Introduction
Recent achievements in health care have to be frequently identified and analyzed to promote health equity. At this moment, there are many serious problems, and the task of healthcare providers is to predict them and avoid complications. Among the list of public health concerns, maternal (or postpartum) hemorrhage is defined as a leading cause of deaths among women in low-income countries and ¼ of all maternal death globally (World Health Organization, 2017). The New York City Health and Hospitals Corporation (NYC HHC) is characterized by a solid system of services offered to insured and uninsured citizens. In this paper, the analysis of the current problems of this organization in terms of predicting maternal hemorrhage will be presented. A future DNP project will identify the connection between financial and organizational aspects and prove the possibility to help mothers avoid lethal outcomes. The purpose of the proposed DNP project is to investigate the worth of oxytocin management in controlling maternal hemorrhage among the patients of the NYC HHC. In this paper, the problem statement, its significance, change implementation, and an evaluation plan will be developed to reduce the number of mothers’ deaths.
Problem Statement and Significance of the Practice Problem
Many health problems occur because of the lack of effective treatment methods and preventive measures in time. Patients suffer from pain and complications, and the medical staff cannot find appropriate solutions. In the NYC HHC, these problems are explained by the impossibility to distribute government funds equally and the rise of financial concerns during the analysis of available resources (Katz, 2018). Therefore, to develop a successful intervention for patients to improve their health, financial problems have to be solved first. A projected deficit is a real challenge for the NYC HHC, and the government has to understand the threats of maternal hemorrhage as a critical problem among patients of different ages, and this project aims at proving the urgency of interventions to predict maternal hemorrhage.
When it is time for a woman to deliver a baby, medical workers have to be ready for a number of complications, and maternal hemorrhage is one of them. Wormer et al. (2019) define this condition as a blood loss of about 500 mL in a vaginal delivery or about 1000 mL during a cesarean delivery or within the next 24 hours of delivery. The investigation of the etiology of this condition shows that there are primary and secondary causes. On the one hand, such problems as retained placenta, abnormal placentation, or uterine atony provoke loss of blood during delivery (Wormer et al., 2019). On the other hand, women may be at risk of infection or inherited coagulation deficit that provokes maternal hemorrhage after a delivery process (Wormer et al., 2019). If blood loss is impossible to predict, such complications as prolonged hospital length of stay or mortality have to be identified. Patients must deal with additional psychological, physiological, and economic changes (Marshall et al., 2017). As a result, one health problem (maternal hemorrhage) leads to the development of multiple concerns at different levels.
Global Perspective
Maternal deaths are common in many developing countries where a low income turns out to be a cause of a poor level of health care. About 25% of maternal deaths are caused by maternal hemorrhage and the inability to manage safe delivery procedures (Evensen et al., 2017). Abedzadeh-Kalahroudi (2015) states that about 14 million women are diagnosed with postpartum hemorrhage, and 140,000 of them die, while 1.6 million become anemic. Healthcare facilities offer inadequate services due to existing financial shortages that could be avoided if the governments pay close attention to medical needs (Ngwenya, 2016). The third stage of labor is defined as a critical period for many patients because it is the time when obstetricians or other involved doctors decide to add medications and identify the allowed dose.
National Perspective
Despite the fact that the United States is a developed country with a properly organized healthcare system, the work of the NYC HHC shows that, sometimes, financial concerns lead to serious physiological problems during labor. Approximately 700 women die because of pregnancy-related complications annually, while 3 out of 5 deaths could be prevented (Centers for Disease Control and Prevention, 2019). Obstetric emergencies in the form of severe bleeding are the outcomes patients experience during and after pregnancy. Many American hospitals are ready for such situations and provide their patients with the necessary help. However, there are many facilities where the expectations of patients cannot be met due to the lack of human resources, medications, or evidence-based interventions.
