Becker's Clinical Quality & Infection Control

20 Executive Briefing Sponsored by: Q uantitative blood loss measurement remains largely a subjective process in many healthcare organizations. This is an issue for many different types of patients, but it is an especially acute problem in labor and delivery. Between 2014 and 2017, postpartum hemorrhage accounted for 10.7 percent of pregnancy- related deaths. Becker's Hospital Review recently spoke with three experts about the challenges associated with quantitative blood loss measurement and opportunities for improvement: • Imana Mo Minard, MSN-Ed, RN, Director of Nursing, Emergency Center, Beaumont Farmington Hills (Mich.) • Deborah Mordecai, DNP, MS, MA, BSN, CNM, CENP, Assistant Chief Nursing Officer and Director of Patient Care Services, Women's, Infants' and Children's Division, University of Texas Medical Branch in Galveston • Lisa Spencer, MBA-NM, BSN, RNC-OB, Nurse Manager, Labor and Delivery/High Risk Obstetrics, University of Texas Medical Branch These nursing leaders shared insights about the products, processes and change management approaches their organizations have adopted to improve quantitative blood loss measurement. Solving the blood loss estimation puzzle Leading healthcare organizations have recognized quantitative blood loss measurement is a competency that needs greater attention in the clinical setting, as well as in nursing and medical schools. "My team just completed a large project on estimating blood loss in the emergency center. One of the big findings was the lack of formal training in this area," Ms. Minard said. "Clinicians, nurses, physicians and tech1s aren't formally trained on this as part of their education. Blood loss comes up in the context of different disorders and patients who need blood transfusions, but the estimating piece isn't there." In labor and delivery, early recognition of postpartum hemorrhage is critical. Two key challenges in this area are human error and the subjective assessment of blood loss. "In earlier years when I worked at the bedside, I can remember coming out of ORs or deliveries. These were procedures where patients lost blood," Dr. Mordecai said. "Many times, I'd look at an EBL that documented the patient lost 250 milliliters and I'd think it was at least 450 or 500." Teams find it both challenging and frustrating to essentially guess how much blood a patient has lost. In the emergency setting, clinicians often have to evaluate the blood on a patient's clothing or on the floor and try to determine the volume. "When we have women who present in the emergency center with heavy abnormal bleeding, whether it's from a miscarriage or issues with their menstrual cycle, we may have to transfuse," Ms. Minard said. "Once again, we are stuck, trying to figure out how many pads they filled up. It really is kind of a big puzzle. That's the best way to describe it." The journey to more accurate blood loss measurement Clinicians have turned to different visual and measurement techniques to estimate patient blood loss, such as visual aids that show blood measurement on laps and pads, graduated drapes and weighing laps and pads. For patients with a gastrointestinal bleed, teams may quantify blood loss by measuring the fluids that the nasogastric tube has suctioned into a canister. The University of Texas Medical Branch recently conducted a blood loss estimation research study on 242 women who underwent scheduled Cesarean sections. 1 The study conducted was to compare subjective estimated blood loss estimated by the surgeons to the Triton quantitative system. "We used Triton, which is a Gauss Surgical system for quantitatively measuring blood loss," Ms. Spencer said. "Clinicians used an iPad app to take pictures of laps and 4x4s. Based on the photos, the app measures the blood lost. For heavier laps, we put them in a bowl, and it weighed them. We found that the quantitative blood loss estimates correlated with post op hemoglobin. However, we do not feel that it adds to us clinically. The main reason it that we overestimate rather than underestimate blood loss. I think people want quantitative blood loss because they are worried that we underestimate blood loss, but we did not find that." If a health system introduces new approaches for quantitative blood loss measurement, change management is essential. "Weighing pads is a little different than just cleaning up the room and walking out," Dr. Mordecai said. "As we evaluate new systems, we consider their accuracy, how important they will be and how much time it will take to complete tasks." Quantitative blood loss competency — Insights from Beaumont Farmington Hills and The University of Texas Medical Branch

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