Improving patient blood management in obstetrics ... · Improving patient blood management in...

Improving patient blood managementin obstetrics: snapshots of a practiceimprovement partnership

Cindy J Flores,1 Farah Sethna,2,3 Ben Stephens,4 Ben Saxon,5 Frank S Hong,1

Trish Roberts,5 Tracey Spigiel,5 Maria Burgess,4 Belinda Connors,4 Philip Crispin3,6

To cite: Flores CJ, Sethna F,Stephens B, et al. Improvingpatient blood management inobstetrics: snapshots of apractice improvementpartnership. BMJ QualityImprovement Reports2017;6:e000009.doi:10.1136/bmjquality-2017-000009

1Australian Red Cross BloodService, West Melbourne VIC,Australia2Obstetrics & Maternal/FetalMedicine, Canberra Hospitaland Health Service, GarranACT, Australia3Australian NationalUniversity Medical School,Garran ACT, Australia4Canberra Hospital andHealth Service, Garran ACT,Australia5Transfusion Policy andEducation, Australian RedCross Blood Service,Adelaide SA, Australia6Haematology, CanberraHospital and Health Service,Garran ACT, Australia

Correspondence toCindy Flores, Australian RedCross Blood Service, 100-154 Batman St, WestMelbourne, VIC 3003Australia; [email protected]

ABSTRACTIron deficiency and anaemia are common in pregnancy.Audit data from our tertiary obstetrics unitdemonstrated 22% of maternity patients experiencing apostpartum haemorrhage received a transfusion; athird of whom were anaemic on admissionintrapartum. Australian Patient Blood Management(PBM) Module 5 Obstetrics guidelines focuses onmaximising red cell mass at the time of delivery andreducing the reliance on transfusion as a salvagetherapy to treat blood loss. A clinical practiceimprovement partnership began in February 2015 andcompleted in April 2016; which aimed to implementsystems to improve antenatal identification andmanagement of iron deficiency, and improvepostpartum anaemia management. In order to developchange strategies, reasons for poor detection andcorrection of iron deficiency in the antenatal periodwere identified following a quality improvementmethodology. Education was delivered to maternityhealthcare providers. Standardised algorithms and anoral iron prescription handout were developed andpiloted. Follow-up audit, staff and patient feedback, andother hospital data were collected to measureoutcomes. The rate of anaemia on admissionintrapartum fell from 12.2% in 2013 to 3.6% in 2016following the introduction of unselective ferritinscreening and other antenatal interventions. Sixty to70% of maternity patients screened each month hadiron deficiency. The algorithms aided staff to becomeconfident in blood test interpretation and managementof iron deficiency and anaemia. Patients found the oraliron prescription handout helpful. Additionally, singleunit transfusions significantly increased from 35.4% to50% (p=0.037) over the project timeframe. Thisproject demonstrated the potential to improve patientblood management in obstetrics, reduce anaemia andtransfusions by active antenatal interventions.

PROBLEMSuspected iron deficiency and anaemiaremain a problem for pregnant womencoming into delivery, and may lead to a redcell transfusion in the event of postpartumhaemorrhage (PPH). An audit of transfusionin PPH at our hospital identified the

potential for optimisation of antenatalhaemoglobin and iron stores to potentiallyreduce red cell transfusion requirements andimprove outcomes. In addition, red celltransfusion appeared to be undertaken liber-ally, both in terms of the haemoglobintrigger and the number of units transfused.Having identified a gap in antenatal andperipartum blood management, the hospitaland the Australian Red Cross Blood Service(Blood Service) collaborated to conduct aclinical practice improvement (CPI) activity.The CPI project aimed to align practice

with current PBM Module 5 Obstetrics guide-lines in two specific ways: (1) to improve theidentification and management of irondeficiency during the antenatal period; and,(2) to improve the management of anaemiapostpartum by rapidly replenishing ironstores when appropriate and reduce un-necessary transfusion. The PBM Module 5guidelines state that transfusion should bebased on symptoms, especially when thehaemoglobin concentration is greater than70 g/L, and is generally inappropriate whenthe haemoglobin is more than 100 g/L.1

The transfusion of a single unit followed byclinical reassesment is also advocated. Weaimed to see whether implementing PBMstrategies in the antenatal and postnatal set-tings would improve haemoglobin concentra-tions prior to delivery and reduce the rate oftransfusion.

