title: Opportunities for improvement in care among women with severe maternal morbidity.
abstract: Severe maternal morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe maternal morbidity to identify opportunities for improvement in maternal care.
  
  
  
  The aims of our study were to apply newly described gold standard guidelines to identify true severe maternal morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care.
  
  
  
  We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe maternal morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe maternal morbidity to determine if true severe maternal morbidity occurred. Each true case of severe maternal morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition.
  
  
  
  There were 16,323 deliveries of which 386 (2%) screened positive for severe maternal morbidity. Following review of each case, true severe maternal morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe maternal morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors.
  
  
  
  We demonstrated the feasibility of a recently recommended review process of severe maternal morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: John.Ozimek@cshs.org.
authors.forename: John A
authors.initials: JA
authors.lastname: Ozimek
authors.affiliation: Division of Nursing, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Rhonda M
authors.initials: RM
authors.lastname: Eddins
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Naomi
authors.initials: N
authors.lastname: Greene
authors.affiliation: Division of Obstetric Anesthesiology, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Daniela
authors.initials: D
authors.lastname: Karagyozyan
authors.affiliation: Division of Nursing, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Sujane
authors.initials: S
authors.lastname: Pak
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Wong
authors.affiliation: Division of Obstetric Anesthesiology, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Mark
authors.initials: M
authors.lastname: Zakowski
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Kilpatrick
mesh_terms: D001803:Blood Transfusion; D015331:Cohort Studies; D004461:Eclampsia / Q000628:therapy; D005260:Female; D006801:Humans; D046110:Hypertension, Pregnancy-Induced / Q000628:therapy; D007362:Intensive Care Units; D033183:Interdisciplinary Communication; D009017:Morbidity; D006473:Postpartum Hemorrhage / Q000628:therapy; D017410:Practice Guidelines as Topic; D011225:Pre-Eclampsia / Q000628:therapy; D011247:Pregnancy; D011248:Pregnancy Complications / Q000628:therapy*; D047928:Premature Birth; D011787:Quality of Health Care; D012189:Retrospective Studies; D014481:United States; D014592:Uterine Hemorrhage / Q000628:therapy
keywords: hemorrhage; hypertension; opportunity for improvement; severe maternal morbidity