Implementation of a statewide bundle on obstetric hemorrhage in New York

Obstetric hemorrhage is one of the leading causes of maternal death and also one of the most preventable. In 2017, a New York statewide initiative led by the New York State Perinatal Quality Collaborative asked birthing hospitals to implement an ACOG District II Safe Motherhood Initiative evidence-based bundle on recognition and management of hemorrhage, and to assist and offer extensive education, assistance, and feedback. This report describes the process and results.

The bundle was available to all birthing hospitals. Hospitals were asked to implement 21 measures, with a goal of each measure being implemented by at least 85% of hospitals. Webinars and teaching sessions were attended by participating hospital teams to foster collaborative learning, share best practices, provide technical assistance and education, and serve as a forum for discussion of successes and barriers. Hospitals used standardized data collection forms to report measure implementation, aggregate patient data, and for major hemorrhages (requiring massive transfusion, hysterectomy, transfer to a higher level of care, or death), deidentified patient-level data. Data were analyzed using chi-square, repeated measures ANOVA, linear regression, and Cochrane's Q tests.

Eighty-six hospitals initially engaged (78 ultimately completed), with teams attending 35 webinars and 3 learning sessions. At the initiative's start, 6 of the 21 measures already were in place at 85% of hospitals; by the initiative's end, this increased to 19 of 21 with significant increases (p < 0.05) for all but two. The percent of patients defined as having obstetric hemorrhages increased during the initiative as use of quantitative blood loss (QBL) increased from 9.8% to 14.5% (p < 0.001); among patients with major hemorrhages, exclusive QBL use increased blood loss volume by 287 mL (p = 0.004). Among patients with major hemorrhages, the need for transfer to higher levels of care decreased during the initiative (p = 0.02), although rates of hysterectomy or use of massive transfusion were unchanged.

A comprehensive statewide initiative encouraging hospitals to adopt an evidence-based bundle on obstetric hemorrhage was successful in that 19 of 21 measures were implemented by ≥85% of hospitals. Focused statewide initiatives can improve hospitals' ability to provide evidence-based obstetrical care.