An evidence-based approach to process standardization

POSTPARTUM HEMORRHAGE (PPH), the leading cause of maternal death according to the World Health Organization, requires time-sensitive and compassionate intervention. The American College of Obstetricians and Gynecologists (ACOG) defines PPH as greater than 1,000 mL of blood loss in 24 hours, regardless of delivery method. From a survey of deliveries from 2000 to 2019, Corbetta-Rastelli and colleagues estimated that complications from PPH affect approximately 3% of deliveries, with an overall upward trend from 2.7% to 4.3% across the study period.

Research from Main and colleagues via the California Maternal Quality Care Collaborative demonstrates that protocol standardization and debriefs improve severe maternal morbidity and mortality for those who experience PPH. The most recent obstetric hemorrhage patient safety bundle from the Alliance for Innovation in Maternal Health (AIM) specifically calls for involving the patient in the post-event debrief. Including the patient’s perspective as a standard of care in PPH management can help uncover aspects of PPH not easily recognized by the clinical team.

Clinical issue and challenge

In my organization, a mid-sized academic community hospital in the Mid-Atlantic region, we consider PPH management a key competency for obstetric staff. The obstetrics unit provides tools and checklists to help nurses identify and respond to PPH, implements quantitative blood loss measurement, and follows a post-PPH debriefing process. These interventions align with the Maryland Perinatal-Neonatal Quality Care Collaborative (MDPQC) AIM-guided initiative on obstetric hemorrhage. (See What’s quantitative blood loss measurement?)

Despite the hospital’s comprehensive approach, the unit didn’t have a process in place to satisfy the AIM core process metric: Patient Support After Obstetric Hemorrhage. Excluding patients and their support people doesn’t acknowledge their experience, nor does it account for how their perspective might improve teamwork and communication during PPH.

In recognition of this gap, a nurse-led project team (project champion, clinical coordinator, and unit educator) worked to standardize a new process for debriefing with patients and their support people after PPH. The project team used the Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals (JH EBPM). (See About JH EBPM.)

Literature search

The team conducted a literature search with the following question: In patients who experience a postpartum hemorrhage, does using a standardized debriefing process between the clinical team and patient improve communication and teamwork compared to using no standardized debriefing process? The search yielded 25 articles appropriate for review.

A systematic review by Hale and colleagues analyzed six common debrief frameworks and noted that choosing a format should focus on its appropriateness to department needs. Studies of particular debrief frameworks in diverse clinical settings—including by Conoscenti and colleagues on an organ transplant unit, Ugwu and colleagues at a community hospital, and others—demonstrate that staff welcome debriefing protocols, which offer positive opportunities for healthcare teams to improve clinical care and safely analyze critical events.

Many obstetric units use AIM bundles to standardize and improve debriefing after PPH, but these efforts require regular follow up to ensure consistent and sustainable bundle adherence. In both Oklahoma and Texas, Stierman and colleagues linked the use of an AIM-aligned bundle with improved rates of debrief after major obstetric complications. Duzyj and colleagues also found that implementation of the AIM bundle resulted in staff initiating debriefs with patients and families; however, their use required repetitive team training. Unfortunately, as noted by de Tina and colleagues, staffing and patient care demands frequently limit consistent opportunities for debriefs.

Project overview

Guided by the JH EBPM, we implemented a pilot project to standardize a process for debriefing with patients after a PPH. Informed by our literature review, the team easily adapted the project into the existing PPH workflow. Using the JH EBPM Translation and Action Planning Tool, the team’s organization-specific recommendations included sharing evidence recommendations with perinatal staff, reinforcing use of the hospital’s internal obstetric emergency debrief tool (OBERT) for patients after PPH, surveying staff about attitudes related to teamwork and communication after providing education, and ensuring project sustainability via documentation protocols and annual PPH simulations.

Debriefing format

Because the literature didn’t identify a single debriefing format as superior, we followed a model used by Paquay and colleagues to embed a supplemental patient debrief into our OBERT debrief process. The model aligned with how debriefs were already conducted on the unit. The project included several of Paquay and colleagues’ key programmatic elements, including a leadership team (the current project team), the project champion (similar to the role of debrief coordinator), a debriefing strategy, an opportunity for analysis, and linkages to existing processes.

Before the go-live date, the project team developed and the informatics team approved an electronic health record (EHR) SmartPhrase for documenting the debrief. SmartPhrases allow EHR users to quickly add a template to their clinical note. This SmartPhrase documented the occurrence of a PPH, the completion of a debrief with the patient and clinical team, and any resolution related to patient concerns. At a unit staff meeting, the project team offered education to providers and nurses about the importance of debriefing; the relationship between debriefing and emergencies, such as PPH; and the new protocol. Additionally, the project team updated the existing OBERT debrief tool to include a PPH debrief checklist item.

