Journey of medication reconciliation compliance in a lower middle-income country: a retrospective chart review.

OBJECTIVE: There were three main objectives of the study: to determine the overall compliance of medication reconciliation over 4 years in a tertiary care hospital, to compare the medication reconciliation compliance between paper entry (initial assessment forms) and computerised physician order entry (CPOE), and to identify the discrepancies between the medication history taken by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission. METHODS: This study was conducted at a tertiary care hospital in a lower middle-income country. Data were gathered from two different sources. The first source involved retrospective data obtained from the Quality and Patient Safety Department (QPSD) of the hospital, consisting of records from 8776 patients between 2018 and 2021. The second data source was also retrospective from a quality project initiated by pharmacists at the hospital. Pharmacists collected data from 1105 patients between 2020 and 2021, specifically focusing on medication history and identifying any discrepancies compared with the history documented by physicians. The collected data were then analysed using SPSS V.26. RESULTS: The QPSD noted an improvement in physician-led medication reconciliation, with a rise from 32.7% in 2018 to 69.4% in 2021 in CPOE. However, pharmacist-led medication reconciliation identified a 25.4% (n=281/1105) overall discrepancy in the medication history of patients admitted from 2020 to 2021, mainly due to incomplete medication records in the initial assessment forms and CPOE. Physicians missed critical drugs in 4.9% of records; pharmacists identified and updated them. CONCLUSION: In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.

The clinical manifestations and pregnancy outcomes of COVID-19 infection at a tertiary care hospital.

Objective: To evaluate clinical presentation and pregnancy outcomes in pregnant women with Covid-19 infection in our local tertiary care from lower middle-income country. Methods: A retrospective study was conducted at Obstetrics & Gynecology department, Sheikh Saeed Memorial Hospital (SSMH) of The Indus Hospital and Health Network (IHHN) from March 2020 to August 2021. Data of 422 admitted pregnant women with COVID-19 infection was retrieved for demographic and clinical information, laboratory tests, pregnancy outcome, and neonatal outcomes on RED-Cap and analyzed on SPSS 26. Univariate and multivariable logistic regression analyses were performed to estimate odds ratios (OR) for symptomology with categorical variables and feto-maternal outcome. Results: Of the total 422 pregnant women, 24.4% were symptomatic, 74.7% exhibiting mild symptoms. Largely reported symptoms were fever (71.8%), cough (36.9%) and body ache (35.0%); while odds of symptomatic COVID-19 infection was less in educated pregnant women (OR 0.3; 95% CI 0.1-0.9) compared to uneducated. Amongst maternal comorbidities, odds of having symptomatic COVID-19 infection were 3.8 times (95% CI 1.1-13.0) in women with chronic hypertension and 5.5 times (95% CI 2.9-10.4) in women with diabetes. Symptomatic women had significantly greater incidence of miscarriages (p= 0.009), PPROM (p= 0.001), preterm birth (p= 0.000), preeclampsia (p= 0.000), placental abruption (p= 0.006) and maternal ICU admission (p= 0.000) than asymptomatic patients. Still birth was higher (6.4% vs 1.3%, p-value= 0.013) in symptomatic group. The odds of having severe maternal outcome were higher (OR=3.5; 95% CI 1.9-6.0) in symptomatic pregnant women. Conclusion: Majority of pregnant women were asymptomatic. Symptomatic women with COVID-19 infection had an increased risk of adverse feto-maternal outcome.

Breakthrough COVID-19 infections - Analyzing our experience.

Objective: There are many cases of post-vaccination COVID-19 globally. Also, literature on serum antibodies after vaccination is abundant. Our research focuses on breakthrough infections reported at our institution during the third wave of COVID-19. Methods: A total of 177 people recruited at the Indus Hospital Karachi between May to September 2021 with COVID-19 infection were divided into vaccinated, partially vaccinated, and unvaccinated cohorts. Furthermore, a subset of the vaccinated cohort was tested for anti-NP and anti-S antibodies. Results: There were 119 patients with breakthrough infection, however, 74% had mild symptoms. The antibodies against NP and S were found at a higher level in those who had a breakthrough infection in comparison to healthy vaccinated controls. Conclusion: Vaccination does not prevent disease but does confer some immunity causing less severe infection.

The quality of life of HIV positive Transgender and homosexual population in Karachi, Pakistan.

