In France, post partum haemorrhage (PPH) is the leading cause of maternal deaths. In 2005, The French Confidential Enquiry into Maternal Deaths concluded that 80% of maternal deaths from haemorrhage could have been avoided if timely and appropriate care had been provided. In France, the first national clinical guidelines for PPH management were released in November 2004. However, the simple passive dissemination of these guidelines remains insufficient to improve clinical practices. This was also observed at the regional level although development and distribution of regional guidelines were made in collaboration with all healthcare professionals involved to improve their level of appropriation. Few studies have assessed the effectiveness of a clinical audit in obstetrics setting. The feasibility and the results that can be expected from such clinical audit should be more disseminated and known by clinicians. Objective To describe (1) the results of a standardised clinical audit of severe PPH conducted in a random sample of maternity hospitals, and (2) the change in the rate of severe PPH following the routine implementation of the audit in two hospitals. Study design A clinical audit of PPH management was carried out in 54 randomly selected maternity units of six perinatal networks in 2006. All cases of severe PPH observed during a 4-month period were analysed in each maternity unit by external reviewers –obstetrician, anaesthetist, midwife-, with active participation of staff. Following this, two maternity units conducted regular clinical audits quarterly until 2008,while measuring the severe PPH rate. Results The clinical audit reviewed 94 severe PPH. Management was not optimal in 27% of cases (7/26) post caesarean section (CS) and in 62% of cases (42/68) post vaginal delivery (VD). Overall, the main causes of non-optimal care were the delay in diagnosis (22%), under estimation of blood loss (18%), and the delay in care (40%). Examination of the uterine cavity was not done in 8.8% (6/68) or done after 15 minutes in 27.9% of cases (19/68). In severe PPH due to uterine atony, sulprostone was administrated in 70% of cases (39/56), and administrated over 30 min in 58% (17/29) of cases after VD and in 10% of cases after CS (1/10). The first blood test was performed more than 30 min post diagnosis in 47% of VD cases and in 38.5% of CS cases. A significant reduction of severe PPH rate was observed between 2006 and 2008 in the two maternity units which performed regular audits, from 1.54% to 0.96% in the level III maternity (p=0.04), and from 0.74% to 0.26% in the level II maternity (p=0.04). Discussion PPH-related practices were not optimal but may be improved if clinical audits were regularly performed. The strength of clinical audit is to prompt practitioners to discuss together about the management of severe PPH cases, and to define relevant improvement objectives based on the audit9s results. Being proactive rather than reactive could be important to improve quality and security of care. The guidelines are a support for discussion but they are not sufficient to change practices. In order to design the most adequate intervention to improve health issues, local context, characteristics of a team and professional decision making are crucial parameters to be taken into account. Conclusion This audit has been able to identify deviations from guidelines and causes of non optimal care, which depended more on individual medical practice than care organization. The management of severe PPH seemed more adequate in CS than in VD. The routine implementation of the clinical audit in two maternity units was associated with a significant reduction of severe HPP rate. En France, l9hemorragie du post partum (HPP) est la premiere cause de mortalite maternelle. En 2005, le Comite national d9experts sur la mortalite maternelle a conclu que 80% des deces lies a une HPP auraient pu etre evites si des soins appropries avaient ete administres sans delai. En France, la premiere recommandation de pratique clinique (RPC) pour la prise en charge des HPP a ete diffusee en novembre 2004. Cependant, la diffusion passive des RPC est insuffisante pour ameliorer les pratiques. Ceci a egalement ete observe a un niveau regional, alors que les RPC ont ete developpes et diffusees avec les professionnels impliques pour ameliorer leur appropriation. Peu d’etudes ont evalue l9efficacite des audits cliniques en obstetrique. Leur faisabilite et les resultats attendus de ce type d9audit doivent etre dissemines et connus des cliniciens. Objectif Decrire (1) les resultats d9un audit clinique standardise des cas d’ HPP severes conduit dans un echantillon tire au sort de maternites et (2) l’evolution du taux d9HPP severe dans deux maternites ayant poursuivi ces audits cliniques regulierement. Type d’etude Un audit clinique de la prise en charge des HPP severe a ete conduit dans 54 maternites tirees au sort de 6 reseaux de perinatalite. Toutes les HPP severes survenues au cours des 4 mois d’etude etaient examinees au cours de seances d9audit animees dans chaque maternite par un trinome exterieur –obstetricien, anesthesiste, sage femme-, avec participation active des equipes. Deux maternites de type 2 et 3 ont poursuivi cet audit clinique trimestriellement entre 2006 et 2008, et l’evolution du taux d9HPP grave au cours de cette periode a ete etudiee. Resultats L9audit a concerne 94 HPP severes. La prise en charge n’etait pas optimale dans 27% des cas (7/26) apres cesarienne (CS), et dans 62% des cas (42/68) apres un accouchement voie basse (AVB). Les raisons principales identifiees etaient le retard au soin (40%), le retard au diagnostic (22%) et la sous-estimation de la perte sanguine (18%). Apres AVB, il n9y a pas eu de revision uterine dans 8.8% des cas (6/68) ou elle a ete realisee apres 15 minutes dans 27.9% des cas (19/68). En cas d9atonie uterine, la sulprostone a ete administree dans 70% des cas (39/56), et le delai d9administration etait superieur a 30 minutes dans 58% des cas apres un AVB (17/29), et dans 10% des cas apres une CS (1/10). Le 1er bilan biologique a ete effectue plus de 30mn apres le diagnostic dans 47% des cas apres un AVB et dans 38.5% apres une CS. Dans les 2 maternites qui ont poursuivi l9audit, une reduction des taux d9HPP grave a ete obtenue entre 2006 et 2008, de 1.54% a 0.96% dans la maternite de type 3 (p=0.04), et de 0.74% a 0.26% dans la maternite de type 2 (p=0.04). Discussion En obstetrique, les pratiques de prise en charge des HPP severes sont non conformes mais peuvent etre ameliorees si un audit clinique est realise regulierement. La force de ces audits est d9inciter les equipes a discuter ensemble de la prise en charge des cas severes d9HPP et de definir les axes d9amelioration a partir des resultats de l9audit. Etre proactif plutot que reactif pourrait etre important pour ameliorer la qualite et la securite des soins. Les RPC sont une base de discussion mais sont insuffisantes pour changer les pratiques cliniques. Pour obtenir la meilleure adequation entre une intervention et un objectif precis, la prise en compte du contexte local, les caracteristiques d9une equipe et les processus de decision collectifs sont des parametres essentiels a considerer. Conclusion L9audit clinique a permis d9identifier les ecarts a la pratique attendue et les motifs de soins non optimaux dans toutes les maternites. Les dysfonctionnements relevent plus de la pratique medicale que de l9organisation des soins. La realisation reguliere de cet audit dans deux maternites a ete associee a une reduction significative du taux d9HPP grave.

