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Report on 5-year Experience with Obstetric Hemorrhage Protocol
Abstract Number: T-22
Abstract Type: Original Research
Obstetric hemorrhage continues to be a leading cause of maternal death worldwide. In our practice the incidence of significant maternal hemorrhage is less than 1%. Recent publications suggest use of protocols, checklists, and cognitive aids improve team performance and outcome in critical events.1 We developed an obstetric hemorrhage protocol (OHP) to guide management for these life-threatening situations. The following describes our experience with an OHP in our practice.
Quality improvement data collected from 2010-2015 from OHP implementation to present was reviewed. The OHP was activated 121 times in setting of approximately 16,000 deliveries in that period. Results are summarized in table 1.
Since critical hemorrhage events can evolve rapidly, management requires coordination of personnel, supplies and blood products. Consistent with recommendations of organizations such as WHO,2 the goals of our OHP included organizing staff and systems, as well as providing guidance for lab-based decisions for treatment of hemorrhage and coagulopathy. In response to emerging trends in the management of massive transfusion periodic updates were made in the OHP. The introduction of tranexamic acid and fibrinogen concentrate to the OHP addressed inhibition of fibrinolysis and rapid treatment of hypofibrinogenemia. Point-of-care coagulation testing allowed for detection of coagulopathy, facilitating goal-directed therapy. Interval analysis following process improvement changes suggest they led to improved hemorrhage management as measured by reduced RBC transfusion. Indicators of severe maternal morbidity associated with maternal hemorrhage, ICU admission or transfusion of 4 or more blood products, were also reduced.3 We recognize factors not recorded in our data could also have significant influence such as concurrent changes in organization of our approach and changes in work culture facilitated by the OHP.
Our analysis suggests that OHP refinements since implementation have led to changes in our transfusion practices.
1.Hilton G et al.Checklists and multidisciplinary team performance during
simulated obstetric hemorrhage.IJOA(2016),25:9-16
2.World Health Organization."WHO recommendations for the prevention and treatment or postpartum haemorrhage:evidence base."(2012)
3.Comprehensive Accreditation Manual for Hospitals Update, January 2015; https://www.jcrinc.com/assets/1/14/CAH15_Sample_Pages.pdf