Objectives: To study the demographics and the quality of life of Transgenders and men who have sex with men (MSM) infected with Human Immunodeficiency Virus (HIV). Methods: A Cross sectional study conducted from 2019 to 2021 in the Indus Hospital Karachi. A 30 minutes interview was conducted among HIV positive homosexual participants. Results: Out of 100 patients enrolled 58% were transgender, 39% uneducated, 76% not supported financially by family, 20% reported hospital misconduct, 50% were commercial sex workers and 64% had anxiety. Our results also showed that increasing patient knowledge does not guarantee safe sex habits (p-value=0.82). Conclusion: We found declining psycho-social wellbeing in this population. Education and family support may help establish a good standard of living in them. More studies are needed in the Pakistani transgender population in order to understand their needs better.

WHO Point Prevalence Survey to Describe the Use of Antimicrobials at a Tertiary Care Center in Pakistan: A Situation Analysis for Establishing an Antimicrobial Stewardship Program.

Antimicrobial stewardship is a systematic approach for promoting and monitoring responsible antimicrobial use globally. We conducted a prospective point prevalence survey of antimicrobial utilization among hospitalized adult patients during September 2021. The survey instrument was adapted from the WHO methodology for point prevalence surveys, and it was conducted at The Indus Hospital and Health Network, Karachi. Among the 300 admitted patients, 55% were males and the mean age was 44 (±18) years. At least 67% of the patients received one antimicrobial agent and the most common indication was surgical prophylaxis (40%). The most frequently used were antibacterial agents (97%) among all antimicrobials. Amoxicillin/Clavulanic acid and Ceftriaxone were the most frequently used antibacterial agents, i.e., 14% each. At least 56% of the antibacterial agents were amenable to antimicrobial stewardship when reviewed by infectious disease (ID) experts. Reasons for stewardship were: antibacterial not indicated (n = 39, 17.0%), unjustified prolonged duration of antibacterial (n = 32, 13.9%), extended surgical prophylaxis (n = 60, 26.2%), non-compliance to surgical prophylaxis guidelines (n = 30, 13.1%), and antibacterial not needed on discharge (n = 27, 11.7%). Median days of therapy (DOT) per agent was 3 days (IQR 2-4), while median DOT per patient was 2 days (IQR 1-4). These data have described the pattern of antimicrobial utilization in our institute. We found a higher prevalence of antimicrobial use overall as compared to the global figures, but similar to other low- and middle-income countries. Two important areas identified were the use of antimicrobials on discharge and extended surgical prophylaxis. As a result of these data, our institutional guidelines were updated, and surgical teams were educated. A post-intervention survey will help us to further determine the impact. We strongly recommend PPS at all major tertiary care hospitals in Pakistan for estimating antimicrobial utilization and identifying areas for stewardship interventions.

Retraction: Determinants of Hypertension Among Patients With Type 2 Diabetes Mellitus in Karachi, Pakistan: A Cross-Sectional Study.

[This retracts the article DOI: 10.7759/cureus.22157.].

Determinants of Hypertension Among Patients With Type 2 Diabetes Mellitus in Karachi, Pakistan: A Cross-Sectional Study.

INTRODUCTION: Hypertension is the persistent rise of systemic arterial blood pressure. Among diabetic patients, hypertension is one of the important public health challenges. The frequency of hypertension among diabetic patients is almost twice than that of non-diabetic patients. This study aims to determine the determinants of hypertension among type 2 diabetes patients in Karachi, Pakistan. METHODOLOGY: This was a cross-sectional study conducted in diabetic clinics of a tertiary care hospital from August 2020 to August 2021. The source population included all adult patients with type 2 diabetes at the follow-up clinic of Liaquat National Hospital and Aga Khan Hospital. Data collection was done using a structured interviewer-administered questionnaire. REDCap software (Vanderbilt University, Nashville, TN) was used for the data collection. RESULTS: A total of 610 patients were included in the study. The mean age of participants was 57.37 (±11.32) years. The overall prevalence of hypertension among diabetic patients was 39.84%. Age, physical activity, family history of hypertension, smoking status, BMI, sedentary lifestyle, stress level, and serum creatinine were independent determinants of hypertension among people with type 2 diabetes mellitus. CONCLUSION: In this study, age, physical activity, family history of hypertension, smoking status, BMI, sedentary lifestyle, stress level, and serum creatinine are independent determinants of hypertension among type 2 diabetes patients. The findings of the study call for strategies that can target these predictors, and clinicians need to start educating their patients about hypertension and ways to prevent it.