BACKGROUNDIron deficiency is the most common cause ofanaemia worldwide, and even in developedcountries where dietary iron is readily avail-able, remains a significant cause of morbid-ity.2 Anaemia is associated with fatigue,decreased exercise tolerance and reducedquality of life. During pregnancy, anaemiahas a deleterious effect not only on thewoman affected, but also on the fetus and

Flores CJ, et al. BMJ Quality Improvement Reports 2017;6:e000009. doi:10.1136/bmjquality-2017-000009 1

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subsequent child health outcomes, including reducedbirthweight, increased risk of preterm birth and anincreased risk of anaemia in infancy.3 4 The rising con-cerns about the safety of transfusion have given rise to arenewed focus on conserving the patient’s blood withefforts designed to maximise red cell mass and reducebleeding rather than rely on transfusion to replace lostred cells.5

The Australian Patient Blood Management (PBM)guidelines Modules 1–6 have been developed to focusclinical practice towards not merely reducing transfu-sion, but to improve the ability of the patient to tolerateimpending blood loss as might be anticipated withsurgery or childbirth.1 6 These guidelines recognise theneed to have adequate haemoglobin prior to suchhaemostatic challenges, and the need for reserve storesof iron to enable a rapid response from the marrow toreplenish lost red cells. They also recommend a focuson the appropriateness of transfusion decisions, both interms of the clinical triggers for transfusion and theamount of blood transfused, noting that liberal transfu-sion strategies have not shown benefit, and in many cir-cumstances cause harm when compared with restrictivestrategies.7–9

Women are at risk of iron deficiency due to increasediron demands from menstruation, pregnancy and lacta-tion. Obstetric guidelines from developed countries gen-erally recommend screening for anaemia withhaemoglobin measurement alone.10–12 Organisationsfollowing recommended guidelines will only be detect-ing iron deficiency if anaemia develops before routineantenatal testing, which in most cases is completed by24–26 weeks gestation. Non-anaemic iron deficiency andanaemia developing after this time is not routinelyscreened for or treated. Other guidelines for peripartum

bleeding do not address the issue of optimising haemo-globin during pregnancy, which indicates there is vari-ability of clinical practice in preparing pregnant womenfor a known haemostatic challenge with a significant riskof transfusion.13

BASELINE MEASUREMENTAudit data from our tertiary obstetrics unit found that12% of maternity patients who had a PPH (defined asbleeding in the first 24 hours of childbirth of ≥500 mLand ≥1000 mL following vaginal and caesarean deliver-ies, respectively13) were anaemic on admission intrapar-tum.14 A majority of this group (58.5%) requiredtransfusion, whereas maternity patients without anaemiarequired transfusion in only 17.8% of cases. Iron studieswere not routinely taken, but with 49% of anaemicmaternity patients having red cell microcytosis and afurther 28% having falling mean cell volume (MCV) orlow ferritin, iron deficiency was suspected or confirmedin the majority of cases of anaemia. Additionally ninewomen required a postpartum transfusion in theabsence of a PPH, seven of these maternity patients pre-sented anaemic.Postpartum transfusion was also audited. Although

PBM Module 5 guidelines recommend transfusing asingle unit of red cells then re-evaluating the clinicalneed, only 14% of transfusions involved a single unit.15

Transfusions were also assessed as likely to be inconsist-ent with guidelines in a large number of cases. As aresult of the audit, significant under-recognition andunder-treatment of iron deficiency and overuse of redcell transfusion was identified.The key areas identified as contributing to poor detec-

tion and correction of iron deficiency in the antenatalsetting (Figure 1) included a lack of standardisation in

Figure 1 Causes of poor detection and correction of iron deficiency in the antenatal setting

2 Flores CJ, et al. BMJ Quality Improvement Reports 2017;6:e000009. doi:10.1136/bmjquality-2017-000009

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testing protocols for iron deficiency; no standardisedapproach to oral iron prescription with a wide range ofproducts (many of limited efficacy); and, poor interpret-ation of iron studies. A snapshot audit of 30 pregnantwomen at booking demonstrated only 10 (33%) had afull blood count (FBC) at booking, 3 (10%) had ferritinmeasured, and only 4 (13%) had a clinical risk assess-ment for iron deficiency. Similarly, in the second andthird trimesters there were low rates for FBC (53%, 30%respectively) and ferritin (10%, 6%) with no pregnantwomen offered iron therapy when appropriate.

