Main findings
Similar to previous reports,13,15-17 our study showed
that the J-MELS programme was effective at Kirkpatrick level 3. Although
the SI on arrival significantly improved and cases of massive
transfusion significantly decreased, the occurrence of hysterectomy,
IVR, and maternal death did not differ between the two periods.
Changes in providers’ behaviours were observed, such as increased rates
of SI recording and using IV lines ≥20 gauge, which might have resulted
in earlier administration of first aid measures such as transfusion of
extracellular fluid to maintain circulation. The increased number of
maternal transfers, lower amount of blood loss at the referring
hospitals, and shorter time to transfer between the two periods in our
study indicate the effectiveness of the programme, which emphasises the
importance of earlier awareness of the occurrence of PPH and earlier
transfer using the same standardised protocol. Moreover, earlier
awareness, application of first aid measures, and transfer might have
resulted in the improvement of the maternal SI on arrival. The
implementation of earlier awareness and earlier transfer procedures to
prevent maternal collapse and DIC was the goal of the simulation-based
training. This goal was achieved to some degree. The decrease in the
massive transfusion rate indicates the effectiveness of the programme at
Kirkpatrick level 4. The results of logistic regression analysis support
the independent effectiveness of the programme in terms of a reduction
in the rate of massive transfusion (OR 0.29); an earlier transfer leads
to a better maternal status on arrival, a lower amount of blood loss, an
earlier administration of advanced treatment, such as IVR, and reduction
of massive transfusion. The results of logistic regression analysis also
showed that completing the J-MELS programme independently decreased the
risk of massive transfusion. We concluded that our attempt to have
practitioners from all clinics participate in the programme and use the
same standardised protocol was successful in changing providers’
behaviours and decreasing the rate of massive transfusion. This study is
one of the valuable studies that evaluated the efficacy of a regional
attempt to encourage obstetrical providers to attend simulation-based
training and use a standardised treatment protocol. An earlier decision
of maternal transfer can achieve a lower rate of massive transfusion.
However, to evaluate whether this truly decreases maternal death,
further study with a greater number of included patients is essential.