Practicum Site
In organizations like the NYC HHC, the problem of postpartum hemorrhage is not new, and its employees continue working and promoting improvements. The significance of interventions lies in the necessity to understand how to protect patients from lethal outcomes and reduce the possibility of excessive bleeding. The chosen hospital aims at treating patients with or without insurance and analyzing recent demographic changes that increase expenses on equipment and medications. NYC HHC wants to become a culturally competent organization where an appropriate healthcare environment is available to all patients (NYC Health +Hospitals, 2016). Therefore, if maternal hemorrhage as one of the leading pregnancy-related causes of death among female patients can be predicted, this chance has to be used.
Current Practice
At this moment, there are many studies where treatment and prevention of maternal hemorrhage are discussed. For example, Evensen et al. (2017) describe oxytocin as one of the most effective treatment methods for maternal hemorrhage. Uterine atony is a primary cause of blood loss that leads to patient death, and the use of uterotonic agents (oxytocin or ergometrine) is one of the common solutions that can be offered during labor. However, ergometrine is associated with the risks of vomiting and nausea, and there are restrictions for patients with high blood pressure (Wormer et al., 2019). Therefore, intravenous oxytocin, along with regular physical examinations, will help to prevent blood loss and identify the cause of the bleeding at an early stage.
PICOT Question
The practicum site is in need of intervention with the help of which the prevention and control of maternal hemorrhage are possible. The PICOT question is as follows: “In female obstetric patients (P), would oxytocin management along with regular physical examinations at the third stage of pregnancy (I) compared to no active management (C) help to prevent maternal hemorrhage and reduce pregnancy-related deaths over ten weeks (T)?” There are five main parts that have to be properly identified and explained in this DNP project:
- (P) – population – The choice of a population (participants) plays a crucial role because a researcher demonstrates an ability to identify a group of people who suffer from the offered health problem. In this project, females who are at the third stage of pregnancy undergo change and are examined.
- (I) – intervention – The identification of change is based on the needs of a hospital and the possibility of researchers. In this case, it is necessary to manage oxytocin with regular physical examinations in order to identify the causes of bleeding and prevent its development.
- (C) – comparison – In the DNP project, it is important to create a control group (where patients do not receive a tested variable) and an experimental group (where patients experience intervention) for comparison of the results. The absence of oxytocin in treating pregnant women proves the effectiveness of the offered intervention plan.
- (O) – outcome – The results of the intervention show if oxytocin combined with physical examinations could help female patients prevent maternal hemorrhage. The number of complications within the next 24 hours after delivery is registered and analyzed.
- (T) – time – Regarding the scope of the problem and available resources, it is expected to implement change and observe its impact during the next ten weeks. Statistical data should be enough to understand if the NYC HHC should implement this change on a regular basis.
Project Implementation and Evaluation Plan
Intervention
The main problem that is raised in this project is the impossibility of predicting the risks and outcomes of maternal hemorrhage during the third stage of labor. Some obstetric patients agree to take medications and treat pregnancy-related complications as soon as they are observed. Sometimes, females are in need of additional explanations of why pharmacological treatment turns out to be a serious part of labor (Evensen et al., 2017). In this project, the evidence-based intervention is the management of oxytocin with regular physical examinations. As soon as a newborn is delivered, this intervention is implemented to reduce the amount of blood. To prevent bleeding, it is enough to use 10 IU of oxytocin intramuscularly or 5 IU intravenously (Evensen et al., 2017). In addition to the injection of oxytocin, placenta manipulations, and a physical examination of the uterus through massage with palpation are the initial steps during the third stage of labor.