DESIGNThe project was conducted in a tertiary regional referralobstetric hospital with over 3000 deliveries per yearwhich has specialist fetomaternal medicine and neonatalintensive care facilities. Maternity patients delivering atthe hospital were identified as having a large number ofservice entry points including general practitionershared care, midwife led, standard risk, bariatric andhigh risk medical, young parent, mental health and sub-stance abuse antenatal outpatient clinics, indigenoushealth services, and referrals antepartum from localprivate and interstate hospitals for high acuity care.In response to baseline results coupled with issues

contributing to poor detection and correction of irondeficiency in the antenatal setting, a standardised algo-rithm was developed for use in all hospital antenatalclinics (Figure 2a). The key features included testing forhaemoglobin and serum ferritin on all pregnant womenat booking (first antenatal visit) and providing iron

therapy to all women with ferritin ≤30 µg/L. Oral ironwas preferred but intravenous iron was given when oraliron was poorly tolerated or in late pregnancy when thetime to respond to oral iron was limited. Repeat testingwas performed as required. The aim was for testing tobe conducted with standard antenatal visit when haemo-globin and blood group and screen testing were beingperformed to avoid additional inconvenience forwomen. A plan for funding and administration of intra-venous iron was developed using iron carboxymaltose asit can be given over 20 minutes by short infusion, mini-mising the impact on outpatient clinic time. An oraliron prescription handout was developed to providewomen with information on the need for oral iron, sideeffects and the differences between products on themarket, highlighting those with doses large enough tobe recommended for treatment of iron deficiency(Figure 2b). Implementation was supported by an edu-cational strategy for clinicians and midwives.The impact of interventions was monitored predomin-

antly by observation. Short, open-ended questions wereused to elicit target user views on tools developedduring the project. Resource utilisation, including path-ology testing, intravenous iron and red cell usage rates,were assessed to gauge the impact of interventions, andthe effect on pre-delivery haemoglobin and iron defi-ciency levels were measured to determine the overalloutcomes from the interventions.The CPI activity was led by a multidisciplinary team

including representation from obstetrics, haematologyand the Blood Service. The improvement team metevery month to monitor the project progress. The

Figure 2 CPI tools for maternity






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project began in February 2015 and was completed inApril 2016.

EthicsThe audit met institutional ethics committee guidelinesfor quality improvement. Data collection was alsoapproved by the institutional Human Research EthicsCommittee as low risk research. All clinical interventionswere conducted within standard clinical practice modelsand medications prescribed and administered withinapproved product information. When feedback wassought from patients or staff, providing such feedbackwas voluntary.

StatisticsChanging variables during the project were plotted inrun charts at variable intervals depending on the collec-tion of data with different audits, or monthly for retro-spectively collected data. Descriptive statistics were usedto feedback survey results. Comparisons before and afterinterventions were evaluated by the use of two tailed Ttests for means or Chi-squared tests where event rateswere compared.

STRATEGYAntenatal care processes were mapped to maximise theidentification of women in early pregnancy and theteam reviewed these processes to determine the causesfor presenting with iron deficiency. Strategies were thendevised and tested to maximise identification of irondeficiency during pregnancy. These were determined bygroup consensus, aiming to identify potential areas forsustainable changes to practice, considering the ease ofimplementation and current areas of weakness.

Improvement (PDSA) Cycle 1Knowledge gaps were identified and addressed withrolling out education across maternity health providersin the hospital. Simultaneously, key stakeholders includ-ing midwives and medical leadership were identifiedand approached to support changes to antenatal clinicand postpartum transfusion practices.

