Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review

OBJECTIVE

Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment.

DATA SOURCES

We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible.

METHODS

Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively.

RESULTS

Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution.

CONCLUSION

The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.

Prognostic Role of Initial Thromboelastography in Emergency Department Patients with Primary Postpartum Hemorrhage: Association with Massive Transfusion

BACKGROUND

The early prediction of the need for massive transfusions (MTs) and the preparation of blood products are essential for managing patients with primary postpartum hemorrhage (PPH). Thromboelastography (TEG) enables a thorough evaluation of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. We investigated the role of TEG in predicting the need for MT in patients with primary PPH.

METHODS

A retrospective observational study was conducted in the emergency department (ED) of a university-affiliated, tertiary referral center between November 2015 and August 2023. TEG was performed upon admission. We defined MT as the requirement for transfusion of more than 10 units of packed red blood cells within the first 24 h. The primary outcome was the need for MT.

RESULTS

Among the 184 patients with initial TEG, 34 (18.5%) required MT. Except for lysis after 30 min, the MT and non-MT groups had significantly different TEG values. Based on multivariate analysis, an angle < 60 was an independent predictor of MT (odds ratio (OR) 7.769; 95% confidence interval (CI), 2.736-22.062), along with lactate (OR, 1.674; 95% CI, 1.218-2.300) and shock index > 0.9 (OR, 4.638; 95% CI, 1.784-12.056). Alpha angle < 60 degrees indicated the need for MT with 73.5% sensitivity, 72.0% specificity, and 92.3% negative predictive value.

CONCLUSIONS

Point-of-care testing of TEG has the potential to be a useful tool in accurately predicting the necessity for MT in ED patients with primary PPH at an early stage.

Delta neutrophil index and shock index can stratify risk for the requirement for massive transfusion in patients with primary postpartum hemorrhage in the emergency department

Background

Postpartum hemorrhage (PPH) constitutes a major risk for maternal mortality and morbidity. Unfortunately, the severity of PPH can be underestimated because it is difficult to accurately measure blood loss by visual estimation. The delta neutrophil index (DNI), which reflects circulating immature granulocytes, is automatically calculated in hematological analyzers. We evaluated the significance of the DNI in predicting hemorrhage severity based on the requirement for massive transfusion (MT) in patients with PPH.

Methods

We retrospectively analyzed data from a prospective registry to evaluate the association between the DNI and MT. Moreover, we assessed the predictive ability of the combination of DNI and shock index (SI) for the requirement for MT. MT was defined as a transfusion of ≥10 units of red blood cells within 24 h of PPH. In total, 278 patients were enrolled in this study and 60 required MT.

Results

Multivariable logistic regression revealed that the DNI and SI were independent predictors of MT. The optimal cut-off values of ≥3.3% and ≥1.0 for the DNI and SI, respectively, were significantly associated with an increased risk of MT (DNI: positive likelihood ratio [PLR] 3.54, 95% confidence interval [CI] 2.5–5.1 and negative likelihood ratio [NLR] 0.48, 95% CI 0.4–0.7; SI: PLR 3.21, 95% CI 2.4–4.2 and NLR 0.31, 95% CI 0.19–0.49). The optimal cut-off point for predicted probability was calculated for combining the DNI value and SI value with the equation derived from logistic regression analysis. Compared with DNI or SI alone, the combination of DNI and SI significantly improved the specificity, accuracy, and positive likelihood ratio of the MT risk.

Conclusion

The DNI and SI can be routinely and easily measured in the ED without additional costs or time and can therefore, be considered suitable parameters for the early risk stratification of patients with primary PPH.

Implementation of the D-A-CH postpartum haemorrhage algorithm after severe postpartum bleeding accelerates clinical management: A retrospective case series

Implementation of the D-A-CH postpartum haemorrhage algorithm after severe postpartum bleeding accelerates clinical management: a retrospective observational case series. Jean-Jacques Ries, Lena Jeker, Michelle Neuhaus, Deborah R. Vogt, Thierry Girard, Irene Hoesli.

OBJECTIVE

Postpartum haemorrhage (PPH) is a leading cause of maternal death and severe morbidity. The algorithm for the three German speaking countries ("D-A-CH Handlungsalgorithmus Postpartale Blutung") for the management of PPH was introduced in 2012 at the University Hospital Basel. The aim of this study was to compare the blood loss, the initiation and application of the clinical management of severe PPH (≥1000 ml) after vaginal deliveries before and after the implementation of the algorithm.

METHODS

In this retrospective case series data were collected from a manual and an electronic database. The study was approved by the local ethical committee. Patients with an estimated blood loss of 1000 ml or more were included. The primary endpoint was the estimated total postpartum blood loss. Secondary endpoints were differences in pharmacological and surgical treatments, time from delivery to the initiation of a specific treatment and total costs. A propensity score analysis was performed to minimize potential bias between control and intervention group.