The Effects of live- in rehabilitation on ARV adherence, abstinence from drugs and lifestyle modification in people who inject drugs (PWID) Living with HIV - A clinic review.

Background & Objective: HIV/AIDS is mostly seen in people who inject recreational drugs (PWID). Adherence has to be optimum for its treatment to be effective. Compliance to HIV medication has been problematic in PWID making HIV control difficult. Many studies in the past have validated educational activities like rehabilitation programs beneficial in maintaining regularity in medication intake. This brought us to the question of looking at such programs and its effects on our population. This study was conducted to assess the impact of other perspectives of abstinence and adherence including family support and employment status on a person's willingness for treatment continuation and avoidance of drugs. Methods: A retrospective chart review of 241 PWID was conducted to assess adherence to antiretroviral agents (ARVs) and abstinence from recreational drugs post visit to the rehabilitation center. Associations with family support, marital status, employment, income and back to work status were also assessed. Results: Adherence to ARVs had significant statistical association with marital status (p=0.025), starting work again (p=0.001), family support (p=0.009), employment status (p=0.009) and monthly income (p=0.025). While family support (p=0.033), employment status (p<0.0001), Going back to work (p<0.0001), mode of travel to Rehabilitation center (p<0.0001) and monthly income (p=0.004) were associated with abstinence from drugs. Duration of rehabilitation or age had no effect on adherence or abstinence in our patient population of PWID. Conclusion: Family and spousal support and employment promote optimal ARV compliance and should be encouraged when starting ARVs. Enrollment in a long-term complementing educational program would further enhance ARV intake and abstinence.

Effect of Remdesivir on mortality and length of stay in hospitalized COVID-19 patients: A single center study.

Objectives: To see the difference in mortality among hospitalized COVID-19 patients given Remdesivir (RDV) with those who were not given RDV. Methods: A prospective cohort study was conducted on patients who were admitted to the COVID-19 isolation unit at The Indus Hospital, Korangi Campus Karachi between March and June 2020. Results: Groups were similar in age and gender distribution. RDV group was more hypoxic, had severe ARDS and needed higher Oxygen support compared to non-RDV group (p=0.000). Median SOFA score was 2 in RDV vs 5 in non-RDV (p=0.000). More than moderate COVID pneumonia was found in 92% of the RDV group while 89% of non-RDV group (p value=0.001). Median day of illness to administer Remdesivir was 10. There was no difference in mortality (45.5% in RDV vs 40.4% in non-RDV; p=0.4) between the two groups. Median length of hospital stay was 12 days (IQR=7.5-14.5) in RDV group compared to 10 days (IQR=6-14) in non-RDV group (p=0.009). Conclusion: RDV did not show any difference in in-hospital mortality in our patients. More patients had severe ARDS in the RDV group while patients in the non-RDV group had higher SOFA score and multi-organ failure. Length of stay was longer in patients receiving Remdesivir.

Evaluating the Clinical Risk Factors Associated With Miscarriages in Women in Karachi, Pakistan.

Introduction Spontaneous pregnancy loss is unquestionably common worldwide, with roughly 5% of pregnancies ending in this way. Miscarriage can lead to serious psychological issues for women as well as their mothers. Although, it is irreversible but can be prevented through proper risk assessment of women. The goal of this study is to find clinical predictors of miscarriages in Karachi, Pakistani women. Methodology The study is a retrospective chart review that used data of women having livebirth and miscarriages at the Liaquat National Hospital Karachi Pakistan. Data of a total of 517 women were included in the study, out of which 453 have had a live birth, and 64 had miscarriages. To determine the factors associated with miscarriages, multivariable logistic regression was used.  Results The mean age of women was 31.08 (±5.10) years. Age of mother over 40 years (adjusted odds ratio [AOR]=10.28; p-value=0.001), overweight and obesity (AOR=3.01; p-value=0.001) and history of miscarriage (AOR=2.91; p-value=0.003) are variables significantly associated with miscarriages. Conclusion Findings of the current study shown that risk factors of miscarriages included age of mother, increased BMI and previous history of miscarriages. All these factors need to be considered while providing antenatal care to mothers to mitigate the risk of miscarriages.

