Instances of IHS Labor and Delivery Care Not Following National Clinical Guidelines or Best Practices

WHY WE DID THIS STUDY

During a review of medical records for the Office of Inspector General (OIG) study (OEI-06-17-00530), our clinician-reviewers identified instances in which labor and delivery patients received care that did not follow national clinical guidelines or best practices. We conducted this companion study because most of these instances, although concerning, did not result in patient harm, and therefore do not appear in our main report about adverse events. Due to the small number of labor and delivery patients included in this review and our sample design, these instances are not projectable to all labor and delivery patients in Indian Health Service (IHS) hospitals.

HOW WE DID THIS STUDY

We reviewed medical records associated with 48 labor and delivery patients to identify instances in which providers did not follow national clinical guidelines or best practices. For each record, an obstetrics nurse and an obstetrician-gynecologist—each with specialized experience in patient safety—assessed whether the care met national clinical guidelines for diagnosing and treating postpartum hemorrhage, induction of labor, delivery via Caesarean section, and diagnosis and treatment of severe hypertension/preeclampsia. In addition, our reviewer examined whether the diagnosis of postpartum hemorrhage incorporated the best practice of quantitative estimation of blood loss. We also asked IHS hospitals to describe training for providers of maternal care, and their implementation of the Alliance for Innovation on Maternal Health (AIM) "bundles" of maternal-safety best practices.

WHAT WE FOUND

We found that 27 of 48 labor and delivery patients (56 percent) had some aspect of care that did not follow national clinical guidelines (13 patients), did not use best practices for blood loss estimation (8 patients), or included both concerns (6 patients) during their stays at IHS hospitals.

Postpartum hemorrhage is one of the most severe maternal health complications and is rare nationally, affecting about 1 to 3 percent of deliveries. Among the 48 IHS labor and delivery patients in our sample, 16 patients (33 percent) experienced a postpartum hemorrhage. Most of these patients—14 of the 16—received care related to the hemorrhage that did not follow national clinical guidelines or best practices. For some patients, IHS hospital staff did not diagnose the hemorrhage in a timely manner, resulting in delays in treatment that could have reduced the excessive bleeding. Other instances of care included IHS providers not following national clinical guidelines when inducing labor. Of the 13 patients in our sample with induced labor, providers did not follow national clinical guidelines for 10 patients, most often related to inappropriate doses of induction medication.

IHS has also taken steps to directly address improvement in labor and delivery services via its ongoing implementation of maternal-safety best practice "bundles," or sets of maternal-safety best practices, developed by AIM. Yet at the time of our review, 3 of the 10 IHS hospitals with labor and delivery units had yet to implement any of the AIM best practice bundles as requested by the IHS Chief Medical Officer.

WHAT WE RECOMMEND

OIG recommends that IHS comprehensively assess its labor and delivery practices and consider changes based on the results of this assessment. Specific to postpartum hemorrhage, OIG recommends that IHS provide guidance to its hospitals and training to clinicians focused on diagnosing and treating postpartum hemorrhage. Finally, OIG recommends that IHS encourage and support its hospitals in adopting AIM's maternal-safety best practices. IHS concurred with our recommendations and described actions it has already taken toward implementation. These efforts include facility site visits and expanded training. IHS also reported that all IHS hospitals that provide planned childbirth services have implemented the AIM guidance for postpartum hemorrhage and severe hypertension.