An effort to make hospitals safer for women giving birth in Texas has been underway for more than a year now. Doctors and hospital administrators say Texas AIM, which was launched in the summer of 2018, has led to big shifts in how medical staff treat women facing medical complications while having a baby.
Dr. Amy Papst, M.D., the chief medical officer at Ascension Seton Medical Center in Austin, said her hospital delivers about 4,800 babies a year. So, she said, the staff felt compelled to join the state in its effort to improve maternal health here.
“We deliver the most babies and we are the biggest hospital [in Austin],” she said, “and we wanted to reduce morbidity and mortality associated with childbirth.”
A few years ago, state officials began to hear growing concerns about the rate of women dying – or almost dying – while giving birth. Manda Hall, the associate commissioner for community health improvement at the Texas Department of State Health Services, said health officials saw an opportunity to step in.
“We all kind of have looked at it and understood that there were things that we could get better at as far as improving our maternal health outcomes here in Texas,” she said.
Hall said hospitals are just one piece of this larger effort – but a big piece. Out of the roughly 225 hospitals in the state with obstetric services, almost all have joined Texas AIM.
So far, doctors say, the program has changed hospital protocols a lot.
Dr. Jeny Ghartey, the maternal medical director at Ascension Seton Medical Center in Austin, said the first huge shift has been in how doctors screen for hemorrhage, or significant blood loss, after delivery.
In the past, she said, medical staff relied mostly on guesswork.
“Traditionally physicians have just estimated the blood loss at the time of delivery,” Ghartey said. “And it’s usually a visual inspection; it’s notoriously inaccurate.”
In other words, doctors would literally just look at the amount of blood on a hospital bed and decide whether they think it’s a problem. Now, Ghartey said, staff take steps during every vaginal delivery to figure out “quantitative blood loss,” which means using math to figure out exactly how much blood a woman has lost.
“There is actual measurement in a calibrated drape of blood after a vaginal delivery,” she said. “And then also any of the sponges that are soaked with blood are weighed.”
Medical staff also constantly look out now for changes in vital signs, Ghartey said. Certain changes automatically trigger a series of steps that’s been compared to the precise routine of a pilot landing a plane.
Papst said these checklists and protocols have reduced the differences in care from patient to patient.
“Reducing the variability… leads to better outcomes,” she said. “We have a ton of data that proves that.”
Another big change since Texas AIM launched is that hospitals now have open lines of communication with one other.
"I have been with the state since 2012 and ... [this is] the first time I have encountered something like this," Hall said. "I feel like it has really just shown a level of commitment across our state."
Hall said she and other health officials are seeing hospitals share policies, procedures and tools with other providers.
“Hospitals are coming together and they can talk about their challenges,” she said. “They can also talk about areas where they have excelled in, and they kind of share that.”
This has been particularly helpful for smaller rural hospitals in Texas.
Leslie Barnard, the director of family birth place at Permian Regional Medical Center in Andrews, said her hospital in far West Texas delivers only about 330 babies a year. In the past, she said, when she wanted to improve care she often could only get in touch with bigger hospitals for advice.
“So many times I talked to different directors of the large hospitals and I’m like, ‘How do you get this done?' Or, you know, 'How do you do this?’"
The answer was always something like: "On our team ...," Barnard said. “And I’m like, ‘Well, you don’t understand we don’t have a team like that here.’”
Hall said rural hospitals like Barnard’s have been able to figure out how to make all these ambitious protocols work.
“Around 90 percent of rural hospitals in our state have enrolled [in Texas AIM],” she said. “They have to be a little more innovative in kind of thinking through different challenges they may have."
Barnard said when a smaller hospital does come up with a creative solution to some of these issues, they share it with the other small hospitals. She said it’s been a game-changer.
“It’s nice to be able to meet with other small hospitals and hear how they get that to work for them,” she said.
Researchers and advocates have been raising concerns for years about how unreliable maternal mortality and morbidity data is in Texas. One of the last big changes under Texas AIM is the creation of a central location where all hospitals send data on health outcomes for women who have babies in their delivery wards.
And hospitals aren’t just sending data along, Hall said; they are also taking a close look at it themselves.
“We’ve also seen an increase in the number of hospitals that are having these multidisciplinary reviews so that they can learn from an event that happened,” Hall said. “So that we can continue to improve and get better.”
Because this program is relatively new, there's no data to show whether these changes have saved lives. But Hall said she’s seeing broad improvements in how hospitals are operating.
All these changes, though, are more work for hospitals. And in some cases, these new protocols have required administrators to hire more staff and spend more money.
But Papst said it’s been worth it for a lot of reasons.
“We are actually saving money,” she said. “If you are identifying a patient who is at risk for a post-partum hemorrhage and you are able to intervene … not only have you reduced the total cost of care, but you have improved their morbidity and mortality.”
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