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.