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.