Accuracy of Spontaneous Breathing Trial Using ET-CPAP in Predicting Successful Extubation of Neonates.

OBJECTIVE: Extubation failure is common in mechanically ventilated neonates. Finding objective criteria for predicting successful extubation may help to reduce the incidence of failure and the length of mechanical ventilation (MV). We conducted this study to determine the accuracy of the spontaneous breathing trial (SBT) and lung function measurements in predicting successful extubation in neonates. METHODOLOGY: This cross-sectional validation study was conducted at a tertiary care neonatal intensive care unit (NICU) over 12 months from December 2019 to December 2020. Neonates intubated for >24 hours and considered ready for extubation were enrolled in the study. Neonates who met defined eligibility criteria underwent a three minutes SBT using endotracheal continuous positive airway pressure (ET-CPAP) before extubation. The primary clinical team was blinded to the results, and all neonates were extubated after SBT. Extubation was considered successful if patients remained extubated for 48 hours. RESULTS: Among the 107 infants, 77.5% (n=83) of infants passed the SBT. Of these, 78 were successfully extubated, giving the positive predictive value of 93.97%. The overall extubation success rate was 90% (n=96). The sensitivity and specificity of SBT were 81.2% and 54.5%, respectively. VE (ET-CPAP) and VE-ventilator at a cutoff of ≥238 ml and ≥143.7 ml have an area under the curve (AUC) of 0.77 and 0.75 respectively to predict successful extubation (p-value 0.003, 0.008 respectively). CONCLUSION: SBT predicts extubation success with pronounced accuracy. Therefore, we propose SBT as a valuable and crucial step that guides clinicians' decision-making regarding extubation preparedness or impending failure in neonates.

Variation in Oxygen Saturation by Pulse Oximetry During and After Breastfeeding Among Healthy Term Neonates During Early Postnatal Life at Tertiary Care Hospital.

Background Breastfeeding plays a vital role in a newborn's life as it increases its chances of survival and is considered the optimal nutritional source for newborns. All newborns must have developed the suck, swallow, and breathe coordination in order to safely breastfeed. Studies conducted on breastfeeding in healthy term babies are limited as most studies available on breastfeeding focus on preterm babies. Full-term healthy infants can also present with feeding difficulties but due to a lack of studies conducted on them, there is no existing oxygen saturation pattern for healthy term infants. Thus, our study is designed to observe variations in the oxygen saturation of healthy term infants during breastfeeding. Methodology A cross-sectional study was conducted in a tertiary care hospital from March 2021 to April 2021. Using a non-probability consecutive sampling technique, 60 neonates were enrolled in the study. The baby was monitored for heart rate and oxygen saturation before, during, and after feeding. Results The oxygen saturation levels were lower during feed while it was significantly high after a feed (p < 0.001). No significant variation was seen between saturation before feeding and during feed (0.635) or before feeding with after feed (p = 0.108). Maximum oxygen saturation drop was observed in 21% at the first minute and cumulatively 73% of neonates within the first five minutes of feeding. Heart rate remained in the physiological range (120-160 b/min) in 85%, above 160 in just 11.6% of the babies. Conclusion Effective breastfeeding is crucial for the growth and development of every infant, which is why there is a need to have an understanding of how infants develop suck, swallow, and breathe coordination. Having breathing and sucking patterns for infants can help medical personal identify when an infant is having difficulty with oral feeding and suggest safer, more effective methods of breastfeeding.

Experience of using home-based fortified diet in rehabilitation of malnourished children at Indus Hospital, Karachi, Pakistan: an institution based retrospective chart review study.