Improvement (PDSA) Cycle 2Consultation with key stakeholders led to the developmentof a standardised algorithm and an oral iron prescriptionhandout. The algorithm was posted up in the antenatalclinic wall and handout for patients were provided in theclinic. Feedback from maternity staff and patients werepositive. These tools were embedded in practice.

RESULTSAntenatalThere was a significant increase in the number of fer-ritin tests being requested from the hospital antenatalsettings during the project with 60% to 70% of womenscreened each month had iron deficiency (Figure 3). Anincrease in the use of intravenous iron during the sameperiod indicated that iron deficiency, once identified,was treated. A record of women receiving oral iron wasnot kept as the iron was advised and available from thewomen’s local community pharmacies. Anaemia at deliv-ery improved during the project, with 2/55 women(3.6%) at the end of the project compared to the 53/434 (12.2%) in the 2013 audit.

Patient informationAn audit of 24 iron deficient pregnant women wasundertaken. Women were contacted approximately 3

Figure 3 Number of ferritin requests






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weeks after iron deficiency had been identified. Of the21 women successfully contacted by telephone, 20 hadbought and were taking oral iron as recommended bythe clinical team. Only 14 (67%) had received the oraliron prescription handout, all of whom found it helpful.If they indicated that it was helpful, patients were askedhow they found it helpful, with some of the responsesnoted in Table 1. Clinical staff were also invited toprovide written feedback during the implementationphase, with comments on the tools developed alsorecorded in Table 1.

TransfusionsThere was considerable variability month to month inthe number of transfusions and the proportion of trans-fusions that were single unit transfusions, in large partdue to the occurrence of large volume PPH. Despitethis, the number of transfusion episodes decreased froma mean of 13.1 per month to 8.9 per month (p=0.008),corresponding to a reduction in transfused units from amean of 26 to 17 per month (p=0.03). There was also

an increased proportion of single unit transfusions, from79/223 (34.4%) to 31/62 (50%, p=0.037) before andafter the project interventions and implementation of ahospital-wide single unit transfusion policy (Figure 4).Although our educational strategies encouraged clini-

cians towards a restrictive transfusion strategy, with trans-fusion generally considered appropriate when Hb<70 g/L, there was no strict cut-off, with cliniciansencouraged to consider patient symptoms in the deci-sion to transfuse. Rates of transfusion with Hb <70 g/Lremained stable before and after our interventions (32%v 37%, p=0.4). The strategy of considering symptomsafter single unit transfusion may have had an impact ontransfusion targets, with post transfusion Hb <90 g/Lbeing found in 49% of cases prior to intervention, com-pared with 61% afterwards (p=0.08).

LESSONS AND LIMITATIONSConventional practice in obstetrics acknowledges irondeficiency anaemia as a potential cause for morbidity.

Table 1. Feedback from Staff and Patients on Resources

Staff comments – iron pathwayStaff comments – oral ironinformation

Patient comments – oral ironinformation

I have learnt about the importance of

looking at more than just the Hb result.

It took me some time to get used to the

algorithms, and I had to keep looking

things up. I have to do that less now.

They are easy to follow and use. I have

not come across a situation when the

chart did not tell me what to do.

Having the information leaflets made it

easier for me to have a conversation

with her about her results, and to tell

her what iron preparation she could try.

Helped me understand about anaemia.

Helped select the tablet I bought.

I was showed pictures of preparations.

Just helped with understanding what was

happening.

Listed all the different types and iron

levels in each.

Showing the pictures of the bottle and

how to take the tablets was helpful.

What foods to be eating and how to take

the supplements.

