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Designing and implementing an all Wales postpartum haemorrhage quality improvement project: OBS Cymru (the Obstetric Bleeding Strategy for Wales)
  1. Sarah Frances Bell1,
  2. Thomas Kitchen1,
  3. Miriam John2,
  4. Cerys Scarr3,
  5. Kevin Kelly4,
  6. Christopher Bailey4,
  7. Kathryn James1,
  8. Adam Watkins5,
  9. Elinore Macgillivray5,
  10. Tracey Edey6,
  11. Kathryn Greaves7,
  12. Ingrid Volikas4,
  13. James Tozer8,
  14. Niladril Sengupta9,
  15. Claire Francis3,
  16. Rachel Collis1,
  17. Peter Collins10
  1. 1Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
  2. 2Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
  3. 3Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
  4. 4Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
  5. 5Improvement Cymru, Cardiff, UK
  6. 6Midwifery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
  7. 7Midwifery, Cwm Taf Health Board, Methyr, UK
  8. 8Anaesthesia and Critical Care, Aneurin Bevan University Health Board, Newport, UK
  9. 9Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Rhyl, UK
  10. 10Haematology, University Hospital of Wales, Cardiff, UK
  1. Correspondence to Dr Sarah Frances Bell; sarah.bell3{at}wales.nhs.uk

Abstract

Background Postpartum haemorrhage (PPH) contributes to substantial maternal morbidity. Research into PPH has led to improvements in care which have been incorporated into the Obstetric Bleeding Strategy for Wales.

Intervention A national quality improvement team supported local teams in implementing multiple interventions including risk assessment, objective measurement of blood loss, multiprofessional assessment (at the bedside at 1000 mL blood loss) and point-of-care (POC) testing of coagulation to guide blood product resuscitation during PPH. The project was rolled out to all 12 obstetric units in 2017. The interventions were reinforced by an All Wales Guideline, PPH proforma and standardised training. A national database, biannual audits, and patient and staff surveys reported process and outcome measures.

Results Process measures: during 2017, there was an increase in the percentage of maternities with documented risk assessment (0%–76%), objective measurement of blood loss (52%–88%) and POC testing for coagulation for PPH ≥1500 mL (38%–59%). Maternity staff survey indicated that 94% were aware of the project and 87% stated that it had changed their unit’s management of PPH. Interim outcome measures: the incidence (95% CI) of PPH ≥2500 mL per 1000 maternities in 2017 was 6.03 (5.23–6.95). The annual number of women receiving any red blood cell transfusion, level 3 intensive care admission and hysterectomy for PPH was 19.7 (18.2 to 21.3), 0.702 (0.464 to 1.06) and 0.255 (0.129 to 0.504) per 1000 maternities, respectively.

Conclusions A high level of project awareness across Welsh maternity units has been achieved. Measurement of blood loss was reported to be the most important early change in practice, while PPH documentation and POC testing continue to be embedded. Combining qualitative and quantitative measures to inform implementation has improved project delivery and allowed teams to adapt to local contexts.

  • healthcare quality improvement
  • obstetrics and gynecology
  • teamwork
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Footnotes

  • Contributors SFB, holds the grant from the Welsh Government, devised and leads OBS Cymru, designed the analysis, interpreted data and wrote the first draft of the manuscript. AW, analysed and interpreted the data and critically reviewed the manuscript. MJ, EM, TK, CS, CB, KK, KJ collected and interpreted the data and critically reviewed the manuscript. TE collected the data, interpreted data. IV, NS, CF, KG JT, PC analysed the data, interpreted data and critically reviewed the manuscript. RC holds the grant from the Welsh Government, devised and leads OBS Cymru, collected the data, interpreted data and critically reviewed the manuscript.

  • Funding This study was funded by 1000 Lives Improvement Wales, NHS Wales (Efficiency Through Technology Fund) and Werfen.

  • Competing interests PC has received support for research from CSL Behring and Haemonetics. He has acted as a paid consultant to Werfen and Haemonetics. RC has received support for research from CSL Behring.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting and dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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