Rural Maternal Health Series: Implementing Patient Safety Bundles in Rural Hospitals

Featured Speakers

	Kristen Dillon, MD, FAAFP, Chief Medical Officer, Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services
	Christie Allen, Senior Director, Quality Improvement and Programs, American College of Obstetricians and Gynecologists (ACOG)
	Isabel Taylor, Senior Data Program Manager for AIM, American College of Obstetricians and Gynecologists (ACOG)
	Stephanie Radke, MD, MPH, Clinical Associate Professor of Obstetrics and Gynecology at the University of Iowa and Director of the Iowa Maternal Quality Care Collaborative and the Iowa AIM Program
	Ashley Tangen, Nurse OB Lead at Gundersen Palmer Hospital in West Union, Iowa

Standardizing clinical care is a foundational element of improving safety and quality in healthcare. The AIM bundles, developed by the Alliance for Innovation on Maternal Health, are a set of processes that hospitals can implement to make complex care and teamwork more effective. In a presentation especially relevant for hospital leaders who want to move forward in this work but don't know where to start, speakers will address examples specific to rural and small hospitals, acknowledging the limited staffing and other constraints that these facilities often face.

Additional Resources

• SaferBirth.org

From This Webinar

• PowerPoint Handout
• Listen to or download an audio version [MP3]

Transcript

Kristine Sande: I'm Kristen Sande and I'm the program director of the Rural Health Information Hub, and I'd like to welcome you to today's webinar. This is the third in a four-part series that we've been hosting in collaboration with the Federal Office of Rural Health Policy on Rural Maternal Health. And today's webinar will focus on implementing patient safety bundles in rural hospitals. With that, I will turn it over to my co-host from the Federal Office of Rural Health Policy, Kristen Dillon.

Kristen Dillon: So hello, thank you so much for joining us today. My name's Kristen Dillon and I'm the Chief Medical Officer for the Federal Officer of Rural Health Policy. We can tell from the over a thousand of you who've registered for one or more of these webinars that there is a strong commitment across our country to transform our rural healthcare system for safer, higher quality care and better outcomes across pregnancy, birth, postpartum, and the newborn period. I want to thank today's speakers as well as my colleagues from within the US federal government's Department of Health and Human Services, and also our partners at the Rural Health Information Hub for contributing to this series.

Here at the Federal Office of Rural Health Policy we have a role in improving health and healthcare for the one in five Americans who live in rural areas. So many of us are watching with alarm as the landscape for maternity care in rural communities changes. Based on recent CDC data, the rates of maternal death have risen over the past 30 years and death rates as of 2019 were highest in rural communities and small towns. In these places, the risk of death was nearly double that of the lowest risk group, which was residents of suburban communities. This happens in a context where many rural birth units are closing impairing access to optimal care. It's for this reason that the fourth installment in our series, in two weeks on April 23rd, will focus on strategies for hospitals that do not have birth units, how they can define and train to a scope of care that will optimize outcomes for pregnant, birthing, and postpartum patients who arrive for care.

From our office, we see the many struggles that rural hospitals and healthcare providers face; finances, workforce, technology, extreme weather events, changing demographics, we understand. That's why we're so grateful that among all the things competing for your time and attention, you've chosen to join us here today to learn, and we hope, to improve and demonstrate your capacity to provide maternity care that's high quality, safe, and patient-centered. I'm a practicing family physician. For nearly 20 years, I provided obstetrical care in critical access hospitals, and I've seen the wonderful promise of close to home family-centered birthing services at such an important life transition. I've also experienced caring for patients during harrowing, obstetrical and neonatal emergencies, many of which could not have been anticipated. I've seen the life-saving potential of identifying complications early, preparing and practicing and bringing consistency to our care processes whenever possible, as well as learning to work as a team.

That's why we decided to focus the first three webinars in our maternity care series on the new CMS measure for birthing-friendly hospitals. It evaluates hospitals on foundational competencies, learning collaboratively across a peer group, and standardizing care processes. The second is what we'll focus on today. These are not check the box activities. Doing the work to meet this measure will help your staff do a better job and help your patients have confidence in the care you provide. They may take substantial work, but it's the work we need to be doing to improve outcomes for birthing people and babies in our country. And with that, it's my pleasure to introduce our speakers for today's webinar.

Christie Allen is the Senior Director of Quality Improvement and Programs at the American College of Obstetricians and Gynecologists and provides clinical support to and supervision of national patient safety and quality improvement efforts for people who seek obstetric and gynecologic care. A nurse by background, Ms. Allen has worked in obstetrics, neonatology, and quality improvement for over 25 years and holds a degree in health policy. Ms. Allen has also served as the project director of AIM since 2019.

Isabel Taylor is the senior data program manager for AIM at ACOG and leads the program's data and evaluation team. She's responsible for the overall development and management of AIM's data program to support data-driven quality improvement reporting and system learning. Additionally, she supervises or directly contributes to various other AIM program functions such as program operations, communications, and resource development.

Stephanie Radke is Clinical Associate Professor of Obstetrics and Gynecology at the University of Iowa, where she's also the Director of Patient Safety and Quality Improvement for Obstetrics. She's an expert on quality improvement methods and trained as an improvement advisor by the Institute for Healthcare Improvement. She has an active role in improving the quality and safety of obstetrical care in the state of Iowa as the co-chair of Iowa's Maternal Mortality Review committee, the director of the Iowa Maternity Quality Care Collaborative and the Iowa AIM Program. Through these roles, she applies population health outcomes to support Iowa's 56 maternity hospitals in targeted improvement strategies to make birth safer for Iowans.

