Fluent Essays

parent teaching project: There are two articles there/template Teach a parent about: warning signs of maternal mortality and morbidity Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. http://crossmark.crossref.org/dialog/?doi=10.1016/j.nwh.2016.10.009&domain=pdf Improving POSTPARTUM EDUCATIOJl About Warn i ng Signs of MATERNAL MORBIDITY and MORTALITY PATRICIA D. SUPLEE LISA KLEPPEL ANNE SANTA-DoNATO DEBRA BINGHAM Maternal mortality or pregnancy-related death is the death of a woman from compli- cations of pregnancy and childbirth occurring up to 1 year postpartum. In a report using data from 2010, the United States ranked 49th out of 184 countries for mater- nal mortality (Central Intelligence Agency, 2016); it is one of eight countries where maternal mortality rates have been on the rise in recent years (Hogan et aI., 2010; Kassebaum et aI., 2014). Abstract: Maternal morbidity and mortality rates remain high in the United States compared with other developed countries. Of par- ticular concern is the rise in postpartum deaths, because many of the risk factors for complications associated with maternal morbidity and mortality may not be clearly identified before a womans discharge after birth. Although nurses provide some form of postpartum discharge education to all women who give birth, the information women receive on common potential complications is nat always consistent or evidence based. By improving postpartum education, nurses may be better poised to teach women how to recognize and respond to warning signs. This article describes a project intended to increase womens access to predischarge education about the risks for postbirth complications. http://dx.doi.org/ 10.1016/j.nwh.20 16.10.009 Keywords: maternal morbidity I maternal mortality I postpartum complications I postpartum education I pregnancy-related death Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. Although the most current u.s. pregnancy-related mortal- ity rate shows a slight decrease in maternal deaths, from 17.8 deaths per 100,000 live births in 2011 to 15.9 deaths per 100,000 live births in 2012 (Centers for Disease Control and Prevention [CDC], 2016), this rate is more than double the 1987 rate of 7.2 deaths per 100,000 births. However, research- ers working to better understand the measurement limitations of maternal mortality trends found that the CDC estimates may underreport maternal mortality rates. Recently, MacDorman, Declercq, Cabral, and Morton (2016), using adjusted models, reported an estimated maternal mortality rate for 2014 of 23.8 per 100,000 live births (included 48 states and the District of Columbia). During this same time period, the rates of mater- nal mortality in other developed countries decreased (Hogan et aI., 2010). In addition to maternal mortality, the rates of severe maternal morbidity in the United States have more than dou- bled since 1998 (Callaghan, Creanga, & Kuklina, 2012). The seven leading causes of pregnancy-related deaths for 2011 and 2012 in the United States are noncardiovascular dis- eases 05.3\%; not specifically described by the CDC), cardiovas- cular diseases 04.7\%), infection or sepsis 02.7\%), hemorrhage 01.3\%), cardiomyopathy (10.8\%), thrombotic pulmonary embolism (9.0\%), and hypertensive disorders of pregnancy (7.6\%; CDC, 2016). Although any woman can experience one of these complications during pregnancy or childbirth, women with chronic conditions such as cardiac disease, obesity, or high blood pressure are at higher risk of dying or nearly dying from these complications. Health disparities among racial and ethnic groups in the United States have been well documented in the literature (Elo & Culhane, 2010), and eliminating these disparities is an overarching goal of Healthy People 2020 (U.S. Department of Health and Human Services, 2016). In obstetrics, these dispari- ties persist and are clearly evident in reported rates of mater- nal morbidity and mortality. During 2011 and 2012, the CDC reported the deaths per 100,000 live births as 1l.8 for White women, 4l.1 for Black women, and 15.7 for women of other races (CDC, 2016). These data show that maternal mortality rates are approximately three to four times higher for Black women compared with White women. Understanding the timing of maternal deaths and their possible preventability can help guide the development of improvement efforts. In 2013, an international review of Patricia D. Suplee PhD, RNC-OB, is an associate professor in the School of Nursing-Camden at Rutgers University in Camden, NJ. Lisa Kleppel, MPH, PMp, is a project manager at AWHONN in Washington, DC. Anne Santa-Donato, MSN, RNC, is director of obstetric programs at AWHONN in Washington, DC. Debra Bingham, DrPH, RN, FAAN, is a perinatal consultant and founder of the Institute for Perinatal Quality Improvement in Silver Spring, MD. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected] 554 © 2016, AWHONN maternal mortality found that, on average, nearly 25\% of deaths occurred antepartum, another 25\% occurred intrapartum or immediately postpartum, and almost 50\% occurred in the postpartum period up to 1 year (Kassebaum et aI., 2014). Cre- anga et ai. (2015), using more recent U.S.