Structure, Process, and Outcome Data of AWHONN's Postpartum Hemorrhage Quality Improvement Project.

Objective: To describe the structures and processes implemented during the Association of Women's Health, Obstetric, and Neonatal Nurses Postpartum Hemorrhage (AWHONN PPH) Project.

Design: An 18-month, multiregion, multihospital quality improvement project.

Setting/local Problem: Fifty-eight hospitals located in Washington, DC; Georgia; and New Jersey.

Participants: Volunteer registered nurse hospital leaders implemented the AWHONN PPH bundle, which consisted of structure and process improvements.

Intervention/measurements: The process and effectiveness of the implementation of the interventions were measured and compared between baseline and after implementation.

Results: All structures and processes showed improvement but were not fully implemented at all sites. Registered nurse participation in drills increased from 0% to 92%, quantification of blood loss increased from 5% to 45%, hemorrhage risk assessment increased from 10% to 70%, prebirth risk assessment increased from 2% to 52%, postbirth risk assessment increased from 2% to 57%, and debriefing increased from 1% to 13%. No statistically significant differences were found in the pre- and postimplementation outcomes measured (maternal deaths, blood products transfused, women with massive transfusions, peripartum hysterectomies during the birth admission, and ICU admissions for women who gave birth and/or had a postpartum hemorrhage). Participants' self-assessments of their monthly implementation efforts (leader intensity) were not correlated with implementation fidelity (the degree to which the intervention was provided as proposed).

Conclusion: None of the 58 hospitals were able to implement all of the structure and process changes before the end of the 18-month implementation phase. This suggests that an 18-month implementation phase may be too short.