Ashley Tangen is the Nurse OB lead at Gunderson Palmer Hospital in West Union, Iowa. One of Ashley's biggest passions is supporting, growing, and improving maternal newborn healthcare in rural facilities. And with that, I'll turn it over to our first speaker, Christie Allen.

Christie Allen: Thank you so much, Dr. Dillon. It's a pleasure to be here with all of you today. We really appreciate the opportunity to talk about the work, and I really appreciate my co-hosts joining, particularly from Iowa to talk about what that looks like on the ground. So I'm going to talk a little bit about what AIM is. It's an interesting conundrum that sometimes I talk to people who are explaining the program to me and the work that AIM does, and it's not my understanding of it, which seems problematic. So as we always want to do with quality improvement, we're going to start with what we call a shared mental model. So I'm going to talk folks through, for some of you, this might be new information and for some of you it's not new at all, but I'm hoping there will still be pieces you can glean.

Next slide please. So a couple objectives. We love objectives in quality. Understanding the background and purpose of the AIM TA Center, that's the Technical Assistance Center. That is a little bit of shift in how we talk about aim that I'll talk about more in a moment. We're going to discuss how evidence-informed patient safety bundles are defined and developed. And then we're going to discuss in data and how to move through an AIM data process for quality improvement or QI in patient safety bundle implementation. So the little bit about AIM itself, the Alliance for Innovation and Maternal Health is funded through a cooperative agreement between ACOG and the Health Resources and Services Administration's Maternal Child Health Bureau. So we call that HRSA and the MCHB. We're incredibly fortunate to be in an agreement with them where we have shared goals and make plans together on how to reach them.

We develop, at the TA Center, resources, fund projects, and provide a variety of technical assistance for people that are implementing the AIM patient safety bundles. Implementing is a little bit of a vague term. We'll talk more about what that means, but that means working to do the quality improvement on the ground. And then this cycle of AIM is funded from September of 2023 through August of 2027. So our main goal, always want to know what that is and have a shared understanding, we provide comprehensive, high impact technical assistance to anybody implementing AIM. So our goal is always that assistance isn't necessarily checking the box, as Dr. Dillon mentioned, or a prescribed way of giving care. But our goal is always just to make birth safer, improve maternal health outcomes and to save lives. And what that means on the ground can look really different in rural facilities versus academic, larger urban facilities. And there's also a lot of shared complexity in those spaces.

So just historically, for those of you that are familiar or less familiar with the AIM program, AIM first came about in 2014 when HRSA awarded that to ACOG and it was supposed to be a little bit of a pilot program. The round was to actually enroll just a few states. These were states that they knew had higher rates of maternal mortality and morbidity and just to make sure we're all on the same page, mortality is a pretty obvious definition. Morbidity or severe maternal morbidity, SMM, is a little bit different. That is lifelong impacts of harm that occurs during the birth process or after related to the perinatal period. And there's some really complex definitions about that that you can hear, folks in the data world argue about, but basically it means harm during or around the birth process and also in the postpartum, which is really important to know as I move through this and talk a little bit about the patient safety bundles.

So the program between 2018 and 2021 blossomed, a lot of folks committed to the work. We began to revise some of the original patient safety bundles because as you can imagine, between 2014 and 2021 things changed and we learned and then we started moving towards more of a technical assistance model. We no longer needed to just tell people what bundles were, we needed to tell them how to use them and provide folks with stuff that they may not have on the ground. Whether it's a clinical site or a public health site, we know resources are thin and scarce. And so our goal is always to provide free resources, technical assistance and learning in a variety of ways that help people do their job better and safer. Whether they have the resources immediately available to them or not, they can access them hopefully through the AIM TA Center.

So as you can see, we continued that technical assistance and then by the time the award was re-awarded in 2023, HRSA also recognized that that was our primary role. And you can see we move towards videos and webinars and we'll talk more about all those resources, but that's sort of the trajectory and the evolution and growth of AIM. I'm incredibly fortunate enough to have joined in 2019 and helped the program grow. And I'm very grateful to the folks that got us started, both at HRSA and at ACOG, and more broadly. So we have some desired outcomes, goals, objectives that we've agreed upon with our funder, and these are the primary ones. I just talked a little bit about technical assistance that we provide.

Another goal we have is birthing facility engagement. So typically hospitals, sometimes free-standing birth centers. We're very interested in increasing the number of folks participating. We want more folks to have access to the pieces they need to make birth safer and to make care more seamless. And part of that is engaging with folks. Bundle implementation, so we want folks to not only do all the bundles or more of the bundles, but we want them to be able to sustain them as they implement them. It's not the point of a bundle to just do it and be done, it's to integrate things into practice. And we'll talk a little more about that. And then just providing support. What we learn, more and more, is that folks on the ground are best poised to identify what they need help with as they move into that space, whether it's respectful and equitable care, whether it's resources around hemorrhage measurement or other pieces, we sometimes can glean from all of you and the folks providing that care on the ground and build resources that are appropriate to help address needs.

