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Evaluating Adherence to Guideline-Based Quality Indicators for Postpartum Hemorrhage Care in the Netherlands Using
Mallory Woiski1, Suzan de Visser, Helena van Vugt
1Departments of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Reinier de Graaf Gasthuis, Delft, Diakonessenhuis, Utrecht, Groene Hart Ziekenhuis, Gouda, Gelre Ziekenhuizen, Apeldoorn, Academic Medical Centre, Amsterdam, Spaarne Ziekenhuis, Hoofddorp, Laurentius Ziekenhuis, Roermond, University Medical Centre Utrecht, Utrecht, Onze Lieve Vrouwe Gasthuis, Amsterdam, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, Spaarne Gasthuis, Haarlem, Maxima Medical Centre, Veldhoven, Pantein Maasziekenhuis, Boxmeer, and Maastricht University Medical Center, Maastricht, the Department of Obstetrics, Leiden University Medical Centre, Leiden, and the Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, the Netherlands.
Objective:
To assess adherence to the national postpartum hemorrhage guideline and Managing Obstetric Emergencies and Trauma course instructions and its determinants in the Netherlands.
Methods:
A prospective observational multicenter study in 16 Dutch hospitals analyzing data from medical records of 398 women at high risk for postpartum hemorrhage, of which 293 were supplemented with data from prospective video recordings. Adherence to guideline-based quality indicators for prevention, management, and organization of postpartum hemorrhage care was measured. Indicators for prevention and management of postpartum hemorrhage were categorized according to the amount of blood loss (less than 500, greater than 500, greater than 1,000, and greater than 2,000 mL).
Results:
Overall, a lack of adherence was observed, particularly for the actions to be undertaken with blood loss greater than 1,000 mL (69 patients). Actions were not or only taken in a later stage when the blood loss had already increased to greater than 2,000 mL (21 patients). In almost 41% (n=119/293) of the deliveries, no active management was performed, and in almost 80% (n=89/112), vital signs were not monitored (blood loss greater than 500 mL) or monitored too late with respect to blood loss. The video recordings showed that in general the actual care given was considerably underreported in medical records. Postpartum hemorrhage care in the hospitals was well organized. Fifteen hospitals had a local postpartum hemorrhage protocol, and in 12 hospitals, team trainings were organized. Regarding the determinants, high-risk patient identification and type of hospital (university vs nonuniversity hospital) were mostly associated with better adherence.
Conclusion:
This study showed low adherence to the guideline-based quality indicators, indicating a problem with Dutch quality care. The unique video observations provided additional, valuable information at which level improvement can be made. A tailor-made implementation strategy to improve quality of postpartum hemorrhage care has been developed.
Clinical Trial Registration:
ClinicalTrials.gov, NCT00928863.
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