consensus that hemorrhage is one of the state’s most preventable maternal mortality issues and the highest priority because hemorrhage is one of the top causes of maternal mortality in Florida and because hospital and provider strategies to address the issue are highly feasible and effective.
Multi Hospital Collaborative
Hospitals are asked to spend 18 months implementing the recommended changes and 6 months institutionalizing them in their facilities.
Hospitals and providers participating in the OHI will be better prepared to assess for hemorrhage risks, prepare for and manage obstetrical hemorrhage in earlier stages, and measure their results. The FPQC helps Collaborative participants meet OHI goals by sharing the best available scientific knowledge, teaching and applying methods for organizational change, involving experienced hospital experts, and sharing participating hospital experiences, challenges, and successes.
Strategies are adaptable to all hospital settings and recognize that some facilities do not have the necessary equipment or trained professionals to utilize some of the higher technology or complex procedures and guidelines. There are core elements that are recommended in a priority order to be included in all locations, including participation in data collection for core metrics. Each facility either adopts an existing set of protocols or guidelines and tools or develop/adapts protocols or guidelines and tools using the evidence based elements. Collaborative hospitals learn improvement strategies that include establishing goals and methods to develop, and test and implement changes to their systems.