And then data, data is critical and you're going to hear a little bit from my colleague about that, but the goal is to provide TA because the number one ask we get is for technical assistance around data. And this is not population health data or big overarching data, this is the data that is used for quality improvement so you can know how you're doing so you can do better, and that's what we all need to be successful.

So where does AIM fit into the broader landscape? That's a frequent question and it can be really confusing. AIM is not meant to be a standalone entity. It takes people to implement AIM, it takes to support AIM, and it takes people to direct what kind of work AIM is being used for.

So you can see here I've listed a few, there's lots of acronyms. We do love acronyms in healthcare, but MMRCs are Maternal Mortality Review Committees. These are committees that prioritize statewide prevention after reviewing any kind of maternal mortality case in their state or region. The role that they have and that they kind of contribute to AIM is letting us know which bundles and which clinical conditions need to be addressed at a state or regional level. We don't want people just randomly implementing things, we want to know what's going to address the drivers of morbidity and mortality in their state.

The other is state quality improvement team. Sometimes these are what you hear called PQCs or Perinatal Quality Collaboratives and sometimes they're not that we work with, we'll work with any comers including facilities. We just want to help folks and provide those needed supports. But so you see this, we work like cogs. AIM is a tool that uses are identified by the MMRC and then the state quality and teams work with the hospitals to implement those bundles.

So we can't do it alone. Obviously, I've already talked about the commitment and the folks on the ground doing the work, but we also work with the Clinical and Community Advisory Group through AIM. These are folks that have experience, input, and support our bundle implementation processes. Sometimes it's reviewing documents, sometimes it's building documents, sometimes it's giving us a subject matter expert to talk. And sometimes I need consensus. So what do we think about this? And having that expert weigh in really helps. So as you can see, there are a lot of professional member organizations, the folks who really touch folks through their care during birth and beyond. So anesthesia, nurse midwives, family medicine providers, some physician associates, nurse practitioners, emergency nurses.

We're casting as broad a net as we can because we want to make sure that the folks that might encounter patients and need the care are giving input on how we can do that effectively and efficiently. And then you see AMCHP and National Healthy Start also help support more of a community focus and they represent a broad landscape mostly, and we try to get input from those folks on things and directions, which is incredibly helpful.

So patient safety bundles, you've heard me talking about these. We're going to talk a little bit about what they are and what they mean. So patient safety bundles are a structured way to think about improving processes of care and patient outcomes. The goal of a bundle is not to tell someone how to treat a clinical condition. I'm not going to tell you exactly how to use your clinical judgment as a clinician at the bedside to treat hypertension, but it's putting the systems and structures in place so that we are ready to do that, so that we are able to do that and we can evaluate the kind of care that is provided. So these are collections of evidence-informed best practices and they're developed, as I mentioned, by multidisciplinary experts including people with lived expertise and experience who've experienced the clinical conditions or been impacted by them. And the goal is to address really specific clinical conditions that we know cause harm in pregnant and postpartum people.

So as I mentioned, we use a couple of components to develop these bundles. They have to be impacted by a few factors. Expert consensus is helpful, but we really also need them to be evidence-informed. We need to know that what we're doing has backup behind what we're doing. And then also, the specific clinical conditions. And you can see these are our icons we use to represent each bundle and you'll get some clarity on what they are in just a moment.

So I use a term that might be less familiar to people, evidence-informed. We hear evidence-based a lot in healthcare, which is incredibly important. But we also know that evidence-based can be somewhat limiting because there's certain things that we would not actively withhold from care that are kind of common sense, make sense, and I sort of joked in the past about evidence-based practice and practice-based evidence. Anyone who's been in healthcare for a variety of years knows that sometimes you need to know things that also enrich the previous research and don't limit it.

So as you can see, it's research, it's lived expertise, patients telling us what they need, what they don't need, what was helpful, what caused harm, and then, clinical expertise. You have these experts who've been providing this care for many, many years in an evidence-informed way, and they also weigh in and give some of that input. So we try to take a holistic approach in the development of the patient safety bundles. And the goal of the patient safety bundles is not to give one type of care to everyone, it's to provide high quality of care that can be adapted to meet the needs of everyone. I want to be really clear about that. It isn't that we treat everyone the same, as you may hear some people say, is that we're providing high quality care to meet people where they're at with the clinical conditions they're experiencing.

So as I mentioned, the multidisciplinary experts, there's a lot of them. We joke that it's herding cats, but we want everybody to have a voice on what's happening. And then after we develop a patient safety bundle with a working group and a data collection plan, which we'll hear a little bit more about from Izzy Taylor, they're reviewed by a wide range of relevant organizations and individuals. Sometimes it's folks that are actually implementing on the ground and have been over time as we revise a bundle, sometimes patient organizations, advocacy organizations, for instance the American Heart Association, when we worked on a cardiac conditions bundle. We want to make sure that we're hitting the points not just in our own limited scope or the scope of obstetrics, we want it to be applicable across the care continuum because we recognize that's when harm can occur, not just at a delivery hospitalization.

