Wisconsin Perinatal Quality Collaborative 4th Annual Summit

Introduction: During pregnancy, postpartum recovery, and the transition to parenthood, women have increased need for health promotion. It is also a time when women are motivated to engage in health-related learning and grow supportive networks. Women experiencing pregnancy during the COVID-19 pandemic must meet their health-related needs in an environment marked by change, uncertainty, and social isolation. The purpose of this study was to qualitatively describe preferences of women seeking childbirth information during a global pandemic.

Objectives: (N/A qualitative)

Intervention: Women who were pregnant or <90 days postpartum (n=26) were invited to share their experiences in semi-structured interviews. Women were asked to discuss their experiences, health concerns related to pregnancy and childbirth, impact of the pandemic on their pregnancy, the role of technology in their care, and any unmet health needs. Verbatim transcripts were coded by the research team according to Braun and Clark�s approach to thematic analysis.

Results: Women revealed needs in the dimensions of information, support, and relationship. When women felt secure in these three dimensions, they reported fewer negative emotions and constructive coping. Obstetric providers were viewed as highly credible, but even more so when a supportive relationship could be established. Women identified internal and external factors that disrupt how their needs are met through usual systems of care. During the COVID-19 pandemic, long-standing challenges in prenatal care were magnified, and new barriers arose. Many participants sought alternative ways to meet their needs for information and support through web and mobile app resources; however, these sources often lacked credibility or created confusion. Women identified ways they wish their health care providers or health systems would meet these needs including tailored information, increased, transparency, and strategic use of mobile health.

Conclusions: The COVID-19 pandemic magnified strengths and weaknesses in perinatal care systems and resources. Women described topics where information was lacking as well as strategies healthcare systems could use to improve support. Lessons learned from women experiencing pregnancy during a pandemic may inform innovative strategies to improve health promotion in a dynamic health environment.

Lucy C. McNamee, RNC-OB, CLC

University of Wisconsin Milwaukee

Obstetric care, Preconception and prenatal, Postpartum

Introduction: On November 1, 2019, Froedtert Hospital implemented a severe hypertension protocol, developed from the Alliance for Innovation on Maternal Health (AIM) patient safety bundle. We expected the three interventions, Labetalol, Hydralazine or Nifedipine to increase the percentage of severely hypertensive patients receiving timely treatment. We evaluated obstetric patients with elevated blood pressures 6 months pre/post-protocol implementation with ongoing monthly assessments.

Objectives: This protocol outlines 3 algorithms with IV Labetalol, IV Hydralazine or Oral Nifedipine. We expected the protocol to increase the percentage of severely hypertensive patients receiving timely, evidence-based treatment.

Intervention: Severe hypertension was identified by two severe-range blood pressures (systolic ≥ 160 and/or diastolic ≥ 110) within 60 minutes, and evaluated for acute treatment within 60 minutes and for further protocol adherence. We collected medication administration time, dose and route and considered Labetalol PO and Nifedipine XR non-acute. Deviation type was defined as late/absent blood pressure readings, late/absent medication administration, or incorrect dose or administration method.

Results: We initially reviewed 500 pre- and post-protocol opportunities between April 23, 2019 and July 4, 2020, where adherence improved from 66% pre- to 71% post-protocol. Following data presentation to providers for feedback, adherence was added to provider maintenance certification in November 2020, order sets defaulted to protocol-defined medications, and protocol procedures were placed in provider workspaces and patient rooms. Subsequently, adherence increased from 85% to 90% between October 2020 to December 2020. Numbers decreased in early 2021, however, and in March-May 2021 Nursing simulations were held, leading to adherence rates ≥ 83% from May 2021 to present.

Conclusions (applicability/lessons learned/etc.): Implementation of the protocol and continued efforts to streamline provider and nursing workflow has increased acute hypertensive medication treatments within 60 minutes. This effort will continue to evaluate and monitor adherence to the hypertension protocol, and implement interventions to improve adherence.

Laura Grogan MS3

Medical College of Wisconsin

Obstetric care, Neonatal care, Postpartum, Nursing care, Pharmacology/pharmacy

Introduction: Newborn Opiate Withdrawal Syndrome continues to be a universal dilemma that has historically been associated with increased hospitalization cost, resource utilization, and length of stay in addition to family separation when a neonatal intensive care unit admission occurs. Eat Sleep Console (ESC) is an evidence-based protocol that addresses these issues and fosters parental interaction and caregiving. In order to provide state of the art care and promote optimal maternal-infant dyad outcomes, it is imperative to implement ESC. Objectives: To implement the Eat Sleep Console (ESC) model of care for infants with Neonatal Opioid Withdrawal Syndrome (NOWS) with intent to decrease pharmacologic intervention and length of stay (LOS) while promoting parental caregiving.

