Maternity iron, anaemia and blood management in South Australia: a practice-based evidence for clinical practice improvement.

BACKGROUND: Anaemia at delivery is a strong modifiable risk factor for transfusion in women with a postpartum haemorrhage (PPH). A Maternity Patient Blood Management (PBM) Practice Based Evidence Clinical Practice Improvement (CPI) was conducted to optimize antenatal haemoglobin and iron stores prior to delivery. METHODS: Australian maternity PBM CPI resources (featuring algorithms on diagnosing iron deficiency with both haemoglobin and ferritin screening, as well as information on oral iron therapy for maternity patients) were introduced at a major tertiary hospital from November 2016 to March 2017. To assess the effectiveness of these resources on haemoglobin and iron stores, an interrupted time series (ITS) analysis was conducted for 11,263 deliveries from January 2016 to June 2018. The evaluation timeframe was divided into baseline (pre-CPI), pilot (during CPI) and post-pilot (post-CPI). RESULTS: In 1550 patients with haemoglobin and ferritin in the first trimester, non-anaemic iron deficiency was detected in 416 women (26·8%) and iron deficiency anaemia (IDA) in 239 women (15·41%) throughout the whole study period. The number of women with IDA increases as pregnancy progresses but applying PBM CPI shows a reduction of IDA rate in all trimesters and reduction in anaemia at delivery in the post-pilot period from baseline. More anaemic episodes were observed in the postpartum period compared to the first trimester. ITS analysis for the whole study period showed a clinically significant increase in the monthly average predelivery haemoglobin of 0·9 g/l (P = 0·16). This corresponded with a reduction in the monthly rate of anaemic patients by 18% (P = 0·12). There was a significant decrease in the rates of anaemia at delivery and decrease in red cell transfusion in anaemic women, even though the number of women with PPH was stable. The factors associated with red cell transfusion are anaemia at delivery (P < 0·001) and the incidence of PPH (P < 0·001). CONCLUSIONS: The maternity PBM CPI resources had a clinically relevant but not statistically significant effect in optimizing antenatal haemoglobin and decreasing the risk of predelivery anaemia. This study demonstrates how a CPI can modify one risk factor for blood loss, which is the anaemia at delivery, and subsequent transfusion in the perinatal period.

Embedding best transfusion practice and blood management in neonatal intensive care.

BACKGROUND: Transfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best transfusion principles in the neonatal intensive care unit (NICU) by aligning local policies, providing targeted education and partnering with parents. METHODS: Practice-based evidence for clinical practice improvement (PBE-CPI) methodology was used. Previous hospital accreditation audits were reviewed and a neonate-specific transfusion audit was developed. Audit was performed at baseline and repeated following the intervention period. NICU clinicians received targeted education in obtaining informed consent, prescription and safe administration of blood components during a 'Blood Month' awareness period. A neonate-specific parent handout about transfusion was developed in partnership with parents. A pilot video demonstrating a shared consent discussion was also developed to assist in the consent process. Parents' knowledge, concerns and feedback regarding transfusion practice was sought at baseline (survey) and on project completion (experience trackers). RESULTS: Neonate-specific baseline transfusion audit showed inconsistent consent, monitoring and documentation processes in neonatal transfusions. Post-targeted education audit showed improvement in these parameters. The targeted PBM and transfusion-related education delivered during 'Blood Month' was well-received by staff. Parents' feedback about the NICU transfusion consenting process was consistently positive. NICU medical and nursing clinicians (n=25) surveyed agreed that the parent handout was well set out, easy to understand and recommended that it be used to complement practice. CONCLUSION: PBE-CPI tools aligned with Australian PBM guidelines for clinicians and parents were well-accepted by clinical stakeholders and were associated with practice improvement in PBM awareness and transfusion consent processes. This PBE-CPI project developed NICU-specific consent information, not previously available, by partnering with parents to ensure quality of care in transfusion practice. Adoption of this also helps to meet accreditation for Australian Blood Management Standards. These strategies and tools translate readily into other NICUs to embed and support best PBM and transfusion practice.

Improving patient blood management in obstetrics: snapshots of a practice improvement partnership.

Iron deficiency and anaemia are common in pregnancy. Audit data from our tertiary obstetrics unit demonstrated 22% of maternity patients experiencing a postpartum haemorrhage received a transfusion; a third of whom were anaemic on admission intrapartum. Australian Patient Blood Management (PBM) Module 5 Obstetrics guidelines focuses on maximising red cell mass at the time of delivery and reducing the reliance on transfusion as a salvage therapy to treat blood loss. A clinical practice improvement partnership began in February 2015 and completed in April 2016; which aimed to implement systems to improve antenatal identification and management of iron deficiency, and improve postpartum anaemia management. In order to develop change strategies, reasons for poor detection and correction of iron deficiency in the antenatal period were identified following a quality improvement methodology. Education was delivered to maternity healthcare providers. Standardised algorithms and an oral iron prescription handout were developed and piloted. Follow-up audit, staff and patient feedback, and other hospital data were collected to measure outcomes. The rate of anaemia on admission intrapartum fell from 12.2% in 2013 to 3.6% in 2016 following the introduction of unselective ferritin screening and other antenatal interventions. Sixty to 70% of maternity patients screened each month had iron deficiency. The algorithms aided staff to become confident in blood test interpretation and management of iron deficiency and anaemia. Patients found the oral iron prescription handout helpful. Additionally, single unit transfusions significantly increased from 35.4% to 50% (p=0.037) over the project timeframe. This project demonstrated the potential to improve patient blood management in obstetrics, reduce anaemia and transfusions by active antenatal interventions.