So these are the clinical conditions the bundles address, obstetric hemorrhage, severe hypertension in pregnancy. I think those are pretty expected. One is safe reduction of primary cesarean birth. The goal is not because we think cesareans are a terrible thing, but we also want to make sure that we reduce them safely from a primary perspective, which I think Dr. Radke will speak a little more about later. And some of these do cover a time period around a clinical condition. Also care of pregnant and postpartum people with substance use disorder, this was formerly known as an opioid use disorder bundle, excuse me. And we brought in that with feedback from the field, recognizing that folks need a particular kind of care across the care continuum during pregnancy. And then perinatal mental health conditions, postpartum discharge transition, this is that critical period of discharge where folks can sort of slip through a safety net or not have appropriate follow-up. This is to address that. Cardiac conditions in obstetric care and then sepsis in obstetric care.

So some expected, some maybe less expected for all of you that are listening, but these are the drivers that have been identified by both HRSA and the broader community of care that we've created bundles for.

So there's five Rs in patient safety bundles. We use a five R framework. And so you'll hear people sometimes talk about the five Rs. These are the five Rs. So readiness, being ready to address a clinical condition should it present. Those can be things like hemorrhage carts or medications on hand, education of clinicians, recognition and prevention. How do we know that the thing is happening or prevent it in the first place? That's always the goal. Response. How do we respond? Do you have an OB emergency team set up? Do you have the transport stuff arranged that you might need to move someone to a higher level of care or where their needs can be better met?

Reporting and systems learning is how did we measure and evaluate what we did and did it work? We never want to just do something to do it. We want to be sure that it is effective in meeting our goals. And then finally, respectful, equitable, and supportive care. And so you can see that one's a little bit bigger and it has an arrow that moves back through the other Rs. The goal is not that we only address respectful, equitable, and supportive care for all people in one R. It should be woven through all of the other Rs things like desegregation of data you're collection by race and ethnicity so that we do know that our outcomes are aligning and we're closing the disparity gap that may present. Things like training, making sure that as we train our clinicians, they're receiving also culturally humble and responsive care principles for the folks that they're going to serve. Things along those lines. But that fifth R calls out specifically elements around respectable, equitable, and supportive care.

So with that, that was sort of the rapid assessment and background on sort of the AIM bundles and the structure of AIM. And now, I'm going to have my colleague, Izzy Taylor is going to come on and talk to you a little bit about resources that support those patient safety bundles that I was referencing earlier.

Isabel Taylor: Yes, our bundles are often described as rich and to help support bundle implementation on the ground over the past several years, really starting in 2021, as Christie was describing, we've expanded our host of resources to help support bundle implementation on the ground for hospitals and facilities of different resource levels. So all of our resources are housed on the AIM website, www.saferbirth.org, and on the AIM Vimeo channel, which is vimeo.com/AIMprogram. All of our resources are open source and freely available to anyone who wants to use them. And they are multimodal, so they are patient safety bundle specific or they support implementation of core patient safety bundle concepts.

So for each patient safety bundle, we have a standard set of resources. We have element implementation details. So these go a little bit deeper into a little bit more context or the why behind certain elements. It might explain what we mean by a specific bundle element so that you can have more details about what it means to implement a patient safety bundle. We also have implementation resources. These are journal articles, guides, and practical resources that are available to help support patient safety bundle implementation. It's just a PDF listing. We have a data collection plan, which I will describe a little bit more in the next slide. We have an implementation webinar, which is on our Vimeo channel. This is where we have subject matter experts who contributed to the development or revision of our patient safety bundles, talk a little bit more in detail about why or how the bundle was developed or revised, as well as give additional context and rationale for different bundle elements that we think are key to implementation.

We have a change package. These are also great for figuring out where to get started with patient safety bundle implementation. We developed these in partnership with the Institute for Healthcare Improvement, and each of our patient safety bundles and their associated elements have change concepts and ideas to help you brainstorm where to get started with rapid cycle quality improvement in your facility. We have an introductory video, which is a quick three to five-minute overarching video that describes key concepts from the patient safety bundle. This is great for introducing patient safety bundles to others in your facility, for helping with change management, for presenting bundle implementation to leadership, et cetera. And then we have a learning module which provides a very comprehensive overview of each of the patient safety bundle elements there, as well as quality improvement strategies for each of these patient safety bundles. And we have continuing education coming soon for the learning modules so that we can make sure that people on the ground have the resources they need.

And we also have data collection plans, these are often something we get a lot of questions about. They consist primarily of process structure and outcome measures. Process measures are referring to what you're doing on the ground to improve a process of care. It could be timely treatment of persistent severe hypertension. It could be doing chart reviews after instances of sepsis, et cetera. We also measure structures, so whether you have a hemorrhage cart, whether you have policies and procedures in place. And then, if you're working with a state team or a perinatal quality collaborative, you'll receive outcome measures from them so that you can receive your severe maternal morbidity rates and things like that. And all of these AIM data collection plans are meant to help with quality improvement. As Christie mentioned, it's not for research or for formal assessment. It's truly to help you on the ground, improve your processes of care.

And we also have plenty of supports and resources for data collection plans that we can go further into in the question and answer sessions. And with that, you can go to our website for all of these resources and I will hand it over to Dr. Stephanie Radke to talk about her experience implementing AIM in Iowa.