BACKGROUND: Globally, it is estimated that 50 million children under five are wasted. National nutrition survey-2018 has shown that 23.3 and 45.5% of children are wasted and stunted in Pakistan. Many studies have shown that hospital-based management of malnutrition is not practical due to high cost and iatrogenic infections and currently WHO recommends community-based management of malnutrition with provision of therapeutic food. There is limited evidence of community rehabilitation of malnourished children by using home fortified diet in Pakistan. This study explores use of energy dense, home fortified diet in achieving weight gain of malnourished children in Karachi. METHODS: A descriptive, retrospective chart review of pediatric patients (aged 6 month-5 years) seen in Indus Hospital between January 2017 to June 2018 was conducted. A pre-designed data abstraction form was used to record detailed information about demographic characteristics, feeding, anthropometric, micronutrient, and nutritional details at enrollment and on follow-up. RESULTS: A total of 361 patients were included in the final analysis. The median age (IQR) of children was 15 (14) months. Forty eight percent (n = 172) children had diarrhea and 54% (n = 195) children had respiratory tract infection. The median length of stay in the program was 28 days. The median (IQR) for average weight gain was 4.8 (0-10.3) g/Kg/day, 64.6% (n = 226) children defaulted, 29% (n = 102) were cured and 3% (n = 10) died. CONCLUSION: This study showed adequate weight gain and recovery in malnourished children by using home fortified diet in real life situations without using therapeutic food or monetary support. Home fortified diets may serve as effective strategy in community-based rehabilitation of malnourished children.

A Pre-Post Intervention-Based Study Investigating the Impact of Standardized Parenteral Nutrition at Tertiary Neonatal Intensive Care Unit in Karachi, Pakistan.

Introduction Conventionally, various parenteral nutrition (PN) components are individually administered considering an individual neonate's requirements. More recently, standardized PN (SPN) formulations have been initiated for preterm neonates, which may benefit from the enhanced nutrient supply, less administration and prescription errors, reduced risk of infectious disease, and cost-effectiveness. Methodology A multicentered, pre-post intervention-based study was conducted at tertiary neonatal intensive care units (NICUs) in Karachi, Pakistan. Post-graduate residents of neonatology and pediatrics working in NICUs were included in the study, and their perspective was attained regarding PN formulation and a prescription for time consumption, ease, calculation errors, and general feedback. Independent T-test was applied to assess the statistical difference between the pre-and post-implementation of PN formulation for total time required for PN calculation, whereas for the rest of the quantitative variables Mann-Whitney U test was computed. Results The total time required to do the entire writing process, calculating and ordering PN, was 17.1±6.9 whereas significantly (p-value of <0.0001) reduced to 10.5±5.7 after implementing SPN prescriptions. Calculation errors were reduced from 32% to 12%, and writing errors were also decreased from 35% to 8% when the standardized parenteral nutritional formulation was applied. Conclusion Our findings show that implementing standardized prescriptions in the NICU has improved medication safety, with the most consistent benefit by reducing medication errors and time management. The SPN prescriptions save time for post-graduate residents, physicians, and pharmacists by eliminating previously required repetitive activities and calculations.

Determinants of in-hospital mortality in COVID-19; a prospective cohort study from Pakistan.

A prospective cohort study was conducted at the Indus Hospital Karachi, Pakistan between March and June 2020 to estimate the in-hospital mortality among hospitalized COVID-19 patients and its determinants. A total of 170 adult patients were enrolled and all-cause mortality was found to be 39% (67/170). Most non-survivors were above 60 years of age (64%) while gender distribution was quite similar in both groups (males: 77% vs 78%). Most (80.6%) non-survivors came with peripheral oxygen saturation less than 93% while 95% of them had critical disease on arrival. Use of non-invasive ventilation in emergency room was higher among non-survivors (56.7%) versus survivors (26.2%). Median Interleukin-6 levels were higher among non-survivors (78.6: IQR = 33.8-49.0) compared to survivors (21.8: IQR = 12.6-36.3). Most patients in the non-survivor group (86.6%) required invasive ventilator support during hospital stay compared to 7.8% in the survivors. The median duration of ICU stay was longer for non-survivors (9: IQR = 6-12) compared to survivors (5: IQR = 3-7) days. Univariable binary logistic regression showed that age above 60 years, oxygen saturation below 93%, Neutrophil to lymphocyte ratio above 5, procalcitonin above 2ng/ml, unit increase in SOFA score and arterial lactate levels were associated with mortality. We also found that a unit decrease in Pao2/FiO2 ratio and serum albumin were associated with mortality in our patients. Multivariable regression showed that age above 60 years (aOR = 3.4: 95% CI = 1.6-6.9), peripheral oxygen saturation below 93% (aOR = 3.5:95% CI = 1.6-7.7) and serum pro-calcitonin above 2ng/ml (aOR = 4.8; 95% CI = 1.9-12.2) were associated with higher odds of mortality when adjusted by month of admission. Most common cause of death was multisystem organ failure in 35 (56.6%) non-survivors while 22 (35.5%) died due to respiratory failure. Larger prospective studies are needed to further strengthen these findings.