https://qualitysafety.bmj.com/content/qhc/19/Suppl_1/A25.full.pdf

155 Clinical audit: a useful tool for severe postpartum haemorrhage?

Context, objective Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality and the main component of severe maternal morbidity in developed countries. Decreasing the prevalence of severe PPH is a major obstetrical challenge. In most cases, these are considered to be associated with substandard care. A number of PPH-related clinical guidelines have therefore been developed, both nationally and internationally. The harder job, however, is ensuring the actual translation of these guidelines into clinical practice. Guidelines do not by themselves change professionals’ practices, and the effectiveness of active intervention strategies must be assessed. We tested the hypothesis that a multifaceted educational intervention, aimed at improving practices for PPH management, would reduce the incidence of severe PPH. Methods In a cluster-randomised trial spanning 6 regions in France, 106 maternity units (accounting for 17% of French maternity units, and 20% of deliveries nationwide) were randomly assigned to receive a multi-faceted intervention -combining outreach visits, reminders, and peer reviews of severe cases- to implement a protocol for early management of PPH, or to have the protocol passively disseminated. The primary outcome was the incidence of severe PPH, defined as a composite of one or more of the following: transfusion, embolisation, surgery, transfer to intensive care, peripartum haemoglobin delta of 4 g/dl or more, or death. The main secondary outcomes were the rates of the principal procedures for PPH management recommended in the protocol. During the 1 year data collection period (November 2005–October 2006), all deliveries with PPH were prospectively identified in each unit. Information on the patient9s characteristics, those of the pregnancy and delivery, and outcome data was collected from the chart of every delivery with PPH. Differences in outcomes between the intervention group and the control group were tested with a two-level logistic regression with a random intercept, to take into account the hierarchical structure of the data with women clustered in maternity units. Primary and secondary outcomes were estimated for each of the four trimesters of the 1-year-inclusion period. The effect of time was tested in the intervention and control groups separately, and the intervention effect on this temporal evolution was quantified. Results The mean rate of severe PPH was 1.64% (SD 0.80) in the intervention units and 1.65% (SD 0.96) in the control units; the difference was not significant. The intervention was associated with a higher rate of some recommended PPH management procedures: calling for help from senior staff (p=0.005), administration of sulprostone in severe PPH due to uterine atony (p=0.06), blood test within 60 min of diagnosis in severe PPH (p=0.09). The mean rate of severe PPH decreased between the first and third trimesters (1.79% (SD 1.21) and 1.52% (SD 0.87) respectively; p=0.07) in the intervention units, and was significantly lower in both the third and fourth trimesters than in the first trimester (1.60% (SD 1.05), 1.45% (SD 1.05) and 1.91% (SD1.44) respectively; p=0.01 and 0.03) in the control units. The trend of decrease with trimester of the rate of severe PPH was not significantly different between the two groups. Conclusion This educational intervention did not affect the rate of severe PPH, although it improved some practices. A parallel effect in the intervention units (through contamination by the intervention or external factors) may have contributed to the absence of a major difference between the two arms. Further research is needed on the role of organisational factors as well as individual components of the care recommended for PPH on the risk of severe PPH, for many of these are not evidence-based. Such evidence will help to focus future educational interventions on the most important aspects of care. Contexte, objectif L9hemorragie du postpartum (HPP) est l9une des causes majeures de mortalite maternelle et la cause principale de morbidite maternelle severe dans les pays developpes. Diminuer la prevalence de l9HPP severe constitue