As the top two preventable causes of maternal morbidity and mortality are hemorrhage and preeclampsia, the St. Joseph, Michigan-based Lakeland Health set its sights on designing custom electronic health record (EHR) tools to assist in the assessment and prevention of these conditions.
Lakeland Health has applied EHR technologies within its obstetrics (OB) department at all three of its hospitals to support care providers in identifying warning symptoms in a timely manner to avoid costly complications. As a result of this clinical informatics initiative, Lakeland Health has optimized the usage of necessary blood supply as needed by new mothers. Before implementation in January 2015, the OB department used 37 units per 1,000 patients. In May 2016, the department used 24.8 units per 1,000 patients.
Additionally, the project leaders have reported improvements in caring for obstetric patients with regard to preeclampsia. As of May 2016, 82 percent of obstetric patients had a completed hemorrhage risk assessment and with 98 percent of patients had blood pressure taken within 15 minutes of arrival and, of those with elevated blood pressure, care providers were notified 100 percent of the time upon the patient’s arrival.
A community-owned health system, Lakeland Health includes three hospitals, an outpatient surgery center, a regional cancer center, rehabilitation centers, two long-term care residences, home care and hospice services, and 34 affiliate physician practice locations. The Lakeland Health team’s work to improve maternal health was worthy of semifinalist status in Healthcare Informatics’ 2017 Innovator Awards Program.
Robin Sarkar, Ph.D., Lakeland Health CIO, says, “One of the underlying reasons why we choose this project is that patient safety is a number one priority at Lakeland, well above everything else. Of course, we’re interested in getting the best outcomes for patients, but right at the top is patient safety.”
Lakeland Health Innovator team: Front row: Jodi Lute, RN, Tammy Jerz, RN, Merline Abraham, RN; Back row: Cherie File, RN, Karen Yech, RN, Holly Schewe, Lynell De Wind
In the Innovator Awards submission, Sarkar wrote that the initiative to improve obstetric patient care is an example of a creative and innovative application of technology to solve a complex problem. “In this case, innovation is seen in the multi-incremental enhancements that have made impacts in patient safety and outcomes. The individual tools, may have had less significant impact, but the cumulative effect was significant,” he wrote. “The clinical team had a vision to improve the care for the obstetric patient. The IT/EHR analyst team took that vision and developed creative ways of building, modifying, and enhancing the EHR to provide the tools needed to improve the patient experience.”
According to the Lakeland Health project team, research shows that obstetric (OB) hemorrhage is one of the leading causes for maternal death, and a major contributor to maternal morbidity. Deaths from hemorrhage consistently rank as one of the most preventable causes of mortality with 70-92 percent of deaths judged avoidable. Several regulatory agencies identified the prevention of obstetrical hemorrhage as a priority to improve patient outcomes. Therefore, Lakeland Health participated with the Michigan Hospital Association (MHA) Keystone Initiative to innovatively utilize the EHR to support best practices and reduce the risks for morbidity and mortality.
Two years ago, clinical leaders began collaboratively working with IT staff and EHR analysts on efforts that included validating workflows and patient flows as well as technology system build and testing. The result, according to Tammy Jerz, R.N., Lakeland Health’s manager patient care services, outpatient, has been the development of tools to both meet and exceed clinical expectations. “These efforts stitch together multiple strings of data, process and protocols to give care providers the right information, at the right time, helping them make the right decision, to ensure perfect patient care, the first time,” she says.
Deeply involved in the project were a team of Lakeland Health nursing leaders and IT/EHR analysts, including Jerz; Cherie File, R.N., EHR senior analyst; Jodi Lute, R.N., EHR analyst; Marline Abraham, R.N., Karen Yech, R.N. and EHR managers Holly Schewe and Lynell De Wind. Sarkar also was involved as an executive IT leader.
