Teamwork Addresses a Surge in Maternal Hemorrhages

Over the past decade, the United States has seen dramatic increases in the incidence of diabetes and hypertension, including during pregnancy. In the fall of 2022, this increase caused the American College of Obstetricians and Gynecologists to recommend that clinicians induce labor at 39 weeks of pregnancy in people with these conditions – sooner than in the past.

That recommendation, however, raises an additional concern. “For first-time laboring patients, induction at 39 weeks can increase the duration of labor, tire the uterine muscle, and increase the risk of hemorrhage,” says Julie Vasher, DNP, RNC-OB, CNS, C-EFM, C-ONQS, Director for Women’s and Children’s Services at Salinas Valley Health.

Though California has done better than much of the rest of the country on these measures, it has not been immune, with hemorrhage affecting 6.3% of all patients giving birth.

That’s why in 2022, Vasher and a team of physicians, perinatal nurses, and surgical techs partnered with Carla Knight, BSN, Director of Perioperative Services, surgery nurses and other staff and leadership to address the increase in hemorrhage during childbirth. By providing clinician education and adapting obstetrical and surgical workflows, the team has put in place a new approach to pregnancy-related hemorrhages that they expect will significantly improve the Magnet^®-designated hospital’s ability to address this life-threatening condition.

The Concern

The dangers of hemorrhaging are considerable. Vasher notes that a patient can lose their entire blood volume as rapidly as 4 to 7 minutes, and such hemorrhaging is a contributor to increased mortality. In the past, protocols required transferring a hemorrhaging patient down a floor to the main operating rooms (ORs) to perform necessary lifesaving procedures. Though obstetrical (OB) teams trained diligently on getting these patients to the operating room quickly, they believed there might be a better way. OB and OR teams began a series of meetings with Salinas Valley Health anesthesiologists and leadership to identify areas of concern and create a plan.

“When we realized how many minutes we were losing trying to get a hemorrhaging patient down a floor, we knew we had to change this process,” Knight says.

“There were some hard, honest conversations about gaps in our abilities to provide care, but we dug in, determined to improve,” Vasher says.

Empowering OB Teams to Perform Lifesaving Procedures

The group eventually lit on the possibility of licensing one of the two ORs on the OB floor for any OB procedure, including some of the lifesaving procedures needed when the main OR team was not immediately available or the downstairs ORs were booked. The plan to make that happen had multiple components.

• Perioperative teams identified best practices and worked with the OB teams to develop and make available necessary instrument sets that would live on the OB floor.
• Educators worked with the OB physicians, nurses and scrub techs to train them in best practices, including multiple simulations on procedures that included Salinas Valley Health’s protocol for massive transfusions.
• The group put in place communication processes and decision trees for charge nurses on both floors and, when possible, for OR teams to come upstairs to perform the lifesaving procedures.

“When we realized how many minutes we were losing trying to get a hemorrhaging patient down a floor, we knew  we had to change this process.”

Carla Knight, BSN, Director of Perioperative Services

Knight and Vasher believe that the entire initiative also demonstrated the power and efficacy of being a Magnet^®-designated hospital. It began with the nurses, gathered steam with the enthusiastic buy-in of physicians and leadership, and then became effective through frequent input from bedside teams.

“Professional governance encourages a whole different level of staff participation that helps us translate a plan on paper to a workable reality,” Vasher says.

Collaboration Helps Teams Respond to a Surge of Pediatric Respiratory Illnesses

In fall 2022, clinicians in the Salinas Valley Health Emergency Department (ED) began to see an uptick in the number and acuity of pediatric cases. Carla Spencer, MSN, RN, NEA-BC, who at the time was the director of Critical Care and Emergency Services, quickly understood that a storm of respiratory illness was on the way for pediatric patients: a “tripledemic” of COVID-19, respiratory syncytial virus (RSV), and seasonal flu. Some of these patients would likely become critically ill.

“Because we don’t have our own pediatric intensive care unit, we typically transfer critical pediatric patients to tertiary centers like Stanford and UCSF,” Spencer says. But with those centers also getting hit with a surge of critically ill pediatric patients, Spencer knew that timely transfers were going to be more difficult to achieve. “If we were going to hold these pediatric patients longer than usual, we needed to be able to treat them.” The ensuing conversations, which included collaboration with Agnes Lalata, MSN, CMSRN, CNML, Director, Medical/Surgical Services, pediatric teams and senior leadership, led to a comprehensive action plan that not only responded effectively to the surge, but has positioned the Magnet^®-designated hospital to respond to future surges.

A Concentrated, Collaborative Effort

Lalata led what came to be known as the Pediatric Surge Preparedness Meetings, a unit-based interdisciplinary approach. “We also formed a task force of pediatric clinicians, educators, respiratory therapists, administration and nursing leadership to focus on how to care for these potentially critically ill patients,” she says.

Respiratory therapists helped train the intensive care unit (ICU), ED and pediatric nurses. Erica Barnum, RN, BSN, MSN, CNS, a pediatric clinical nurse specialist who was working in the ED, was enlisted to help adapt and implement pediatric-specific protocols that had been developed at Stanford.

To manage the doubling and sometimes tripling of patients, the task force also sought to increase nursing coverage with a combination of traveling (contract) nurses and the help of other nurses who had pediatric backgrounds.

In addition, the team ensured that pediatric-specific equipment was available in the adult ICU and, in December, decided to resurrect the negative pressure respiratory tents that had been deployed during the worst of the COVID-19 pandemic.

Finally, on the pediatric units, daily huddles were held that included pediatric clinicians, respiratory therapists, administrators, nutrition services, social services and case management to discuss these patients. “We also huddled with the ED if patients who could not be transferred right away needed to come to the pediatric unit,” Lalata says. “If we needed to intubate, we had a team that could do that. Our response was very collaborative with other disciplines.”

While the ICU infrastructure is now in place to help with pediatric patients, it never became necessary during the surge.

“In the pediatric unit, though, we did have a lot of very sick children who were there longer than we are used to,” Lalata says. “But we were able to take care of them until we could transfer them. There were some challenging days, but the staff did very well, and thank goodness, we got through the surge fine.”