Rationale for Intervention
This intervention was chosen for several important reasons and assessments of the needs of the practicum site. From the pharmacological point of view, oxytocin is characterized by fewer adverse effects and effectiveness in prediction uterine atony compared to other medications (like misoprostol) (Evensen et al., 2017; Marshal et al., 2017). This drug usually interacts with other medications without serious complications. From the financial perspective, an existing projected deficit and an increased number of uninsured patients provoke the existence of low-resource settings (Katz, 2018). This evidence-based intervention is suitable for settings with limited resources (Ngwenya, 2016). The NYC HHC is not a poor organization, and its services are always of a high level. However, until the government does not solve the problem of funding, it is better to think about affordable alternatives. The example clarifies the situation: 10 units of oxytocin cost from $1 to $13, and the price of care for patients with maternal hemorrhage reaches thousands of dollars per one patient (Evensen et al., 2017). Other benefits of oxytocin management include a small amount of time for its dosing, as well as application, and common access for many hospitals.
Participants
The choice of participants is an integral stage in project planning and implementation. It has to be a purposive sample with patients who meet inclusive criteria like being in labor, delivering a baby, and having no serious chronic diseases that could cause death. In the majority of cases, researchers have to submit their proposals to the Institutional Review Board (IRB) and describe their goals and methods. When an evidence-based practice or quality improvement project is developed, no IRB approval is needed because it is not research but an effort to examine an already existing practice in the facility. Oxytocin intervention has to be a regular step in preventing and treating a certain number of patients, while some patients do not receive the same help. The absence of the ethics committee requires anonymity for all the participants (Ngwenya, 2016). If there is a need for IRB approval, a nurse is involved in sharing information about the DNP project, its purpose, and methods of analysis. Informed consent may be obtained from each participant, but a researcher is not able to do it due to the lack of direct communication with a patient.
Outcomes and Evaluation
The offered idea to use oxytocin along with a physical examination of women in labor has several important goals and outcomes. The project aims to investigate the causes of maternal hemorrhage at the third stage of labor, predict complications from bleeding, and reduce the death rating among obstetric patients. On the one hand, oxytocin helps to stimulate safe contractions and control bleeding after delivery (Abedzadeh-Kalahroudi, 2015). On the other hand, massage is an activity that allows a doctor to facilitate patient pain, assess the condition of the uterus, and identify the source of bleeding if any. Proposed outcomes include the reduction of pregnancy-related complications and deaths among women during or after delivery and the improvement of a female emotional state.
Implementation and Feasibility
To identify the feasibility of the project, an independent study has to be developed. It includes an understanding of drivers and solutions and the choice of the most appropriate alternatives within the established frames (8-10 weeks). During this period, it is possible to spend one week researching the area and identify the already made achievements in the obstetric practice. One week is given to contact patients, gather personal information, and explain the criteria of the study. During the next four weeks, observations and data gathering occurs, with experiences of an experimental group and a control group being noted. Two weeks should be used to analyze information, compare practical and literature findings, and make the necessary adjustments. Two additional weeks have to be taken into consideration if not enough information is found, and new data is required to support conclusions. In general, 8-10 weeks seem to be enough to accomplish everything that is necessary for this evidence-based practice.
Barriers
Potential barriers to a future DNP project can be the lack of participants who meet all the necessary inclusive criteria and poor cooperation with the staff of the NYC HHC. To overcome these challenges, certain preparations are required at the organizational and research levels. First, it is important for a researcher to establish contact with an administrator and several nurses of the facility. Additional sources about how to strengthen communication skills with the medical staff and patients should be found. Second, an extensive research program is recommended to obtain a solid background about the organization, its current problems, and the discussions about maternal hemorrhage as a leading cause of death among female patients during or after child delivery.
Data Collection Plan
The data collection plan consists of two major parts: to review the literature about the topic under research and to find personal information about patients and the results of the intervention. As a rule, medical organizations save their reports about surgeries and other procedures. If patients and the staff allow the researcher to read disease history and childbirth results, this opportunity has to be used. It is necessary to divide the information where oxytocin and a physical examination were and were not implemented as a treatment method for patients. Personal reports are also helpful in discovering the results of the practice. Before the intervention, the literature search should be organized to clarify what discoveries have already been made, and what outcomes have been obtained. Communication with the NYC HHC staff and a systematic review are the instruments to collect data. Reliability is based on measuring changes in death rates and complications among women after childbirth under the same condition. Validity is established to measure the effectiveness of oxytocin in preventing maternal hemorrhage, relying on the examples offered in the NYC HHC and the opinions of experts from credible peer-reviewed sources.