-only data, found that of the maternal deaths reported, 39\% of women died before or on the day of birth and 61\% died in the postpartum period. These data make it clear that postpartum deaths are not just an international issue but are also a problem in the United States. Researchers estimate that 40\% to 50\% of U.S. maternal deaths are preventable (Bacak, Berg, Desmarais, Hutchins, & Locke, 2006). When focusing on obstetric hemorrhage alone, 54\% to 70\% of these maternal deaths are estimated to be preventable (Della Torre et aI., 2011; Main, McCain, Morton, Holtby, & Lawton, 2015). POSTPARTUM CARE AND EDUCATION Within hospital systems, establishing guidelines to optimize and improve postpartum care is important. Recently the Amer- ican College of Obstetricians and Gynecologists (2016) pub- lished a Committee Opinion on optimizing postpartum care. In addition, the Alliance on Innovation in Maternal Care is a multidisciplinary national program convened to reduce severe maternal morbidity and maternal mortality and is supported by the Maternal and Child Health Bureau/Health Resource Ser- vices Administration. The Alliance on Innovation in Maternal Care is developing two postpartum safety bundles to be used by all types of providers (medical, nursing, social service, and public health) to address the basic elements of postpartum care (Kleppel, Suplee, Stuebe, & Bingham, 2016). This first bundle will cover the first 6 weeks postpartum, and the second bun- dle will focus on interconception care and health up to 1 year postpartum. Nurses are the health care providers who perform the most postpartum education in the United States. Thus, it is critical that nurses work to improve discharge education so that the information they provide is efficient, timely, and evidence based. When women are discharged after birth, nurses playa vital role in providing them with education on self-care and infant care and a plethora of information related to transition- ing home and caring for a newborn. Authors have reported that the amount of information women receive is overwhelm- ing (Alden, Lowdermilk, Cashion, & Perry, 2012; Murray & McKinney, 2014). It is not clear how nurses currently decide which information is a priority to provide face-to-face educa- tion on and which information can be given to a woman to read at home. Many hospitals require the discharging nurse to com- plete some sort of checklist that includes a list of educational topics. However, there is wide variation in discharge education related to information on warning signs of maternal morbidity nwhjournal.org Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. and mortality (Suplee, Bingham, & Kleppel, 2016). This holds true for women being discharged from birth centers as well. For rates of postpartum maternal morbidity and mortality to be reduced, it is vital for women who have just given birth to be instructed on specific warning signs so that they know what to look for, when to call a health care provider, or when to go to the nearest emergency department. Many of the complications women experience can be successfully treated if they are identi- fied quickly and women receive prompt medical attention. To that end, below we describe the findings from the implemen- tation phase of a pilot project of the Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) entitled Empowering Women to Obtain Needed Care and discuss implications for clinical practice. WHY POSTPARTUM DISCHARGE EDUCATION NEEDS IMPROVEMENT The United States Agency for Healthcare Research and Qual- ity defines quality health care as doing the right thing, at the right time, in the right way, for the right person-and having the best possible results (2003, p. 1). For the past few decades, postpartum education has evolved around maternal self-care and infant care (Alden et aI., 2012; Murray et aI., 2014). We conducted a literature review in CINAHL and found no studies that focused on educating women about specific potential complications after birth. One recent study (Suplee et aI., 2016) found a lack of standard information and approaches to how nurses meet the challenge of educating women who are considered at risk for maternal mortal- ity, as well as for all women at risk simply on the basis of their postpregnancy health sta- tus. National leaders have stated that earlier recognition of warning signs by postpartum women and earlier interventions by health care providers may lead to a decrease in the current growing maternal morbidity and mortality rates in the United States (DAlton, Main, Menard, & Levy, 2014; The Joint Com- mission, 2010). Comprehensive improvement efforts to advance postpartum education fOCUSing specifically on potential risks for maternal morbidity and mortality are needed. Future education programs should include infor- mation for both at-risk and healthy women, because complications may not be clearly identified or apparent before a womans dis- charge after birth. Dec ember 2016 I January 2017 THE EMPOWERING WOMEN TO OBTAIN NEEDED CARE PROJECT With support from the Merck for Mothers program, a 10-year