RESULTS

A total of 317 women were included, 141 women before (control group) and 176 women after the implementation of the algorithm (intervention group). Total postpartum blood loss did not differ between the groups (Median [IQR]: control group 1600 [1400, 2100] ml, intervention group 1500 [1400, 2000] ml). Use of sulprostone (OR 2.42 [1.52, 3.87], p = 0.004), tranexamic acid (OR 6.27 [3.65, 10.78], p < 0.001) and Bakri Balloon Tamponade® (BBT®) (OR 7.82 [2.68, 22.84], p = 0.004) and the application of rotational thromboelastoemtry (ROTEM®) (OR 32.37 [4.35, 240.56], p = 0.012) were significantly more frequent in the intervention group. In the intervention group tranexamic acid was administered significantly earlier (relative effect: 0.61 [0.50, 0.75], p < 0.001). No differences could be shown in haemoglobin concentration two days postpartum, transfer to the intensive care unit (ICU) or total costs of treatment.

CONCLUSIONS

The implementation of the D-A-CH algorithm in women after vaginal delivery with severe postpartum bleeding did not result in significantly reduced blood loss. However, it accelerated the clinical management and induced the application of a wider range of pharmacological interventions within a shorter interval after delivery without generating more costs.

Short- and long-term effects of clinical pathway on the quality of surgical non-small cell lung cancer care in China: an interrupted time series study

Objective

To examine the short- and long-term effect of clinical pathway for non-small cell lung cancer surgery on the length of stay, the compliance of quality indicators and risk-adjusted post-operative complication rate.

Design

A retrospective quasi-experimental study from June 2011 to October 2015.

Setting

A tertiary cancer hospital in China.

Participants

Patients diagnosed as non-small cell lung cancer who underwent curative resection.

Intervention(s)

Clinical pathway was implemented at January 2013. Hence, the study period was divided into three periods: pre-pathway, from June 2011 to December 2012; short-term period, from January 2013 to December 2013; long-term period, from January 2014 to October 2015.

Main Outcome Measure(s)

Three length of hospital stay indicators, four process performance indicators and one outcome indicator.

Results

ITS showed there was a significant decline of 2 days (P = 0.0421) for total length of stay and 2.23 days (P = 0.0199) for post-operative length of stay right after the implementation of clinical pathway. Short-term level changes were found in the compliance rate of required number of lymph node sampling (-8.08%, P = 0.0392), and risk-adjusted complication rate (9.02%, P = 0.0001). There were no statistically significant changes in other quality of care indicators.

Conclusions

The clinical pathway had a positive impact on the length of stay but showed a transient negative effect on complication rate and the quality of lymph node sampling.

The influence of emergency department crowding on the efficiency of care for acute stroke patients

Objective

To investigate the impact of emergency department (ED) crowding (number of ED patients) and number of ED staff on the efficiency of the ED care process for acute stroke patients.

Design

Retrospective cohort study conducted from 1 May 2008 to 31 December 2013.

Setting

Largest primary stroke center (3000-bed tertiary academic hospital) in southern Taiwan.

Participants

Patients aged 18-80 years presenting to the ED with acute stroke symptoms ≤3 h from symptom onset (n = 1142).

Main Outcome Measures

Door-to-assessment time (DTA), door-to-computed tomography completion time (DTCT) and door-to-needle time (DTN).

Results

Of the 785 patients with ischemic stroke, 90 (11.46%) received thrombolysis. In the multivariate regression analysis, the number of ED patients and the number of attending physicians were significantly associated with delayed DTA and DTCT but not DTN. Initial assessment by a resident was also associated with delayed DTA and DTCT. The number of nurses was associated with delayed DTCT and DTN.

Conclusions

Although ED crowding was not associated with delayed DTN, it predicted delayed DTA and DTCT in thrombolysis-eligible stroke patients. The number of attending physicians affected initial assessment and DTCTs, whereas the number of nurses impacted thrombolytic administration times.

Effectiveness of a multidisciplinary critical pathway based on a computerised physician order entry system for ST-segment elevation myocardial infarction management in the emergency department: a retrospective observational study

OBJECTIVES

The purpose of this study was to investigate whether a multidisciplinary organised critical pathway (CP) for ST-segment elevation myocardial infarction (STEMI) management can significantly attenuate differences in the duration from emergency department (ED) arrival to evaluation and treatment, regardless of the arrival time, by eliminating off-hour and weekend effects.

DESIGN

Retrospective observational cohort study.

SETTING

2 tertiary academic hospitals.

PARTICIPANTS

Consecutive patients in the Fast Interrogation Rule for STEMI (FIRST) program.

INTERVENTIONS

A study was conducted on patients in the FIRST program, which uses a computerised physician order entry (CPOE) system. The patient demographics, time intervals and clinical outcomes were analysed based on the arrival time at the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical outcomes categorised according to 30-day mortality, in-hospital mortality and the length of stay.

RESULTS

The duration from door-to-data or FIRST activation did not differ significantly among the 4 groups. The median duration between arrival and balloon placement during percutaneous coronary intervention did not significantly exceed 90 min, and the proportions (89.6-95.1%) of patients with door-to-balloon times within 90 min did not significantly differ among the 4 groups, regardless of the ED arrival time (p=0.147). Moreover, no differences in the 30-day (p=0.8173) and in-hospital mortality (p=0.9107) were observed in patients with STEMI.

CONCLUSIONS

A multidisciplinary CP for STEMI based on a CPOE system can effectively decrease disparities in the door-to-data duration and proportions of patients with door-to-balloon times within 90 min, regardless of the ED arrival time. The application of a multidisciplinary CP may also help attenuate off-hour and weekend effects in STEMI clinical outcomes.