Results
From January 2015 to December 2020, 203 women were transferred to either of Kagoshima City Hospital or Kagoshima University Hospital because of PPH. No patients were excluded from this study. There were 31,865 births in the Satsuma Peninsula during period 1 and 28,715 during period 2, with an overall decrease of about 10% in period 2. There were 72 patients transferred for PPH during period 1 and 131 transferred for PPH during period 2, representing an overall increase in PPH of 80%. The course completion rate increased from 12.5% to 96.9% between the periods. Two of the 28 clinics and hospitals in Satsuma Peninsula did not participate in the programme until 2020; however, neither clinic had transferred patients with PPH to our hospitals after 2018. The demographics and maternal characteristics are shown in Table S1. Although maternal age significantly increased from 31.1 ± 5.1 years in period 1 to 34.0 ± 5.2 years in period 2 (p < 0.001), other factors, including the rates of primary disease, did not change significantly, aside from the incidence of placental abruption.
The providers’ behavioural changes at the referring hospitals are presented in Table 1. The SI recording rate significantly increased from 9.7% to 36.6% between the two periods (p < 0.001), and the rate of using IV lines ≥ 20 gauge increased from 91.7% to 100% between the two periods (p = 0.00173). The rate of securing multiple IV routes and oxygen administration did not change. The mean time from delivery to maternal transfer decreased from 150 (range, 88–260) minutes to 130 (range, 73–215) minutes, and the mean amount of blood loss at the referring hospitals decreased from 2,000 (range, 1,500–2,720) g to 1,927 (range, 1,100–2,370) g, although these changes were not statistically significant. Nevertheless, these improvements indicate the effectiveness of the programme at Kirkpatrick level 3.
Patients’ vital signs, laboratory data on arrival, and clinical outcomes are shown in Table 2. As expected, the mean SI on arrival significantly decreased from 0.85 (range, 0.72–1.05) to 0.77 (range, 0.65–0.93) (p = 0.0345) (Figure 1). The Hb level (7.5 ± 2.4 g/dL and 8.0 ± 2.3 g/dL, respectively) and Plt counts (14.3 ± 6.8 × 104/μL and 15.8 ± 7.1 × 104/μL, respectively) improved between periods 1 and 2, but not significantly. Although the rates of both impaired consciousness (11.1% and 6.9%) and hypothermia (body temperature <36 ºC) (9.7% and 3.8%) decreased between periods 1 and 2, these findings were also not significant.
The maternal outcomes are presented in Table 3. The occurrence of hysterectomy, IVR, and maternal death did not differ between the two periods. Two maternal deaths were caused by amniotic fluid embolism (AFE). Between the two periods, the rate of massive transfusion (red blood cells [RBC] ≥ 10 units) significantly decreased from 43.1% to 26.0% (p = 0.018), indicating the effectiveness of the programme at Kirkpatrick level 4.
Clinical factors related to massive transfusion (RBC ≥ 10 units) are shown in Tables S2 and 4. There were positive relationships between massive transfusion and the amount of blood loss at the referring hospitals and a negative relationship between massive transfusion and completion of the J-MELS programme. Coagulopathy (placental abruption, AFE, and DIC), a main cause of PPH, was a risk factor for massive transfusion. The ROC curve between blood loss at the referring hospitals and massive transfusion is presented in S3. The cut-off level of blood loss at the referring hospitals for massive transfusion was 2,200 g (sensitivity: 77.8%, specificity: 69.8%, area under the ROC curve: 0.774, 95% confidence interval [CI]: 0.699–0.849). Logistic regression analysis showed that the J-MELS programme effectively decreased the risk of massive transfusion (OR: 0.29, 95% CI: 0.14–0.62); additionally, blood loss ≥2,200 g at the referring hospitals increased the risk of massive transfusion (OR: 8.59, 95% CI: 4.14–17.8), and the same result was shown for coagulopathy as the main cause of PPH (OR: 5.60, 95% CI: 1.74–18.0), as presented in Table 4.