Stephanie Radke: Hi everybody. As said, I'm Stephanie Radke. I am a practicing OB-GYN at the University of Iowa. For anybody who follows women's basketball, our state has gotten a lot of attention recently, all in great ways. Probably that attention is going to fade away here pretty quickly. But Iowa joined the AIM program in, I think, the October of 2020 cohort. So we have been at this for a few years. And Iowa, as I'll get into, is a very rural state with a lot of low volume facilities. And so we've had a little bit of a different journey with AIM in adapting some of the content to fit the needs of our facilities. So just an acknowledgement in addition to AIM being funded through HRSA, here in Iowa, our work is funded also through HRSA in the Maternal Child Health Bureau through a state maternal health innovation award. We're very appreciative of that.

So a little bit about Iowa. We are quite rural. The total population of our state is about 3.2 million people. We have under 35,000 births annually, and we actually have 56 hospitals that have labor and delivery units. As you can imagine when you start thinking about dividing births among that many hospitals, that means we have a lot of facilities that are very low volume. We have 10 hospitals that deliver each over a thousand babies annually and would be considered more sizable hospitals on the national scope and over half the births in our state occur in those 10 facilities. But essentially, the other half of the births occur in the other 46 hospitals, and that includes 11% of births in our state occurring in facilities that deliver individually 250 babies or fewer per year, and 25 of our hospitals fall in that category.

We really wanted in Iowa to make AIM for everyone. We didn't want AIM to just be for big facilities that were maybe used to doing quality improvement. We really wanted it to be for everybody, and we also felt like it needed to be for everybody. We couldn't just focus on our big hospitals because we would be missing half of the births in the state and the vast majority of our facilities would be excluded from the program. So we really ambitiously struck to enroll everybody. And we are in our third initiative with AIM. Our first initiative was safe production of primary cesarean birth. 43 of our hospitals participated in that initiative. Our second initiative was obstetric hemorrhage, and that's when we got all 56 hospitals to work with us, and they are still working with us for severe hypertension.

So a little bit more about Iowa. So despite having all those hospitals, we actually have quite a few maternity deserts, as do most rural states. So March of Dimes would classify 33 of Iowa's 99 counties as maternity care deserts, meaning that there is no hospital or birthing center and no provider of perinatal care in the community. We have a lot of counties in Iowa. And so we also like to look at actual travel time. We're due to update this map because it was done when we had more hospitals back in 2019. But you can see here, we, in one year mapped the actual driving distance between somebody's home address and the hospital where they gave birth. And you can see many areas kind of around the white triangles, which are hospitals, people are traveling less than 30 minutes and that's great.

And then you kind of get a little further out and people are maybe traveling up to an hour to give birth, which may be okay and maybe not ideal, but not the end of the world. But then the yellow and then the small pockets of orange that we have are places where people are traveling more than an hour or more than 90 minutes to get to a hospital to give birth to their baby. And so we recognize, particularly in the southern part of our state, we do have areas where people have to travel a very long way. And since we created this map in 2019, we've had eight additional hospitals close their labor and delivery units. And so I think we are planning to redo this with our 2023 birth data to see what the landscape is looking like today. I certainly don't expect it's going to look better, but it'll be good to be aware of where our geographic deserts are.

So there's a lot of benefits of AIM for rural facilities. I think that we felt a little bit like we kind of had to sell the program a little bit to some of these small hospitals because I think it can sound a little bit intimidating in a small facility to think about participating in something like this and it can lead people to maybe feel like it's not really for them. Some of the challenges that we see in rural facilities, we actually feel like AIM can really support. So one of the first things, and I'm assuming many of the people on this call practice or work in small facilities. And so we know that providers and nurses working in these areas have a really broad scope of practice. You're not only working on a labor and delivery unit as a nurse, you probably work in every unit of the facility. A lot of the providers are family medicine physicians who are truly jack-of-all-trades type providers. But that can also make it challenging to maintain a really strong depth of knowledge in any one area when you're having to cover so many different things.

So I think if you click, I think I have these animated, so I think that it can help to have a really concise list of best practices and help people know what to focus on rather than feeling like they need to educate themselves. Starting with primary literature, AIM has done the work for you in bringing the content together. We've also observed that many small facilities really don't have big quality departments. They usually have somebody who's taking care of their reporting to whatever their regulatory body is, but they probably don't have a unit level quality team. They may not even have unit level leadership beyond the nurse manager, let alone having somebody who is serving in a robust medical director role or directing quality for the unit. So if you click again, so participating and working on these initiatives within that state level collaborative can really help the leaders that are there, the people like Ashley, who you're going to hear from, who are the nurse managers, to have the support they need to implement the practices. And that support, again, isn't always available at the facility level.

And then the last thing is that we've observed that in small facilities, people are busy everywhere, but in small facilities, I've been incredibly humbled to see how much people are doing. Most of our nurse managers in our small hospitals would describe themselves as working managers, meaning that their full-time job is not to be the nurse manager of the unit, that they actually spend the majority of their time in clinical staffing and they have a small amount of time, when they're able to take it, when to do all the duties of leading the unit from a nursing perspective. And so it doesn't leave a lot of hours in the day or night in order to get projects done, to revise policies, to run simulations, to educate their teams. They have very little time. And if you click once more, so again, connecting these folks to peers around the state can be, I think, both emotionally uplifting, but then also allow people to share resources and reduce the amount of work that it is to change practice.