SNAPPE II Score as a Predictor of Neonatal Mortality in NICU at a Tertiary Care Hospital in Pakistan.

Introduction The concept of illness severity scoring has been around for long and is currently being utilized in many neonatal intensive care unit (NICU). Scoring systems that help to quantify mortality risks on the basis of clinical conditions not only help in estimating prognosis, but also help clinicians in making decisions particularly in situations presenting with dilemmas. This study aims to determine SNAPPE-II (Score for Neonatal Acute Physiology-Perinatal Extension) score as a predictor of neonatal mortality in NICU at a tertiary care hospital in Pakistan. Methodology It was a longitudinal cohort study. The study was conducted at a neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH) Karachi, Pakistan. All neonates were included who were born in AKUH and who needed respiratory support in NICU. Results A total of 333 newborns were enrolled for this study. Out of those 30 (9.1%) neonates expired while 298 (90.9%) survived. Area Under the Receiver operative curve was calculated to obtain the SNAPPE-II score's diagnostic discrimination ability. Area under the curve (AUC) was 80.2±4.6% which corresponds to a moderate diagnostic accuracy for the prediction of neonatal mortality. The 95% CI for this was between 71.1-89.2%. SNAPPE-II category III (>40) was found to be the strongest predictor of mortality, with a sensitivity of 40% and a specificity of 98.7%. Conclusion The SNAPPE-II scoring system, we conclude, might be a valuable technique for predicting newborn death in resource-constrained NICUs.

Frequency of early initiation of breastfeeding among women in Thatta, Sindh and factors associated with it: A secondary data analysis.

OBJECTIVE: To determine the early breastfeeding initiation prevalence and factors associated with it in a rural seting. METHODS: The cross-sectional study was conducted at Eight areas of Thatta registed in MNHR from May 2019 to July 2019, and comprised data obtained from a larger survey related to exclusive breastfeeding among women in Thatta, Pakistan, in 2019. The survey had been conducted in areas registered with the Maternal and Neonatal Health Registry, which is a population-based study for developing countries to assess pregnancy-related outcomes. Data was analysed using Stata 16. RESULTS: There were 397 women with a mean age of 27.71±4.92 years. Of them, 305(76.8%) had not received any formal education, 45(11.3%) women had attended primary school, 278(70.1%) were unemployed, and 313(78.8%) had a monthly household income <7,500 rupees. Breastfeeding within the first hour of birth was initiated by 95(20.4%) mothers. Factors associated with early initiation were adequate knowledge, place of delivery, gestational age of the baby and the age of the mother (p<0.05). CONCLUSIONS: Providing counseling and health education to mothers before, during and after the pregnancy are important for motivating them to initiate breastfeeding early and continue exclusive breastfeeding for the recommended period of a minimum of 6 months.

The Impact of Evidence-Based Transformation on Healthcare Practices at a Teaching Hospital.

Objective In this study, we aimed to compare the frequency of anemia, blood transfusions, and the use of antimicrobial therapy (AMT) before the implementation of standard protocols in obstetrics and gynecology with the data after one year of implementation at a teaching hospital. Methods In this retrospective observational study, the pre-intervention data (group A) were compared to the data after the implementation of standard protocols (group B). Data were retrieved from hospital electronic medical records and were entered and analyzed on SPSS Statistics version 24 (IBM, Armonk, NY). Results In obstetrics (n=829), anemia was observed in 43.1% vs. 26.8% (p<0.001) and transfusion rate in 5.4% vs. 0.6% (p<0.001) in the groups A and B respectively. In vaginal deliveries (VD), the use of AMT for >24 hours was 98% in group A vs. 9% in group B, and in cesarean deliveries (CD), it was 100% in group A vs. 54.5% in group B (p<0.001). The cost of AMT decreased by 78.4% in VD and by 51.1% in CD. In gynecology (n=221), the prevalence of anemia was 22.6% in group A vs. 17.9% in group B (p=NS). In minor procedures, the use of AMT for >24 hours was 76.7% vs. 8.4% (p<0.001), and in major procedures, it was 86.5% vs. 38% (p<0.001) between the two groups. The cost of AMT decreased by 79.5% in minor procedures and 26.4% in major procedures. Conclusion The implementation of quality standards can bring about significant improvements in clinical outcomes in a short period of time.