Implementation of a maternity hospital rotational thromboelastometry (ROTEM®) guided transfusion strategy: a quality improvement study*

Abstract

A rotational thromboelastometry (ROTEM^®) guided transfusion strategy for obstetrics was implemented at our institution in September 2022. The aim of the strategy was to facilitate timely, targeted administration of coagulation products based on viscoelastic haemostatic testing, thereby reducing unnecessary transfusions. To improve compliance with the ROTEM^® strategy, an electronic decision tool was developed and integrated into a smartphone application, supported by departmental education and training. We subsequently analysed data on 944 women who experienced postpartum haemorrhage ≥ 1500 ml over a 5-year period, comparing 1 year of data after the formal introduction of the ROTEM^®-guided transfusion strategy (post-ROTEM^®) with the previous 4 years, when a conventional transfusion strategy was in place based on standard laboratory tests (pre-ROTEM^®). Following implementation, the annual use of fibrinogen concentrate, Octaplas^® (Octapharma Pharmazeutika GmbH, Vienna, Austria) and platelets to treat PPH ≥ 1500 ml decreased by 46%, 72% and 79%, respectively, yielding a cost saving of €51,738. Compliance with evidence-based fibrinogen transfusion triggers improved significantly (84% vs. 23%) and empirical product use was eliminated. There was no statistically significant difference in the proportion of women who progressed to severe haemorrhage (≥ 2000 ml) between groups: 97/238 (40%) in the post-ROTEM^® group vs. 312/706 (44%) in the pre-ROTEM group (p = 0.35). This quality improvement initiative demonstrated that embedding a ROTEM^®-guided transfusion strategy into clinical workflows, supported by a decision tool and staff training, can enhance adherence to evidence-based practice, reduce unnecessary coagulation product use and generate substantial cost savings, without adversely affecting clinical outcomes. These findings may inform institutions seeking to optimise transfusion strategies in obstetric haemorrhage through structured implementation approaches.