I wouldn't say that we had to heavily adapt AIM content to fit rural facilities, I think probably a little bit more of adapting, for the most part, really, the approach. But there are some areas where clinical content in the bundles that we've worked on, especially safe reduction of primary C-section required some thoughts about what does it look like when you're trying to allow labor to progress for a little bit longer in a facility where your resources necessary to perform a cesarean are not in-house, your anesthesia team is not in-house. Maybe your surgeon who comes in to do the C-section is not in-house. And so thinking about some of the algorithms and tools and adapting them to those situations. Also, particularly with safe production of C-section, we really encourage small facilities to simulate emergency C-section so they really understood how long it took to get a patient ready to have a C-section in their facility. Because again, it might be a little bit different than a hospital where everybody's in-house and ready to go and you may need to make that decision a little bit sooner.

In the measures area, Izzy was talking about the measures. There are some instances where we've kind of had to adapt a little bit and kind of broaden criteria in some of the measures in order to allow small volume facilities to have enough to talk about and enough to look at when they're looking at their cases, working on safe reduction of primary C-section where you're looking at first cesareans in nulliparous term individuals, as Ashley may remember, that's not something where a small facility has 25 of those cases in a month. And so you need to look at things quarterly or maybe you need to look at other primary C-sections. And so just some little tweak.

And then our implementation approach, we actually really had to flip. We promote the IHI model for improvement largely in Iowa unless the facility has another model that they robustly use. And that is all about testing things at small scale and then growing towards implementation and kind of a natural progression of larger and larger tests. And what we realized is that this is a place where small facilities are really nimble. It's not that hard to educate everybody when you have 10 nurses that work on your unit and three providers. And so it actually can offer an advantage over a large facility where it's an enormous undertaking to educate your entire staff on a change in practice. So definitely pivoted how we encourage facilities to approach change to really lean into the strengths.

How we recruited people, I think one of our big things was really just a message that AIM is for you. AIM is for every hospital in this country. It's for birth centers. We are starting in Iowa to work with midwives in our state that provide birth in the home environment or in birthing centers. And again, kind of going through rounds of adapting the content to align it to their situation. We really put our money where our mouth is. We hired a nurse to work as an improvement coach who has only worked in the critical access hospitals. Her name is Crystal. She has over 25 years of experience in critical access hospitals. She rides with EMS in her county, so she really understands what it's like in a small facility and has really helped educate the rest of our leadership team to make sure that we are appropriate in our expectations for small facilities.

I've mentioned some of the changes that we've made and slightly tweaking some of the content, but the last thing I'll mention is that we have these nurse improvement coaches that work with facilities one-on-one, and I think that's really helped us with engagement so that people feel like they're really connecting with an individual person within our program rather than just only participating in the context of a webinar or a larger group session. And I am now really, really pleased to turn things over to Ashley, who is one of our nurse managers at a very small hospital in Iowa and was so happy to share a perspective from her facility in working with us here in Iowa.

Ashley Tangen: Hi. Thank you, Dr. Radke. I appreciate being here today and being able to share our story. So as I said, my name is Ashley. I am the OB lead here at Gunderson Palmer Hospital in West Union, Iowa. Just a little bit of background on us, we deliver under a hundred babies a year and we have now participated in AIM for about three years, I would say and I am here to tell our story. So where my story starts, where our story starts with a couple patient experiences. I was one day back here on my labor and delivery unit and I received a phone call from a patient. She was at work. She said she had bent over, extreme abdominal pain and she immediately noticed the bleeding. I said, you need to call an ambulance. You need to hang up your phone and get to the hospital as soon as possible.

I took this opportunity to, of course, call our OB provider, called all the on-call staff, because just as previously stated before me, response time for some of these staff can be up to 30 minutes. And on this day, our surgeon was not in-house, so our surgeon needed to get to us. So I took a few of my nurses that were in-house and we met this patient at the front of our hospital with a wheelchair. When she came, when she got to us, we immediately noticed that, of course, her pants were saturated with blood, there was blood all over the front seat of the vehicle, and we got her back to our labor and delivery unit and we immediately started prepping her for C-section. Our OB provider was already at the bedside, we were very fortunate. And as we're doing all these things, we're doing our best to educate the patient and spouse along the way.

We did get this patient to surgery, delivery within 47 minutes, which at our facility in a small rural hospital with all those moving parts, we're very proud of that time. Mom and baby did well in this situation and our QBL that we were able to measure was just over 1200. But of course, we couldn't account for what was already in her clothing and in the car seat. And then just a mere two days later, we had a mom that was a G1P0. This was a side effect to Pitocin induction. This induction was taking a little longer, but as we learned how to do our PPH risk assessments, we learned that her risk was getting higher and higher for hemorrhage. So we made sure that this mom had multiple IVs in place. We made sure that everyone was on the same page with having the medication, postpartum hemorrhage medications at the bedside. We made sure that we had the hemorrhage cart in the room, prepared for delivery.

And then upon delivery, this mom had lost over 1500 mLs of blood within a matter of minutes, and we've managed hemorrhages before, of course, but we've never seen one happen this fast. And of course, we did all the things, she already had IV Pitocin running. We did the Methergine, Hemabate, TXA. Our provider checked for retained products. We did the bimanual massage, checked for lacerations that needed to be sutured. This mom got fluids, blood products, and by the end of it, we needed to use the Jada. The Jada is what eventually was the key to stopping this mom's hemorrhage. But until that happened, there was still 300 more mLs of blood that was in a suction canister from the Jada. Both of these patient situations, we were able to stabilize and keep at our facility.