And while this has been a technology-driven clinical initiative, Jerz says the initial step was getting buy-in from stakeholders and educating clinical staff on using the tools. “We needed to get everyone to understand the safety initiative for what it is and how we can really impact the lives of our patients and the babies that we serve. We need to get everyone to understanding what real blood loss is as well as how we can intervene much faster to prevent those stage 2 and stage 3 hemorrhages,” she says. Jerz adds, “Minutes can save lives, and we want to be ahead of the game every chance that we get.”
Jerz also notes, “We’ve been able to prove that the interventions work with the decrease in the number of units of blood that we’re giving on average.”
Clinical and IT leaders at Lakeland Health collaborated to automate and implement the following four innovative technology initiatives to manage obstetrical hemorrhage—a hemorrhage risk assessment; standardizing Pitocin administration during the third stage of labor; a quantitative blood loss (QBL) calculator; and an OB emergency narrator hemorrhage risk assessment, which is a flowsheet built in Lakeland Health’s EHR.
Sarkar notes that a critical key to this initiative has been working with Epic, Lakeland Health’s EHR vendor, to build the necessary tools within the EHR system. “It’s important to work with your EHR vendor so that they can understand your needs and help in the collaboration of developing the tools needed,” he says.
The first step was developing the hemorrhage risk assessment in the ambulatory office that crossed over to the hospital record and this entailed transitioning nurses and clinicians from using “estimated blood loss” to “qualitative blood loss” with the implementation of a calculator specific to both outpatient and inpatient settings. The previous “estimated blood loss” process was a manual task that left room for error, File says. With the quantitative blood loss (QBL) calculator now a technology tool within the EHR, Lakeland Health has eliminated that manual process and the tool has been integrated into the nurses’ workflow.
“What you see with the quantitative blood loss calculator is more consistency in the documentation, because it’s not as subjective as with an estimated blood loss,” File says.
Documentation starts in the ambulatory offices and continues through the hospital delivery. The risk assessment is a standardized tool that promotes the assessment of the risk of hemorrhage through the continuum of care during the pregnancy by calculating the risk for hemorrhage and prompting the nurse to select the appropriate blood order for the individual patient. This ensures that blood is available for those at greatest risk for hemorrhage and is cost-effective for those at lower risk, Jerz says.
The QBL calculator that was developed has been supplemented by a new OB emergency narrator, a documentation tool in the EHR that enables the end user to perform a number of tasks while viewing the specific timeline used during codes or traumas, according to Jerz. This tool enables real-time documentation, with the same features as the established trauma narrator. Lakeland’s IT/EHR analysts customized the EHR “model narrator” to improve care during postpartum hemorrhages. This narrator tools allows for more rapid administration and documentation of medications, with “one step functionality” and blood products during OB emergencies, Jerz says.
“Our physicians are able to pull the data from the OB emergency narrator into their documentation. This optimization has allowed our team to recognize risk from the mother’s prenatal experience and prepares providers for potential issues during delivery and recovery,” she says.
Additionally, as part of this initiative, the project team collaborated and revised relevant order sets to include standard Pitocin orders to ensure the medication is readily available for administration.
As part of this clinical informatics initiative, project leaders have found that process improvement reports and dashboards have been key elements for process improvement. Care providers stay informed of current patient status and quality metrics with the goal of providing safe and effective obstetrical care. Additionally, the report cards and dashboards show progress towards goals and are reviewed at monthly meetings and shared with all providers, nursing leadership, and staff.
Sarkar points out that the initiative was what he referred to as a “zero cost project.” “There was no incremental dollars from my IT budget or any clinical budget. This was just clinical partners under Tammy and her team stepping up and our EHR team working collaboratively and executing this project,” he says.
Critical to the success of this type of clinical informatics initiative, Sarkar says, is assimilating high-performance teams, both clinically and technically, as well as gaining management support for the organization’s IT initiatives. “Lakeland is fortunate to have very strong and supportive management across the organization, recognizing the efforts needed to provide perfect patient care. They are innovative, encouraging, and responsive, helping us succeed with positive outcomes and results,” Sarkar wrote in the team’s Innovator Awards submission.