PATIENT SAFETY SERIES

Does a postpartum hemorrhage patient

safety program result in sustained
changes
in management and outcomes?
Pembimbing :
Dr. Doddy Gutom,Sp.OG

Shannaz
11.2013.184
Brett D. Einerson, MD, MPH; Emily S. Miller, MD, MPH; William A.
Grobman, MD, MBA

ABSTRACT
OBJECTIVE

To determine whether the introduction of a

postpartum hemorrhage (PPH) safety program
was associated with changes in clinical practice
and outcomes,
To examine whether these changes were
sustained over time.

SETTING

: Northwestern
DESIGN : Cohort Study

ABSTRACT
RESULT

After the introduction of the program there was

a significant increase in the use of uterotonic
medications (P<.001), intrauterine balloon
tamponade (P.002), B-Lynch suture
placement (P .042), uterine artery
embolization (P .050), and cryoprecipitate
use (P.0222).
The number of days between admissions to the
intensive care unit for PPH increased.

PROBLEM
Data

from a nationwide sample in the US suggest

that the rate of maternal hemorrhage has risen
from 1.6% in 1994 to 2.4% in 2008.
The rate of severe PPH (ie, estimated blood loss
[EBL] >1500 mL), has doubled from 1999 through
2008.
As a result, The Joint Commission released a 2010
Sentinel Event Alert that urged hospitals and
obstetric providers to develop and use protocols
in an effort to prevent maternal morbidity and
mortality related to PPH.

HYPOTHESIS
The

introduction of a PPH patient safety

program would result to prevent more
severe PPH and reduction in maternal
morbidity

CASE STUDY
This

was a cohort study of the care and

outcomes before and after the
introduction of a PPH patient safety
program at Northwestern Memorial
Hospital

MATERIALS AND METHOD (1)

Implementation

of a multidisciplinary
program that included:
Mandatory educational sessions
designed to improve EBL assessment
with preintervention and
postintervention testing
Introduction of a multidisciplinary
checklist for PPH management
The institution of universal active
management of the third stage of labor

MATERIALS AND METHODS (2)

The

active management of the third

stage of labor
Administration of oxytocin (either
intramuscular or intravenous)
immediately following delivery of the
fetus
Gentle controlled cord traction to
deliver the placenta.

MATERIALS AND METHODS (3)

Patients

were included in the analysis if:

They had an EBL of >500 ml for
vaginal delivery, >1000 ml for
cesarean delivery
They received a blood transfusion or
uterotonic medications for obstetric
hemorrhage

MATERIALS AND METHOD (4)

PATIENT

CHARACTERISTICS
Maternal demographic: age, selfreported race/ethnicity, and parity.
Obstetric data: the presence of
placenta previa, placenta accreta,
multiple gestation, preeclampsia,
magnesium sulfate use, and
chorioamnionitis.

MATERIALS AND METHOD (5)

PATIENT

CHARACTERISTICS
Additional characteristics: gestational
age at delivery, length of labor,
induction of labor, use of oxytocin,
and birthweight

DOCUMENT (1)
Data

were collected on treatments and

outcomes related to PPH.
Clinical interventions to control
hemorrhage:
The type and number of uterotonic
medications (methylergonovine,
prostaglandin F2-alpha, and
prostaglandin E1)
The use of intrauterineballoon
tamponade, B-Lynch suture placement,
uterine artery embolization, and

DOCUMENT (2)
Clinical

outcomes included:
The type and number of blood products
used (packed red blood cells, platelets,
fresh frozen plasma, and cryoprecipitate)
Admission to the intensive care unit
(ICU)
Maternal death

ANALYSIS
Two
1.

2.

types of analyses were performed

Comparing variables before and after the
program start using the t test,Wilcoxon
rank sum test, or c2 test
Using Shewhart charts (type of chart used
in quality-control analysis) specifically to
identify sustained change over time

RESULT
PPH

was diagnosed more frequently

after the program start (5.3% vs 6.0%,)
The proportion of all PPH that were
estimated to have a volume >1500 mL
increased from 21.5-26.6% after the
safety programs start (P = 0,01).

During the study period

52819 woman delivered:
3105 (9%) experienced
a PPH
Characteristic of
women with PPH were
similar except the
woman in post
intervention group has
slightly greater mean
maternal age and BMI,
ASIAN, undergone
induction of labor

Clinical interventions to
control hemorrhage were
significantly different after
the initiation of the program
and the changes persisted
over time.
Increase in the use of
methergonovine,
prostaglandin F-2 alpha and
prostaglandin E1
Increase in the use of
uterotonic medications,
intrauterine balloon
tamponade, B-Lynch suture
placement, uterine artery
embolization and
cryoprecipitate use
The use of hysterectomy for
PPH did not significantly
changed

Shewhart chart shows

that:
The changes in
management and
outcomes were
sustained over time
Increase use of
cryoprecipitate and
this changed were
sustained over time

The days between ICU

progressively
increased as the
program continued
and become
significantly longer
than at a baseline

COMMENT (1)
After

the introduction of a
multidisciplinary program aimed at
improving patient safety and preventing
maternal morbidity and mortality
related to PPH:
There are changes in the care of
women with PPH and maintenance of
these changes over years

COMMENT (2)
There was an increased use of
interventions for PPH
ICU admissions became less frequent
over time
PPH were more readily identified and
treated

COMMENT (3)

After the program start:

Increased rate of EBL > 1500 ml may
indicate that there were
improvements in blood loss estimation
Increase in transfusion of other blood
products, the increased use of
cryoprecipitate is likely explained by
the increased identification of low
fibrinogen after the program start

COMMENT (4)
Other

studies on the safety programs shows that:

Reduced maternal mortality in women with
severe PPH after a systemic change in their
hospital obstetric hemorrhage management
implemented
A PPH program similar to this study
demonstrated improved early-stage diagnosis
of PPH, a 64% reduction in disseminated
intravascular coagulation and a>50%
reduction in blood product use

COMMENT (5)
The

study has its limitations:

The study was based on an institution
wide quality-improvement initiative,
there was only a historical control
group available.
The group of patients prior to the
intervention was largely similar to the
group after the intervention.

COMMENT (6)
The study was conducted in a single
institution, so its generalizability to hospitals
with different resources, policies, and patient
populations is unknown.
Despite the limitations, these results support the
development of a multidisciplinary patient safety
program can enhance obstetric interventions
and improve maternal outcomes related to PPH.
The results also shows that these improvements
can be sustained over time.

THANK YOU