So let me tell you how we improved our care to be able to take care of these patients. GPLHC has participated in the safe reduction of primary cesarean bundle. This taught us how to prepare for emergency C-sections and how to get it done quicker. We are very proud of being able to cut at least 30 minutes off of our average time. We've participated in a postpartum hemorrhage bundle where we acquired new information and got new equipment. We've updated our practices and learned how to get our uterine tonics to the bedside. We are currently participating in the hypertension bundle, so we are in the process of updating our SOPs, policies, and educating our nurses. We have implemented simulation at our hospital, which has been groundbreaking for us. This is a way that we've been updating lots of our practices.

So this my advice to other rural facilities. After making all these changes and taking care of these moms, and I happened to be involved in both of these situations. By the end of the night after taking care of our second obstetrical emergency within two days, I went home and I cried. I cried because I was so proud of the changes we made that we were able to save these patients. In that moment, I emailed my AIM coach, Crystal, who passed on my message to the rest of the AIM team. I said, "I am so thankful for the education that we received from you because we were able to take care of these moms. Because of what we learned, my team worked like a well-oiled machine because of the simulations. OB and surgery were on the same page. We were able to learn how to get medication to the bedside, work through different processes, get hemorrhage cart to the bedside so that no nurse had to ever leave the patient bedside." So please join AIM, be the most up-to-date you can be and save lives. Thank you.

Kristine Sande: This is a question for Dr. Radke. Can you speak about the challenges of implementing AIM in the context of staff turnover or high prevalence of traveler nurses, which we know are common issues at rural hospitals?

Stephanie Radke: Yeah, and I think there are common issues everywhere. Before I answer that, I just want to once again, thank Ashley for sharing her story. I think Crystal, her coach is on this and she just texted me that she's tearing up. I was tearing up, I don't know about you, Christie, but this is what we want to happen in every hospital. We want everybody to be prepared. So yeah, I think that what we've talked to people about specifically with traveler nurses, and again, for really facilities of all sizes is you do still onboard your travelers. And so thinking about can you compress down what are some of the critical things that they need to know about your practices as travelers so that when they do orient, they're familiar with that.

A space that we've been thinking about getting into, especially if we continue to see such high use of travelers, is actually working with some of the agencies in our state and providing education to them because we've really been working with hospitals. And again, while the bundles aren't so prescriptive that everybody's doing everything exactly the same, the idea is that there is a lot of similarity in how people are providing care in different facilities. And so thinking about maybe even educating the agency nurses so that they are expecting at whatever hospital in Iowa they go to when they admit somebody they need to do a hemorrhage risk assessment and that most people should be quantifying blood loss, not estimating. And so these things are kind of expected. In our state people, we have a reasonable portion of our travelers who are kind of just traveling around the state. And so we're starting to see that where people are traveling between facilities and they're familiar with some of these practices though.

Christie Allen: Just to piggyback briefly, we've been asked this so often that there is a Bundles at the Bedside video on the opening page of the AIM website, it's specifically geared towards folks who are coming into a unit. So like students, travel contract nurses, which I was for five years, so I get that. And then we have the learning modules as well that are free and available. So that's another quick way, but I'm taking notes as Dr. Radke is speaking about other things we might need to develop.

Kristine Sande: Thank you. There are a couple of questions about how to get involved with AIM. What are the steps for a facility to get information and about costs and other things needed to get involved.

Christie Allen: Most facilities that are implementing work with a state quality improvement team. So typically you are a perinatal quality collaborative in your state. That said, if you're not sure how to get involved, there is no cost typically to working with AIM. And that might be individualized by the state, but using our resources or that work is not an issue. The one thing I would recommend is actually you can reach out to AIM at acog.org or via our website, and we're happy to connect you with the TA specialist who works with your state that your facility or your health system is in, and we can make sure to get you connected with the team who's leading the work so that you're fully integrated and not just needing to do it by yourself. I think you heard them speaking about the importance of that integration, and we would want to make sure we help facilitate that for you.

Kristine Sande: Here's a question for anyone. What types of providers do you see in the smallest hospitals involved with AIM? Is it family medicine, OBGYN? And if family medicine OB, how do you handle the surgical complications if an OBGYN isn't available, are there educational tools and approaches for that?

Stephanie Radke: I can answer that. The majority of small hospitals in Iowa are staffed by family physicians, not OBGYNs. We have a handful that do employ OBGYNs, but for many reasons that I'm sure all the rural folks on the call are aware, it's, I think, generally more practical to have family physicians working in small communities. Some of the family physicians in Iowa have surgical training. Some have either received it in their residency or they've completed an obstetric fellowship for one year so they can perform cesareans, in which case they really function very similar to an OBGYN. They can usually perform D&Cs. In other facilities, general surgery is the backup for the family physicians and they perform C-sections and attend to other surgical emergencies. So they're part of the team. If whoever is performing C-sections or responding to emergencies in the facilities should really be considered as part of the team to include in the implementation, whatever the bundle is. Safe production or primary C-section, if somebody's just coming in to do the C-sections, there's maybe a little less for them. But hemorrhage, for sure, is one where whoever is performing the delivery really needs to be prepared for the process and so would be encouraged to participate.

Kristine Sande: All right, so next question is who is paying for your trained nurse who is going to the rural hospitals?