Figure 4 Total and single unit transfusions






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However, obstetric management guidelines recommendscreening pregnant women for anaemia with a FBC onlyand do not suggest universal screening with ferritin oruniversal iron replacement in high income coun-tries.10–12 This is despite prior work demonstrating thepotential to reduce transfusion with antepartum identifi-cation and management of iron deficiency.16 The preva-lence of iron depletion is high in young women andpregnancy, particularly during the third trimester whenthere is an additional strain on iron stores.17 18

In response to our own data showing a significant rateof anaemia at delivery (which increased the risk of trans-fusion postpartum) and new PBM Module 5 guidelines,we implemented a multifaceted quality improvementapproach. Examining our processes demonstrated mul-tiple opportunities for improvement, including not iden-tifying pregnant women at risk, lack of appropriatepathology studies to demonstrate iron deficiency, and afailure to intervene when iron deficiency was confirmed.In addition, transfusion practice was liberal, notresponding to mounting evidence of lack of efficacy, andpotential for harm with such a strategy.Our interventions were a combination of systemic

changes and education. Systemic changes includedroutine antenatal ferritin testing, the development ofpatient information and iron prescription forms, stan-dardised management algorithms at antenatal clinics,and intravenous iron infusions available within the ante-natal clinic. The results showed a clear benefit in termsof the rate of anaemia at delivery and the number oftransfusions. The algorithms and patient informationhave been made publicly available through the BloodService, enabling easy and rapid adaptation for otherinstitutions. The results are limited by relatively shortfollow up, although the systemic interventions haveshown considerable benefit and have been embeddedwithin clinical practice.Education reinforced the systemic changes and was

well-accepted by clinical stakeholders. Transfusion prac-tice based on transfusion thresholds did not show a stat-istically significant benefit, and is the one area withinour process completely dependent on education of clini-cians alone. Some recidivism is frequently seen inquality improvement strategies reliant solely on educa-tion once the initial enthusiasm for intervention wanes.It is hoped that as clinicians get more comfortable withmanaging anaemic women for short periods of timewhile their haemoglobin increases, the transfusionthresholds may improve.10 The results of our interven-tion are less dependent on education than the antenatalhaemoglobin optimisation interventions.Our project is also limited by a lack of formal cost

benefit analysis. Red cells are expensive to acquire andadminister, and a direct cost saving will occur fromreduced usage. With a reduction in red cell transfusionsof nine units per month, there are direct cost savings of$401.94 per unit19 (∼$3,617.46 per month), and the

cost saving is even higher if administration costs weretaken into account.20 21 Expenditure on iron, particu-larly intravenous iron, offsets some of these savings, with1000 mg of ferric carboxymaltose costing $306.96,22 andadditional administration costs expected. Cost ofincreased ferritin testing is another direct cost. Indirectcosts include time lost for infusions, side effects of irontherapy, and risks of acute transfusion reactions.Importantly, any formal cost benefit analysis shouldinclude an assessment of the effect of anaemia on theinfant and quality of life for the mother.The strategy for iron replacement in this project

included all women with low iron stores, rather than justthose with anaemia. There is conflicting data on theimpact of non-anaemic iron deficiency in women,23 24 andfurther research in pregnancy to determine the effect ofnon-anaemic iron deficiency on fetal welfare is justified.Although our project has shown benefits, there are oppor-tunities to refine the process. Further research may beuseful to determine the optimal times to assess iron storesduring pregnancy. It is anticipated that more active inter-vention in early pregnancy with oral therapy may reducethe need for intravenous iron later in gestation. Betterawareness of iron deficiency in primary care and proactivescreening for women considering pregnancy would alsooffer an opportunity for further intervention. Strategies toimprove the prescribing of blood in postpartum womenare also warranted and may need to focus on physicianperceptions and experience.25 At postpartum, there aremany conflicting causes of symptoms that may be attribu-ted to anaemia and further work could focus on identify-ing symptoms most specific to anaemia to develop moreobjective criteria for transfusion prescription.

CONCLUSIONA combination of systemic changes and education thatare aligned with PBM Module 5 Obstetrics guidelineswere well-accepted by clinical stakeholders, which led toa practice improvement embedded in practice. This CPIproject demonstrated the potential to improve patientblood management in obstetrics, reduce anaemia andtransfusions by active antenatal interventions. In theprocess, strategies and tools were developed that maytranslate readily into other institutions.

Acknowledgements We thank the maternity staff for their support inimplementation of tools and embedding in practice. We also thank thepatients who engaged in the project.

Australian governments fund the Australian Red Cross Blood Service toprovide blood products and services to the Australian community.

Declaration of interests None declared.

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