Intervention: Design: Retrospective data from 2017-October, 2020 was reviewed for neonatal intensive care unit (NICU) LOS. Subsequent metrics for the last 9 months included number of administered morphine doses and infants receiving mother's own milk (MOM). Following ESC role out, prospective data was collected over the next 7 months. Metrics included those previously listed plus number of administered morphine doses, maternal enrollment in an opioid treatment program, and ESC prenatal consults. Setting: This setting was a Wisconsin hospital system consisting of 2 Labor, Delivery, Recovery, and Postpartum units with 12 and 31 bed capacity, a 16 bed level 3 NICU, and a 5 bed level 2 NICU. Sample: The sample consisted of 27 mother-infant dyads.

Methods: Quality improvement measures were implemented using the plan, do, study, act model.

Results: Prior to ESC, infants with NOWS requiring pharmacologic treatment based on modified Finnegan scores were admitted to NICU. In the years preceding ESC, average NICU LOS was 9.7-25.5 days. From January-October 2020 infants with NOWS were admitted to NICU for pharmacologic therapy and received an average of 132.75 morphine doses. Additionally, 70% of infants with NOWS had MOM within 24 hours of discharge. Post ESC implementation, 14 NOWS infants were solely managed in the birthing units with one newborn requiring 2 doses of morphine. Additionally, 71% of infants received MOM within 24 hours of discharge and 50% were exclusively breast fed. Average LOS on the birthing unit was 4.8 days. Maternal enrollment in the hospital system's affiliated opioid treatment program was 36% with a 29% prenatal ESC consult rate.

Conclusions: The ESC care model has significantly reduced LOS and morphine therapy. Additionally, newborns are cared for by their mothers in their room rather than being separated by a NICU admission.

Jan Gill, DNP, APRN, NNP-BC

ProHealth Care

Obstetric care, Neonatal care, Public health, Preconception and prenatal, Birth Postpartum, Medical care, Nursing care, Mental health, Pharmacology/pharmacy, ESC

Introduction: This poster will provide an updated, in depth look at the Poppy's Dream bereavement milk donation memorial program. The Mothers' Milk Bank of the Western Great Lakes (Milk Bank WGL) is the non-profit milk bank serving all of Wisconsin and Illinois.

Objectives: Approximately 10 - 15% of our donors are mothers who choose to donate milk after loss. Since its inception in January of 2016, our bereavement program has grown significantly. Following a loss, lactation can be encouraged or suppressed. Whatever a mother decides, Milk Bank WGL strives to support each bereaved family through the donation process and beyond.

Intervention: Due to the rapid growth of the program, the memorial quickly filled with stars. The entire mural has now been repainted in a new space and is more than triple the size of the original wall. After our first successful, in-person candle lighting event in the new space, the COVID pandemic forced us to temporarily change the way we support our families. On 02/27/21, we hosted our first ever Virtual Candle Lighting Ceremony. Educational opportunities for hospitals, providers, and community partners have also been affected, and have been available primarily via online meeting platforms. We continue to strive for increased awareness about the option of milk donation after perinatal loss.

Results: The feedback from our 2021 post-event survey was overwhelmingly positive. Over 100 families from throughout Wisconsin and Illinois participated in the event, and the virtual format allowed each immediate family to share the experience within their extended family and community of support.

Conclusions (applicability/lessons learned/etc.): We still hear occasionally that some bereaved mothers do not know about the option of milk donation until it is too late. Parents who suffer a perinatal loss deserve the opportunity to make the choice that feels right to them. With ongoing education and outreach, we hope to provide a more comprehensive view of the broad scope of the Poppy's Dream program.

Susan Urbanski, CLS

Mothers' Milk Bank of the Western Great Lakes

Obstetric care, Neonatal care, Preconception and prenatal, Birth Postpartum

Introduction: In recent years, the American College of Obstetricians and Gynecologist (ACOG) released recommendations for implementation of enhanced recovery after surgery (ERAS) pathways in gynecologic surgery, as well as a committee opinion on postpartum pain management which advised on ways to reduce opioid use (ACOG, 2018a; ACOG, 2018b). In addition to ACOG, a three part series on enhanced recovery after cesarean (ERAC) was published in American Journal of Obstetrics and Gynecology (AJOG) and the Society for Obstetric Anesthesia and Perinatology (SOAP) published their recommendations (Machones, et al, 2018; SOAP, 2019). The benefits of ERAS have been seen across many surgical disciplines and include reductions in length of stay, decreased pain, and increased in patient satisfaction without increased readmissions or complications (ACOG,2018a; Machones, et al, 2018).

