Implementation of a statewide bundle on obstetric hemorrhage in New York.

Abstract

Introduction: Obstetric hemorrhage is one of the leading causes of maternal death and also one of the most preventable. In 2017, a New York statewide initiative led by the New York State Perinatal Quality Collaborative asked birthing hospitals to implement an ACOG District II Safe Motherhood Initiative evidence-based bundle on recognition and management of hemorrhage, and to assist and offer extensive education, assistance, and feedback. This report describes the process and results.

Methods: The bundle was available to all birthing hospitals. Hospitals were asked to implement 21 measures, with a goal of each measure being implemented by at least 85% of hospitals. Webinars and teaching sessions were attended by participating hospital teams to foster collaborative learning, share best practices, provide technical assistance and education, and serve as a forum for discussion of successes and barriers. Hospitals used standardized data collection forms to report measure implementation, aggregate patient data, and for major hemorrhages (requiring massive transfusion, hysterectomy, transfer to a higher level of care, or death), deidentified patient-level data. Data were analyzed using chi-square, repeated measures ANOVA, linear regression, and Cochrane's Q tests.

Results: Eighty-six hospitals initially engaged (78 ultimately completed), with teams attending 35 webinars and 3 learning sessions. At the initiative's start, 6 of the 21 measures already were in place at 85% of hospitals; by the initiative's end, this increased to 19 of 21 with significant increases (p < 0.05) for all but two. The percent of patients defined as having obstetric hemorrhages increased during the initiative as use of quantitative blood loss (QBL) increased from 9.8% to 14.5% (p < 0.001); among patients with major hemorrhages, exclusive QBL use increased blood loss volume by 287 mL (p = 0.004). Among patients with major hemorrhages, the need for transfer to higher levels of care decreased during the initiative (p = 0.02), although rates of hysterectomy or use of massive transfusion were unchanged.

Conclusion: A comprehensive statewide initiative encouraging hospitals to adopt an evidence-based bundle on obstetric hemorrhage was successful in that 19 of 21 measures were implemented by ≥85% of hospitals. Focused statewide initiatives can improve hospitals' ability to provide evidence-based obstetrical care.