Stephanie Radke: For us here, that is grant funded. So HRSA is paying for that person currently, and we hope will continue if we're successful with future applications. But I do think money is often what makes the world go round. But particularly for our small hospitals, I think it's extremely helpful to have this. So in speaking to other states who are looking to engage rural facilities, this is often something that I recommend is thinking about having somebody who can work with them a little bit more one-on-one who really comes from their community. I probably could not effectively coach a small facility because I haven't ever practiced in one.

Kristine Sande: Next question is, are the patients followed up after discharge?

Christie Allen: I am not sure if that's directed after experiencing a hemorrhage specifically or patients that receive care that might be related to an AIM bundle in general. But I will tell you that the fundamental pieces of the AIM bundles are really focused on the continuum of care. For instance, the hypertension bundle talks about scheduling follow-up appointments prior to discharge from the hospital or within three days. And I have to tell you that, quite frankly, as someone who practiced at critical access hospitals as well, I think some of the strengths is that community-centered care that allows patients to receive follow-up in a safety net way. I know some of the small hospitals I worked with in Vermont, which was where I practiced as a nurse, actually had a program where folks would come back after two days for all their patients. Because of the volume they had, they were able to see patients in a follow-up way that was more effective.

That said, it's fundamental to all of the bundles that folks receive that follow-up care. And debriefing, frankly, to talk about the experience of what went on with their bodies, what might be related to next pregnancies, any questions they might have, because we all know that those make an impact on the providers and on the patients.

Kristine Sande: Has the perinatal mental health bundle been implemented previously? And if so, how has that worked?

Christie Allen: I would say components of it have been implemented previously. There was a maternal mental health bundle that was created by the Council for Patient Safety and Women's Healthcare years ago. It didn't have a metric combined with it. So the short version is that we revised it and released it in the last few years. It is being implemented now. I think elements of it have been implemented though for many years, and the experts who recommend them are folks that are very engaged in that work nationally. So the methodologies they recommend do work, but it is complex. I process all the care continuums and it is a lifetime chronic condition for some folks, not only perinatal. So like all chronic conditions, we want to make sure we're working with all the different kinds of providers to meet the needs. And so that's where the complexity is going to be.

Kristine Sande: And then this question is there any benefit to implementing AIM bundles for OB emergencies in the ED at non-delivery rural hospitals?

Stephanie Radke: This is such a great question. And yeah, this is something we have worked on in Iowa. We have our 56 hospitals that have labor and delivery units, but we have 64 other hospitals in our state that don't have labor and delivery units. And especially in a rural state, as probably the person asking the question is thinking about, we know that, especially if you're in a maternity desert, that people may show up to a hospital that doesn't have obstetrical staff having an emergency. Maybe they're going to have their baby or maybe they're having a complication. And so we've really recognized here, and I think other rural states have as well, that those folks need to know how to recognize an obstetrical problem. They need to understand the hypertension values, what would define severe hypertension is different in a pregnant population, what to do if someone precipitously delivers and then starts to bleed. And so we have a simulation team that goes to our rural emergency rooms and offers education and simulation for common things that they may see.

My understanding, there's more material coming from AIM that, Christie, you could probably speak to that is targeting this. But I think there is a lot of recognition of the importance of the emergency rooms.

Christie Allen: So I think that's a complex question, and I won't go down a rabbit hole because I think Dr. Radke touched on the important parts, which are you should be including non-obstetric offering facilities, and you should be including the EDs from those and from all facilities because they're the first line that sees these patients and it needs to be able to recognize and provide immediate care for stabilization, as we all know. I won't belabor the point, but those components are incredibly important and they should be integrated in. Can they implement a bundle? Not fully, typically. The data components and the measurement, the quality metrics aren't exactly the same, but it should be a very combined integrated experience.

We do have simulation scenarios that are in development right now we're going to be releasing this year that are specifically for emergency departments in non-obstetric facilities. We're incredibly fortunate to have some wonderful consultants that are working on those with us that are clinicians in those places. And then we also have an OB Emergency Readiness Resource Kit. It is a comprehensive, very long, but hopefully, very useful obstetric emergency resource kit that is specifically designed for facilities to meet those needs when they do not have an embedded obstetric labor and delivery care department. And so it covers all of the bundles of what components and core components you can know, and also has a lot of associated resources like hemorrhage cart links for what you might want in it for supplies as well as algorithms.

Kristen Dillon: Come on back in two weeks. That will be the final installation of these four series. And then another month at the end of May, we'll be doing a fifth installation. That's sort of a sum up and what we've learned from this awesome series on the great collaborators we've had. I think the only other point for hospitals that don't provide obstetric services in a planned way is it's not just the birth-related emergencies to be worrying about. We know most deaths take place postpartum, in many cases from conditions that may not appear to be emergencies when the patient first presents, but a woman who's just given birth is not a regular healthy 28-year-old woman, it's postpartum person, and the things that can happen are different. And we're going to run you through some material to help facilities prepare both for the emergencies we all worry about, and also to provide optimal care across the whole pregnancy continuum so that we can turn the tide on what our country's facing. So thank you all so much for being with us today and come on back in two weeks.

Kristine Sande: The slides from today's webinar are currently available on the RHIhub website at www.ruralhealthinfo.org/webinars.