Objectives: At the end of 2019, our organization began to adopt ERAS elements with the goal to reduce the use of opioids during postpartum hospitalization.

Intervention: In November of 2019, education was provided to both physicians and nursing staff on non-pharmacologic interventions for pain management, multimodal stepwise pharmacologic treatment for pain, including scheduled NSAIDS for all deliveries, and introduced ERAS guidelines. Patients with vaginal deliveries were not prescribed opioid pain relief as part of routine orders. Patient with Cesarean deliveries were recommended to have acetaminophen, NSAIDS and docusate scheduled with opioids only being available on PRN basis for moderate or severe pain. Non pharmacologic principles included the use of ice/warm compresses, early ambulation, early oral intake and foley removal, use of gum chewing, stopping IV fluids when tolerating a general diet.

Results: During this timeframe, all deliveries were reviewed for postpartum opioid use during their admission. Reports were generated for all opioids removed from our automated dispensing unit. For ease of reporting, we excluded PCAs and medications given by anesthesia, as those were usually for epidural or intraoperative use. We also excluded medications prescribed as part of medication assisted therapy (e.g., buprenorphine, methadone) for opioid use disorder. In the 3 months prior to our initial educational roll out, 62.4% of all deliveries used no opioids postpartum, including 17.6% of cesarean deliveries and 80.9% of vaginal deliveries. This averaged to 5.3 oral milligrams morphine equivalence (MME) per postpartum day, 13.6 MME/day for cesarean deliveries and 1.9 MME/day for vaginal deliveries. From April 2020 through May 2021, 73.9% of all deliveries used no opioids postpartum, including 33% of cesarean deliveries and 88.6% of vaginal deliveries. This averaged to 3.3 oral MME per postpartum day, 9.2 MME/day for cesarean deliveries and 1.2 MME/day for vaginal deliveries

Conclusions: Through education and the increased awareness, we have been successful in increasing the number of patients who are able to manage their pain without the use of opioids during postpartum. We have also reduced the amount of oral MMEs given to patients who need opioids following a C-section. We plan to continue monitoring to determine if the re-education and modification of standard postpartum order sets results in further improvements.

Courtney Pickar, MS, RNC-OB, ACNS-BC, C-EFM

ProHealth Care

Obstetric care, Postpartum, ERAS, opioids

Introduction: A North Carolina Pregnancy-Related Mortality review from 1995-1999 found obstetric hemorrhage to be the most preventable cause of maternal death. The Association of Women�s Health, Obstetric and Neonatal Nurses introduced a postpartum hemorrhage risk assessment tool, and a validation study performed found the tool correctly identified patients at higher risk for severe postpartum hemorrhage.

Objectives: In February, 2019, Froedtert Hospital implemented a Postpartum Hemorrhage Risk Assessment bundle based on AWHONN�s guidelines with a goal of 90% compliance. Risk assessments are completed on admission and patients are triaged into low, medium and high risk for hemorrhage with recommendation for type and screen for medium-risk patients and type and cross for high-risk patients. The review of compliance was approved as a quality project and did not require IRB review.

Intervention: Faculty and staff completed initial didactic and simulation education in April-May, 2019. In April, 2021, staff repeated simulation education. Data was reviewed initially in February 2021 and reviewed again post-simulation in May, 2021. Compliance was defined as completed admission hemorrhage risk assessment and appropriate blood bank orders. Blood bank orders serve as a trackable marker to indicate if the postpartum hemorrhage risk assessment was considered at time of admission.

Results: We reviewed 265/276 patients who delivered at Froedtert Hospital in February, 2021 (Data was unavailable for 11 patients). 35 patients were high-risk and 93 patients were medium-risk. Of the 35 high-risk patients, 7 (20%) had type and cross, 26 (74%) had type and screens, and 2 (5.7%) had no blood bank orders. Of the 93 medium-risk patients, 87 (93.5%) had type and screens and 6 patients had no blood bank orders. 5 patients did not have pre-birth assessments. There was an overall compliance with the bundle in 226/265 (85.2%) of the patients with an improved compliance in medium-risk patients (93.5%), however decreased compliance was noted in high-risk patients (20%).

Conclusions: Tracking of completion of post-partum risk assessment and blood bank orders allows markers for assessing implementation of hemorrhage preparedness procedures. We hypothesize that repeated simulations/education are necessary for ongoing sustainment and anticipate May 2021 data to be completed by the time of presentation.

For zoom: Meeting ID: 380 838 5231 Passcode: X4dzLBT7

Danielle Villa (MD Candidate 2022) <dvilla@mcw.edu>

Medical College of Wisconsin

Obstetric care, Public health, Birth Postpartum