initiative focused on improving the health and well-being of women during pregnancy and childbirth, AWHONN initiated the Empowering Women to Obtain Needed Care project. Researchers estimate that 40\% to 50\% of lJ .S. maternal deaths are preventable The goal of this pilot project was to increase womens access to quality information about risks for postbirth complications, especially before discharge from the hospital after giving birth. Accurate and consistent information provided to all women who give birth can better equip them to recognize health changes or warning signs of postpartum complications. Early recognition of postbirth warning signs enables women to seek Nursing for Womens Health 555 Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. and obtain health care for these potentially life-threatening complications. The project was divided into two phases (see Figure 1). PHASE 1: BASELINE ASSESSMENT Baseline assessment included a comprehensive literature review, a review of postpartum discharge materials currently used by nurses to educate women about warning signs, and focus groups with nurses held at selected hospitals to assess what was currently taught to postpartum women and how the education was delivered. Findings showed that inconsistent information was provided to women about postbirth warning signs and what they should do if they experienced any of these signs once discharged (Suplee et aI., 2016) . PHASE 2: IMPLEMENTATION The implementation phase included two components. First, standardized evidence-based educational materials and dis- charge teaching talking points were designed for nurses to use when educating women about maternal morbidity and mor- tality. Second, these educational materials were pilot tested in four designated hospitals to identify barriers and facilitators to FIGURE 1 implementation and to evaluate postpartum nurses satisfac- tion using the materials. The education materials were designed to be easy to use and to have the ability to be integrated into current teaching tools used by nurses across the country. The leading causes of mater- nal morbidity and mortality in the United States formed the basis of what was included by the Expert Panel on the educa- tional tools before pilot testing in 2015. What follows is a report of the results of the implementation phase (Phase 2). METHODOLOGY Sample Four of the six hospitals from the baseline assessment (Phase 1) agreed to participate in the implem entation portion (Phase 2) . Hospitals chosen for this pilot project reflected diverse populations of postpartum women in terms of race, ethnicity, and socioeconomic status. Among the hospitals participating in this project, African American and Hispanic women were reported to make up 25\% to 65\% of the total birth demograph- ics for 2012. In the same year, Medicaid-reimbursed births in these hospitals ranged from 25\% to 75\% of their total births. Although it was not possible to capture the exact number of Phases of the Empowering Women to Obtain Needed Care Pilot Project Phase One: Baseline Assessment - IV outcomes 556 Nursing f o r Wom e n s Hea lt h Phase Two: Implementation • Design educational checklist tool for nurses • Design patient education tool • Design nurses evaluation tool • Design audit tool • Review all tools with Expert Panel • Train/orient nurse leaders • Pilot tools in 4 hospitals • Conduct & analyze health records audit • Analyze nurse evaluations • Redesign tools based on feedback - V o lume 2 0 Issue 6 Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. women who received postpartum education using the pilot project tools, a cumulative estimated calculation of births over a 3-month period included more than 3,000 women. In addi- tion, approximately 150 nurses were involved in providing the education to the postpartum women before discharge. Procedure After recruiting nurse site leaders from the four hospitals, the project manager sent copies of all of the tools to them. A con- ference call was held to introduce the nurse site leaders to the program tools and to explain how they should be implemented and how to train staff nurses to use them. The education for for nurses to use when beginning the conversation with new mothers: Although the majority of women who give birth do not have complications once they go home, all women are potentially at risk. Knowing these postpartum warning signs can save your life as many signs can indicate a life-threatening condition and require immediate medical care. Patient Handout The handout for women to take home, titled Save Your Life (see Figure 3), includes sections on when to call 911, when to call ones health care provider, and descriptions of warn- ing signs that could become life-threatening if women do not Education ~rams should include information for both at-risk and healthy women, because complications may not be clearly identified or aD-parent before a womans discharge after birth nurses included background information on statistics related to rising rates of maternal mortality to ensure that all of the nurses participating in the pilot program had accurate and current information to share with their