The project team posted signage to remind providers of the documentation protocol, and debrief scripts were included on unit-based PPH carts. The team also created a plan to include the new protocol in the unit’s annual PPH simulations for continued reinforcement.

Metrics

The project team tracked and counted the number of patient debriefs that occurred prior to discharge after patients experienced a PPH. Because the debrief literature reinforced the link between debriefing and effective teamwork—for example, Lyman found a link between increased debriefing frequency and increased trust, team orientation, and a shared mental model (staff ability to anticipate tasks in a team environment because of a collective understanding of the same goal)—the team surveyed staff about their perceived sense of communication and teamwork related to PPH management. The survey included Likert scale items and free text response to collect staff feedback at 3- and 6-month intervals after the project implementation date.

Results

For the primary project metric—documentation of a debrief between patient and clinical team after a PPH—the team reviewed the charts of patients with a cumulative blood loss of >1,000 mL for inclusion of the EHR SmartPhrase. In the first 6 months after implementation, the team found 106 cases of PPH out of 1,016 total deliveries. After chart review, 22 cases of PPH (eight out of ten vaginal deliveries and 14 out of 96 cesarean deliveries) included documentation of a debrief with the patient.

The larger number of cesarean deliveries without a debrief and the lack of pre-project comparison data limit interpretation of these data; however, it’s notable that more PPH in vaginal deliveries included documentation of a debrief compared with cesarean deliveries (80% for vaginal deliveries vs. 14.5% for cesarean deliveries). In light of the changes to ACOG classification of PPH, this variance may be explained by a belief among staff members that 1,000 mL of blood loss in a cesarean delivery isn’t consistent with PPH.

The project team found it encouraging that staff completed debriefs with patients after almost all PPH during vaginal deliveries. However, failure to debrief patients who experience PPH with a cesarean delivery deprives patients of an equitable opportunity to gain knowledge for their recoveries.

Regarding the second metric—nurses’ perceived sense of communication and teamwork related to PPH—the team analyzed surveys sent to RNs at the start of implementation and at 3- and 6-month intervals. Unfortunately, a <10% response rate left the team with insufficient data to determine meaningful changes. The project team is developing strategies to improve response, such as an interactive survey for the unit Learning & Engagement Systems Board, a virtual whiteboard-like space for the unit to post updates, announcements, and unit action items.

Although the survey responses received may reflect bias, nurses stated that they believe the clinical team is well prepared to respond to PPH, that the team communicates clearly and uses strategies such as Team Strategies and Tools to Enhance Performance and Patient Safety and closed loop communication during a PPH, and that patients receive support and can recognize PPH warning signs. Nurses indicated that patient debriefs occurred only in approximately one-third (36.4%) of PPH scenarios; however, this number increased from no reported patient debriefs at project implementation to 60% (three out of five respondents) after 3 months of project implementation.

The project team found improvement in the rate of patient debriefs encouraging, but further work is needed to appropriately understand the effect of this intervention on clinical teamwork and communication. The low survey response rate limits the team’s ability to understand the strengths and challenges of PPH management on the unit and the conclusions the team can draw about the relationship among patient debrief, unit communication, and teamwork.

Lessons learned

Implementing a process to document patient debrief after a PPH depends on unit staff complying with the change in protocol, as well as their willingness to complete surveys related to the change. This project’s results indicate modest but encouraging signs that a change in practice can be reasonably achieved when it’s simple, supported by leadership, and easily incorporated into existing unit practices.

Given the stress of a PPH and the busyness of obstetric units, the team understood that the success of the project relied on an intervention that staff wouldn’t view as cumbersome. Other units seeking to implement a similar project should first determine what aspects of their workflow are easily amenable to change.

Given the project’s failure to assess nurses’ perceptions of teamwork and communication during implementation, those seeking to implement a similar change should consider establishing a more robust system for tracking responses. Embedding a QR code to a survey in staff education wasn’t sufficient to ensure adequate responses. Suggestions for improved response rates include establishing a minimum necessary participation, providing windows for response, and implementing a tracking system to monitor response and encourage participation as appropriate.

Although it was outside the scope of this project to survey patients, future projects also could ask patients for their perspective on debriefing after a PPH.

Nursing implications

We hope this project can serve as an example for other units seeking to standardize a PPH patient debriefing; however, our success may stem from our already existing protocol. Key implications for nurses wanting to replicate this project include reviewing their units’ PPH workflow to find areas amenable to patient debriefing, collaborating with informatics teams to build easy solutions for documenting debriefs in the EHR, and advocating for the clinical team to safely debrief with patients at the point of care.

