PATIENT SAFETY SERIES

Brett D. Einerson, MD, MPH; Emily S. Miller, MD, MPH; William A.

Grobman, MD, MBA

Shannaz
11.2013.184
Abstract
OBJECT : To determine whether the introduction of a postpartum hemorrhage
(PPH) safety program was associated with changes in clinical practice and outcomes,
and to examine whether these changes were sustained over time.
SETTING : Northwestern
DESIGN : Cohort Study
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). Concomitantly, the number of days
between admissions to the intensive care unit for PPH increased.
 Problem
Data from a nationwide sample in the United States 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
The program 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
 The active management of the third stage of labor was
instituted routinely and included administration of oxytocin
(either intramuscular or intravenous) immediately following
delivery of the fetus and gentle controlled cord traction to
deliver the placenta.
Patients were included in the present analysis if they had an
EBL of >500 mL for vaginal delivery, >1000 mL for
cesarean delivery, or if they received a blood transfusion or
uterotonic medications for obstetric hemorrhage
Maternal demographic and obstetric data were abstracted from the
medical record of all eligible subjects.

Maternal demographic characteristics included age, self-reported

race/ethnicity, and parity.
Obstetric data included the presence of placenta previa, placenta
accreta, multiple gestation, preeclampsia, magnesium sulfate use,
and chorioamnionitis.
Additional characteristics including gestational age at delivery,
length of labor, induction of labor, use of oxytocin, and
birthweight also were recorded.
 Document
Data were collected on treatments and outcomes related to
PPH. Clinical interventions to control hemorrhage included
the type and number of uterotonic medications
(methylergonovine, prostaglandin F2-alpha, and
prostaglandin E1), as well as the use of intrauterineballoon
tamponade, B-Lynch suture placement, uterine artery
embolization, and hysterectomy
 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), and
maternal death
Two types of analyses were performed
First, we compared variables before and after the
program start using the t test,Wilcoxon rank sum
test, or c2 test, as appropriate.
Second, we used Shewhart chartsea type of chart
frequently used in quality-control analysese
specifically to identify sustained change over time. A
full description of Shewhart chart methodology is
published elsewhere.
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).
Several clinical interventions to control hemorrhage were
significantly different after the initiation of the
program(Table 2) and these changes persisted over time.
Comment
Our study has its limitations. First as 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.
In addition, we monitored the outcomes of PPH after the
introduction of a multifaceted set of interventions that were
aimed at reducing maternal morbidity related to PPH.
Comment
Lastly, the study was conducted in a single institution,
Despite the limitations of our study, these results support the
growing body of literature that suggests the development of a
multidisciplinary patient safety program can enhance obstetric
interventions and improve maternal outcomes related to PPH.
Our results suggest not only that the introduction of a PPH program
yields improvements in care, but also that these improvements can be
sustained over time.