staff. The pilot implementation took place from October through December 2015. During this time, nurse site leaders from all four hospitals reported that the nurses who provided postpartum education at their hospitals were using the new forms with all women after birth and before discharge. Monthly conference calls were held to discuss real and potential issues encountered with the use of the program materials and to share feedback among the nurse site leaders. PROJECT TOOLS Four tools were created by the principal investigators, project manager, an expert panel of nurses and health professionals on the basis of information gleaned from the literature review and focus groups held with nurses from six hospitals in New Jer- seyand Georgia. Two teaching tools were developed-one for nurses to use when teaching women about potential warning signs of maternal morbidity and mortality (see Figure 2) and another for women to take home (see Figure 3). Discharge Education Checklist The Post-Birth Warning Signs: Postpartum Discharge Educa- tion Checklist (see Figure 2) was deSigned to provide nurses with a tool they could use when teaching all women to rec- ognize warning signs of postpartum complications that could occur after discharge. The hospitals were given permission to integrate the checklist into their electronic health record. The checklist defines each potential complication, lists specific signs and symptoms, and explains where and when a woman should seek medical attention. It also includes this suggested script December 20161 January 2017 obtain prompt medical attention. The other important message included in this handout is a reminder for women to tell pro- viders caring for them during the first year after giving birth, I had a baby on [specific date] and I am having the following specific symptoms . ... This message is intended to alert provid- ers that a womans symptoms could be related to a recent preg- nancy. Nurses instructed each woman to keep the handout in a place where she could access and review it easily, such as on her refrigerator. Women were also encouraged to include a partner or family member in the discharge education sessions before discharge so that they could also hear the education to support earlier identification of warning signs and symptoms and help mobilize timely care. Education Evaluation Tool Additional tools were designed by the AWHONN project team to be used for data collection by the site leader and evaluation of the teaching tools by the nurses. The Postpartum Education Evaluation Tool was an online survey distributed to all post- partum nurses at the participating hospitals. Nurses were asked to describe the facilitators and barriers to using the discharge checklist and patient handout by responding to open-ended questions. They were also asked to rate six statements using a Likert scale (strongly agree to strongly disagree) focusing on such elements as satisfaction, ease of use, ease of understand- ing, assistance with teaching, and their assessment of womens abilities to understand the warning signs and describe when to obtain needed care. Audit Tool A quality improvement health record audit tool was devel- oped to be used by nurse site leaders when performing 30 Nursing for Women s Health 557 Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. FIGURE 2 Discharge Education Checkl ist (Full-sized PDF version of Figure 2 appears online as Supplemental Figure 51.) POST-BIRTH WARNING SIGNS: POSTPARTUM DISCHARGE EDUCATION CHECKLIST This checklist is a teaching guide for nurses to use when educating all women about the essential warning signs that can result in maternal morbidity and/or mortality. Instructions: POST- BIRTH WARNING SIGNS • Instruct ALL women about all of the following potential complications. All teaching should be documented on this form or in your facilitys electronic medical record. • Focus on risk factors for a specific complication first; then review all warning signs. • Emphasize that women do not have to experience ALL of the signs in each category for them to seek care. • Encourage the womans significant other or her designated family members to be included in education whenever possible. The information included on this checklist is organized according to complications that can result in severe maternal morbidity or maternal mortality. Essential teaching points should be included in all postpartum discharge teaching. The parent handout, Save Your Life, is designed to reinforce this teaching. This handout is organized according to AWHONNs acronym, POST-BIRTH, to help everyone remember the key warning signs and when to call 911 or a health provider. A portion of this handout is below for reference. Call your healthcare provider if you ha ve: ( If you can t reach your healthcare provider, ca ll 9 11 or go to an emergency room) o P ain in chest o O bstructed breathing or shortness of breath o S eizures o T houghts of hurting yourself or your baby o B leeding, soaking through one pad/hour, or blood clots, the size of an egg or bigger o I ncision that is not healing o R ed or swollen leg that is painful or warm to touch o T emperature of 100.4°F