Data Analysis Plan
The analysis of data in this DNP project will be based on the results of an ANOVA test. Its goal is to reject or accept a hypothesis about the effectiveness of oxytocin management in preventing maternal hemorrhage. The main idea is to test two groups and identify if there are differences between them. A one-way analysis (with one independent variable and one dependent variable) is developed in Excel format with calculations supported by the results obtained by the researcher.
Implementation Phase
There are ten weeks to implement intervention and address the problem of maternal hemorrhage in the NYC HHC, as shown in Figure 1. To succeed in the development of the DNP project, the researcher has to obtain enough background information, establish contact with stakeholders, and have enough time to analyze the gathered results. If some tasks are done before the predicted deadline, another task should be started to have extra time for editing and re-checking the results.
Figure 1. Implementation phase
Resources for Implementation
During the implementation phase, access to several critical resources is necessary. For example, several handouts can be offered to the participants to explain the threats of maternal hemorrhage and recent statistics. Secondly, human resources are important: nurses, obstetricians, and administrators have to be involved in a research process to share their knowledge and observations, and patients’ experiences will be reported and analyzed. Personal stuff like computers, pens, pencils, and notebooks have to be mentioned because this material plays an integral role in making regular remarks about the work done.
Financial Aspects
Within the frames of this intervention, the NYC HHC undergoes a certain financial impact due to the offered changes. First, it is possible to reduce costs on the treatment of postpartum patients (one dose of oxytocin reduces further costs on related complications). Second, several outside funding resources can be found for further improvements and innovations. Finally, the government may be interested in the development of new programs to support the patients of NYC HHC during their labors. The sources of revenue will be billing outcomes and grants offered by the university DNP committee. Other financial aspects are mentioned in Table 1.
Table 1. Budget
Conclusion
In general, the idea to investigate the relationship between the quality of healthcare services, pregnancy-related deaths (or complications), and the financial aspects of the facility has a clear implementation and evaluation plan. The NYC HHC focuses on the development of services for insured and uninsured patients who live in New York. The role of the government turns out to be crucial as funding and support influence access to equipment, human resources, and other information. Maternal hemorrhage is a serious public health problem, and its solution is the goal of many researchers and organizations. In this DNP project, evidence-based intervention in the form of oxytocin management, along with physical examinations during the third stage of labor, is promoted. It includes data collection and analysis, using the reports and recent peer-reviewed studies, as well as observations and control of the injection outcomes. As soon as enough background information about the topic is introduced, the results of experimental and control groups are analyzed to prove the effectiveness of the offered practice within the frames of the NYC HHC services and resources.
References
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Centers for Disease Control and Prevention. (2019). Pregnancy-related deaths: Saving women’s lives before, during and after delivery. CDC. Web.
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Katz, M. H. (2018). Report to the board of directors – September 2018. NYC Health + Hospitals. Web.
Marshall, A. L., Durani, U., Bartley, A., Hagen, C. E., Ashrani, A., Rose, C., Go, R. S., & Pruthi, R. K. (2017). The impact of postpartum hemorrhage on hospital length of stay and inpatient mortality: A national inpatient sample–based analysis. American Journal of Obstetrics and Gynecology, 217(3), 344.e1-344.e6.
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World Health Organization. (2017). WHO recommendations on prevention and treatment of postpartum haemorrhage and the WOMAN trial. WHO. Web.
Wormer, K. C., KJamil, R. T., & Bryant, S. B. (2019). Acute postpartum hemorrhage. StatPearls. Web.