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At HackensackUMC, Integrating IT to Accurately Measure Maternal Blood Loss

February 23, 2016
by Rajiv Leventhal
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Note: HackensackUMC’s real-time quantified blood loss project was named a semifinalist in the 2016 Healthcare Informatics Innovator Awards Program. Short descriptions of the projects of all of the semifinalists in this year’s program can be seen here.

At New Jersey-based Hackensack University Medical Center (HackensackUMC), physician leaders have refined the concept of quantified blood loss (QBL) as a new vital sign as important in preventing morbidity and mortality, and improving patient outcomes.

To date, HackensackUMC officials say there is no precise methodology to accurately quantify a woman’s blood loss during childbirth. Without the ability to accurately quantify blood loss during a vaginal birth or caesarian section (C-section), clinicians crudely estimate the need for medical interventions resulting in over use of care or under use of care. Overestimation of blood loss can lead to costly, highly invasive treatments like transfusions that may be unnecessary and carry serious risks.

Meanwhile, underestimation of blood loss following labor and delivery can lead to the delay of lifesaving interventions and treatments and can have a negative impact upon the mother’s overall health both in the short term and long-term. Indeed, obstetric hemorrhage is estimated to cause 25 percent of all maternal deaths and is the leading direct cause of maternal mortality worldwide.

According to HackensackUMC officials, methods currently used to estimate blood loss include: visual estimation of obstetric-related blood loss (EBL) and gravimetric measurements, an indirect quantification of blood loss using dry (pre-delivery) and wet (post-delivery) weights of delivery items as a proxy for calculating blood lost during a vaginal birth or cesarean procedure (IQBL) and adding blood collected in canisters and in buttock drapes, a volumetric calculation.

As such, looking for a better answer, the team, led by Andrew Rubenstein, M.D., the Section Chief of Obstetrics, and with Shafiq Rab, M.D., CIO, encountered a QBL calculating system called Triton, a mobile platform for real-time monitoring of surgical blood loss, created by the Los Altos, Calif.-based Gauss Surgical Company. At HackensackUMC, healthcare providers use iPad cameras in real time in the operating room to take pictures of surgical sponges and blood canisters. These images are uploaded to a cloud-based system which processes them using a colormetric algorithm that determines the amount of blood contained in the sponge and canister and differentiates it from other body fluids and irrigation.

The chief technology officer and founder of Gauss Surgical, Siddarth Satish, and the HackensackUMC research team met with Rab to review the Triton system and how it might best be implemented into the electronic medical record (EMR) system for real-time clinical use. Rab and the team were able to incorporate and interface the Triton systems’ results into HackensackUMC’s Epic EMR, resulting in real-time reporting of blood loss to the obstetrical team.

This two-way integration with mobile devices and cloud technology allows the obstetrical surgical team to monitor blood loss in real time, the same way a patient’s heart rate, oxygen saturation and blood pressure are monitored, Hackensack officials say. “It does become a vital sign, like a pulse, or blood pressure. You have continuous quantification of blood loss that becomes integral to care,” Rubenstein says.

The result of these efforts is a clinical system deemed Accurate Display of Postpartum Hemorrhage using Triton (ADOPT) for the Modified Early Obstetric Warning System (MEOWS). As such, HackensackUMC officials say that it has become the first organization to accurately calculate true and total quantified blood loss in obstetrics.

One of many alarming stats that Rab and others point out is that of all hemorrhagic deaths, 93 percent were potentially preventable and were due primarily to lack of appropriate attention to clinical signs of hemorrhage, failure to restore blood volume, and failure to act decisively with lifesaving interventions. Utilizing the ADOPT technology, HackensackUMC physicians now have a calculation of blood loss that is proven to be 95 percent accurate, its officials say. “We used to say in the healthcare olden days that if it was a C-section, 1,000 mL of blood would be lost. If it was a vaginal delivery, 500 mL of blood would be lost. We never had the quantified number, though,” Rab says. “No one really knew how much blood was lost. It was a guess. Now we really know,” he adds.

What’s more, the system’s implementation adds a cost of only $30 per each of the 6,300 annual deliveries while reducing the significant costs associated with transfusions, dedicated nurses to perform the traditional gravimetric or volumetric calculations during a procedure, length of stay and overall morbidity, says Jeremy Marut, director of enterprise architecture at the organization.  

Both Rab and Rubenstein quickly point to the saved lives, the improvement of child safety, and maintaining the family bond as the most important results, however. “Even if there was no one else willing to do this on Earth, I would have done this myself,” says Rab. “I understand the benefits it as a physician. Luckily my colleagues are esteemed enough to help me with this project.”