Health systems can use obstetrics department collaboratives and ER interventions to save mothers' lives.
This article appears in the January/February 2019 edition of HealthLeaders magazine.
As seen in the news recently, rising maternal morbidity and mortality is an alarming negative health trend across the country. What can health systems and hospitals do to prevent these adverse events and keep patients safe?
One health system, West Orange, New Jersey–based RWJBarnabas Health, which features 13 hospitals, has launched a pair of programs to reduce maternal morbidity and mortality: an obstetrics department collaborative at the health system's eight hospitals that offer birthing services, and an emergency department initiative.
The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
Here are the two approaches that RWJBarnabas implemented to reduce maternal morbidity and mortality rates.
1. Establish an obstetrics department collaborative
RWJBarnabas' OB collaborative was launched three years ago.
"Our OB collaborative is a leadership committee of physicians, nurses, and other stakeholders in our system with the common goal of improving the health of women, children, and our communities," says Suzanne Spernal, DNP, administrative director of Women's Services at Monmouth Medical Center, a RWJBarnabas hospital in Long Branch, New Jersey.
Spernal says the health system started the collaborative effort in 2015, and members meet bimonthly to review metrics, practice guidelines, best practices, research, innovation, and to standardize practices so that patients receive the same quality at any of RWJBarnabas' birthing hospitals.
Reducing Cesarean sections is a top objective of the OB collaborative.
"The OB collaborative has been focused on reducing the number of unnecessary Cesarean sections being performed in all of our facilities. All eight of our birthing hospitals are participating in the New Jersey Perinatal Quality Collaborative initiative, which is designed to reduce the NTSV Cesarean section rate," she says.
NTSV Cesarean section is used on a subset of women considered at lowest risk and appropriate for vaginal birth.
Limiting Cesarean sections is an important component of reducing maternal morbidity and mortality, Spernal says.
"We want to facilitate a vaginal birth because we know that when a woman gives birth by Cesarean section in the first pregnancy, the likelihood of her having a Cesarean section in any subsequent pregnancy is very high. With Cesarean sections come all of the risk factors of maternal morbidity and mortality," she says.
Cesarean sections are associated with four of the most commonly documented causes of maternal mortality: hemorrhage, sepsis, anesthesia complications, and pulmonary embolism, Spernal says.
In addition to reducing Cesarean sections, the OB collaborative is working to address maternal hypertension.
"We are participating in another initiative through the New Jersey Perinatal Quality Collaborative that looks at the recognition and treatment of severe hypertension in pregnancy. With this initiative, we are tracking process measurements that focus on the length of time from the event of severe hypertension to treatment. This is a new initiative for us, so we only have preliminary data, but what we have looks very good," she says.
2. Involve the ER
RWJBarnabas also recently launched an initiative to include the health system's emergency departments in the effort to reduce maternal morbidity and mortality.
The heart of the initiative is a single question asked of female ER patients of child-bearing age: "Have you had a baby in the past 42 days?"
[A yes answer from the patient] "will automatically alert the care team that this is a patient who may require immediate attention and that the protocols for her treatment may be different than a non-postpartum woman in the same-age population," Spernal says.
The ER initiative started with staff education.
"Our first step was making the emergency room care teams aware of the data for the United States and New Jersey. Then we discussed the national guidelines for treatment and the best way to implement the guidelines in our emergency rooms," she says.
RWJBarnabas will likely involve more service lines in the health system's maternal morbidity and mortality prevention efforts, but emergency departments were a logical next step after the OB collaborative, Spernal says.
"We are starting with the emergency room because we know the majority of adverse events happen in the 42-day window and the biggest opportunity to improve outcomes is in our emergency departments. More than likely, that is where patients are going to present," she says.
For example, a woman who recently had a baby and arrives at the ER complaining of calf pain could have a blood clot, she says. "You would fast-track that patient and get her into a room to be seen by a provider. A woman of the same age who has not had a baby and has calf pain could have a muscle injury."
Impact of the approaches
"The data we have shows improvement in clinical outcomes that are typically the cause of maternal morbidity and mortality, such as Cesarean section rates," says Spernal.
"Six of our hospitals have reduced their overall Cesarean section rate from 2017 to 2018. Seven hospitals have reduced their NTSV Cesarean section rate from 2017 to 2018," Spernal says.
The health system is primarily monitoring a pair of clinical metrics to gauge the impact of maternal morbidity and mortality prevention efforts, she says.
"We are looking at Cesarean section rates, and at the process measurement of the time that the patient presents for labor and delivery, then has an event of severe hypertension and receives treatment—the time that the patient's blood pressure is reduced," she says.
RWJBarnabas' maternal health initiatives have not increased costs for the health system, Spernal says.
For example, the ER initiative has not required hiring new staff members.
"We have not had to add new staff. It's really about asking that basic question to identify women right out of the gate. These are patients you want to pay attention to—you want to fast track them once you find out that the answer to the question is yes," she says.
Both the OB collaborative and the ER initiative are generating benefits with no costs, Spernal says.
"It's a win for everybody. Obviously, there is no cost to having a meeting and having different people attend to share information. If we are identifying these patients earlier and treating them earlier, then the downstream savings come from a timely admission and treatment for something that may not have been recognized in the appropriate time frame," she says.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The CDC says maternal mortality rates rose from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
In New Jersey, RWJBarnabas Health is focusing on reduction of Cesarean sections and controlling severe hypertension in pregnancy.
RWJBarnabas has also enlisted ER staff to help identify new mothers who may be at risk of postpartum complications.