Standardize a process

This project demonstrated feasible implementation of a process to standardize patient debriefing after PPH. Inserting the change into established unit protocols was critical to the project’s success. Although the project team didn’t receive enough survey responses to understand how nurses perceive teamwork and communication during PPH, the initial positive feedback and the increase in debrief documentation proved encouraging. This project can serve as an example for other units and organizations seeking to standardize a process for debriefing with patients after PPH.

Sydney West is a senior clinical nurse at the University of Maryland Baltimore Washington Medical Center.

American Nurse Journal. 2026; 21(9). Doi: 10.51256/ANJ0946

References

Alliance for Innovation on Maternal Health. Obstetric hemorrhage patient safety bundle. 2022. saferbirth.org/wp-content/uploads/U2-FINAL_AIM_Bundle_ObstetricHemorrhage.pdf

American College of Obstetricians & Gynecologists. Practice Bulletin No. 183: Postpartum hemorrhage. Obst Gynecol. 2017;130(4):e168-86. doi:10.1097/AOG.0000000000002351

Bissett K, Ascenzi J, Whalen M. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals: Model and Guidelines. 5th ed. Indianapolis, IN: Sigma Theta Tau International; 2025.

Chu J, Alawa N, Sampayo EM, Doughty C, Camp E, Welch-Horan TB. Evolution of clinical event debriefs in a quaternary pediatric emergency department after implementation of a debriefing tool. AEM Educ Train. 2021;5(4):e10709. doi:10.1002/aet2.10709

Conoscenti E, Martucci G, Piazza M, et al. Post-crisis debriefing: A tool for improving quality in the medical emergency team system. Intensive
Crit Care Nurs. 2021;63:102977. doi:10.1016/j.iccn.2020.102977

Corbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum hemorrhage trends and outcomes in the United States, 2000–2019. Obstet Gynecol. 2023;141(1):152-61. doi:10.1097/AOG.0000000000004972

De Tina A, Chau A, Carusi DA, Robinson JN, Tsen LC, Farber MK. Identifying barriers to implementation of the national partnership for maternal safety obstetric hemorrhage bundle at a tertiary center: Utilization of the Delphi method. Anesth Analg. 2019;129(4):1045-50. doi:10.1213/ANE.0000000000003451

Duzyj CM, Boyle C, Mahoney K, Johnson AR, Ogot G, Ayers C. The postpartum hemorrhage patient safety bundle implementation at a single institution: Successes, failures, and lessons learned. Am J Perinatol. 2021;38(12):1281-8. doi:10.1055/s-0040-1712452

Glantz JC, Roy AL, Bernstein PS, et al. Implementation of a statewide bundle on obstetric hemorrhage in New York. Pregnancy. 2025;1(4):e70046. doi:10.1002/pmf2.70046

Hale SJ, Parker MJ, Cupido C, Kam AJ. Applications of postresuscitation debriefing frameworks in emergency settings: A systematic review. AEM Educ Train. 2020;4(3):223-30. doi:10.1002/aet2.10444

Lyman K. The relationship between post-resuscitation debriefings and perceptions of teamwork in emergency department nurses. Int Emerg Nurs. 2021;57:101005. doi:10.1016/j.ienj.2021.101005

Main EK, Cape V, Abreo A, et al. Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. Am J Obstet Gynecol. 2017;216(3):298.e1-11. doi:10.1016/j.ajog.2017.01.017

Maryland Perinatal Neonatal Quality Collaborative. Obstetric hemorrhage. mdpqc.org/obstetric-hemorrhage

Paquay M, Simon R, Ancion A, Graas G, Ghuysen A. A success story of clinical debriefings: Lessons learned to promote impact and sustainability. Front Public Health. 2023;11:1188594. doi:10.3389/fpubh.2023.1188594

Stierman EK, O’Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork and communication activities in Oklahoma and Texas. Qual Manag Health Care. 2023;32(3):177-88. doi:10.1097/QMH.0000000000000407

Toews AJ, Martin DE, Chernomas WM. Clinical debriefing: A concept analysis. J Clin Nurs. 2021;30(11-12):1491-1501. doi:10.1111/jocn.15636

Tyler SP, Dixon J, Parkosewich J, Mullan PC, Aghera A. Development, validation, and implementation of a guideline to improve clinical event debriefing at a Level-I adult and Level-II pediatric trauma center. J Emerg Nurs. 2021;47(5):707-20. doi:10.1016/j.jen.2021.04.013

Ugwu CV, Medows M, Don-Pedro D, Chan J. Critical event debriefing in a community hospital. Cureus. 2020;12(6):e8822. doi:10.7759/cureus.8822
World Health Organization. Maternal mortality. April 7, 2025. who.int/news-room/fact-sheets/detail/maternal-mortality

Key words: debrief, postpartum hemorrhage, patient communication