or higher o H eadache that does not get better, even after taking medicine, or bad headache with vision changes Below is a suggested conversation-starter: A lthough most women who give birth recover without problems, any woman can have complications after the birth of a baby. Learning t o recognize these POST- BIRTH warn - ing signs and knowing what to do can save your life . I would like to go over these POST- BIRTH warning signs with you now, so you will know what to look for and when to call 9 77 or when to call your healthcare provider. Please share thiS with family and f riends and post the Save Your Life handout in a place where you can get to it easily (like your refngerator). JJ •• u~o. Tn ,., u , ; AWHONN .,,~., ,,,,,n.,, © AWHONN 2016: All Rights Reserved POST-BIRTH Warning Signs: AWHONNs Postpartum Discharge Education Project © 2016 , AWHONN . All rights reserved. Requests for permission t o use or reproduce should be directed to [email protected] (continued) 558 Nursing for Women s Health Volume 20 Issue 6 Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. FIGURE 2 Discharge Education Checklist continued ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• j POST-BIRTH Warning Signs: Postpartum Discharge Education Checklist Pulmonary Embolism Essential Teaching for Women What is Pulmonary Emboli sm? Pulmonary embolism is a blood clot that has traveled to your lung. Signs of Pulmonary Embolism • Shortness of breath at rest (e.g., tachypneic shallow, rapid respirations) • Chest pain that worsens when coughing • Change in level of consciousness Obtaining Immediate Care Ca ll 91 1 or go to nearest emergency room RIGHT AWAY. RN initials ______________________ Date Family/support person present? YES / NO Cardiac (Heart) Disease Essential Teaching for Women What is Cardiac Disease? Card iac disease is when your heart is not working as well as it should and can include a number of disorders that may have different signs and symptoms. Signs of Potential • Shortness of breath or difficulty breathing Cardiac Emergency • Heart palpitations (feeling that your heart is racing) • Chest pain or pressure Obtaining Immediate Care Call 911 or go to nearest emergency room RIGHT AWAY. RN initials ______________________ Date Family/support person present? YES / NO Hypertensive Disorders of Pregnancy Essential Teaching for Women What is Severe Hypertension? Hypertension is when your blood pressure is much higher than it should be. Signs of Severe Hypertension • Severe constant headache that does not respond to over-the-counter pain medicine, rest, and/or hydration What is Preeclampsia/Eclampsia? Preeclampsia is a complication of pregnancy that includes high blood pressure and signs of damage to other organ systems. Eclampsia is the convu lsive phase of preeclampsia, characterized by seizures. Signs of Preeclampsia • Severe constant headache that does not respond to pain medicine, rest, and/or hydration • Changes in vision, seeing spots, or flashing lights • Pa in in the upper right abdominal area • Swellin g of face, hands, and/or legs more than what you wou ld expect • Change in level of consciousness Signs of Eclampsia • Se izures Obtaining Immediate Care Ca ll 911 for seizures. Ca ll healthcare provider immed iately for any other signs. If symptoms worsen or no response from provider/clinic, call 911 or go to nearest emergency room. RN initials ______________________ Date Family/support person present? YES / NO Obstetric Hemorrhage Essential Teaching for Women What is Obstetric Hemorrhage? Obstetric hemorrhage is when you have an excess amou nt of bleeding after you have delivered your baby. Signs of Obstetr ic Hemorrhage • Bleeding through more than 1 sanitary pad/hour • Passing I or more clots the size of an egg or bigger • Character of clots/differentiation of bright red bleed in g from dark with clots Obtaining Immediate Care Call healthcare provider immediately for signs of hemorrhage. If symptoms worsen or no response from provider/clinic. call 911 or go to nearest emergency room. RN initials ______________________ Date Family/support person present? YES / NO Page 1 o f 2 ©AWH ONN 2016: All Rights Reserved POST-BIRTH Warning Signs: AWHONNs Postpartum Discharge Education Proj ect © 2016, AWHONN . All rights rese rved. Requests for permission to use or reproduce should be directed to permiss [email protected] onn .org. (con tinued) December 20161 January 2017 Nursing for Womens Health 559 Downloaded for Anonymous User (n/a) at National Certification Corporation from ClinicalKey.com/nursing by Elsevier on October 16, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved. FIGURE 2 Discharge Education Checklist continued POST- BIRTH Warning Signs: Postpartum Discharge Education Checklist Venous Thromboembolism Essential Teaching for Women What is Venous Thromboembolism? Venous thromboembolism is when you develop a blood clot usua lly in your leg (ca lf area). Signs of Venous Thromboembolism • Leg pain, tender to touch, burning or redness, particu larly in the ca lf area • Swell ing of one leg more than the other Obtaining Immediate Care Ca ll healthcare provider immediately for above signs of venous …