une priorite en obstetrique. La plupart de ces cas severes semblent associes a une prise en charge suboptimale. En reponse, des recommandations de pratique clinique relatives a l9HPP ont ete edictees, au niveau national et international. Cependant, l9existence de telles recommandations ne suffit pas pour obtenir leur traduction effective dans la pratique clinique, et il necessaire d9evaluer l9efficacite de strategies d9intervention specifiques dans ce but. Notre objectif etait d9evaluer l9efficacite d9un programme d9intervention multifacettes destine a favoriser l9integration dans la pratique clinique de recommandations de prise en charge de l9HPP, afin de diminuer l9incidence de l9HPP severe. Methodes Dans un essai randomise en cluster conduit dans 6 regions francaises, 106 maternites (representant 17% des maternites francaises et realisant 20% des accouchements du pays) ont ete assignees par tirage au sort au bras intervention -programme multifacette combinant une discussion des recommandations dans chaque maternite, l9utilisation de “reminders” et un audit clinique-, ou au bras reference -diffusion passive des recommandations. Le critere de jugement principal etait l9incidence de l9HPP severe, definie par la presence d9un au moins des criteres suivants: transfusion, embolisation, chirurgie, trasfert en reanimation, delta peripartum d9hemoglobine de 4g/dl ou plus, deces. Les criteres de jugements secondaires portaient sur la conformite des pratiques reelles de prise en charge de l9HPP aux principales etapes des recommandations. Tous les accouchements avec HPP ont ete identifies prospectivement pendant une annee (Novembre 2005–Octobre 2006) dans chaque maternite. Pour chacun de ces cas, l9information sur les caracteristiques de la femme, de sa grossesse, de son accouchement, et le deroulement del9HPP, etait collectee a partir du dossier obstetrical. Les differences entre les 2 bras pour les criteres de jugement ont ete testees en utilisant un modele de regression logistique a 2 niveaux prenant en compte la structure hierarchique des donnees et la correlation intra-maternite. Les criteres de jugement ont ete calcules pour chacun des quatre trimestres de l9annee d9inclusion. L9effet du temps a ete teste separement dans le bras intervention et dans le bras reference, et l9effet de l9intervention sur cette evolution temporelle a ete quantifie. Resultats L9incidence moyenne de l9HPP severe etait de 1.64% (SD 0.80) dans le bras intervention et 1.65% (SD 0.96) dans le bras reference; cette difference n9etait pas significative. Certaines pratiques etaient plus souvent conformes aux recommandations dans le bras intervention: appel d9un medecin senior(p=0.005); administration de sulprostone en cas d9HPP severe par atonie uterine (p=0.06), bilan biologique dans les 60 min en cas d9HPP severe(p=0.09). L9incidence moyenne de l9HPP severe est passee de 1.79% (SD1.21) au premier trimestre a 1.52% (SD 0.87) au troisieme trimestre dans les le bras intervention (p=0.07), et etait significativement plus basse aux 3eme et 4eme trimestres qu9au 1er trimestre (1.60% (SD 1.05), 1.45% (SD 1.05) et 1.91% (SD1.44) respectivement; p=0.01 et 0.03) dans le bras reference. La diminution de l9incidence de l9HPP severe au cours du temps n9etait pas differente entre les 2 groupes. Conclusion L9intervention n9a pas modifie l9incidence de l9HPP severe, bien qu9elle ait ameliore la conformite de certaines pratiques cliniques relatives a l9HPP. Un effet parallele dans les maternites du bras reference a pu contribuer a l9absence de difference majeure entre les bras. Des travaux ulterieurs sont necessaires pour preciser le role des facteurs organisationnels et des composantes specifiques de la prise en charge recommandee de l9HPP vis-a-vis du risque d9HPP severe, car la plupart ne reposent pas sur des preuves scientifiques solides. Ceci permettrait de cibler les interventions d’education sur les aspects les plus determinants des soins.

/pdf/191-multifaceted-intervention-to-decrease-the-rate-of-severe-1jds4hcyd2.pdf

Touzet Sandrine

Papers

155 Clinical audit: a useful tool for severe postpartum haemorrhage?

191 Multifaceted intervention to decrease the rate of severe postpartum haemorrhage: the pithagore6 cluster-randomised controlled trial