International Journal for Quality in Health Care Advance Access published October 3, 2015

International Journal for Quality in Health Care, 2015, 17

doi: 10.1093/intqhc/mzv068
Article

Article

Implementation of a multidisciplinary clinical

pathway for the management of postpartum
hemorrhage: a retrospective study
HEE YOUNG CHO1, SUNGWON NA2, MAN DEUK KIM3, INCHEOL PARK4,
HYUN OK KIM5, YOUNG-HAN KIM1, YONG-WON PARK1, JA HAE CHUN6,
SEON YOUNG JANG6, HYE KYUNG CHUNG7, DAWN CHUNG8,
INKYUNG JUNG9, and JA-YOUNG KWON1
1
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Institute of Womens Life Medical
Science, Yonsei University College of Medicine, Seoul, Korea, 2Department of Anesthesiology and Pain Medicine,
Yonsei University College of Medicine, Seoul, Korea, 3Department of Radiology, Yonsei University College of Medi-
cine, Seoul, Korea, 4Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea,
5
Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea, 6Department of Quality

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Improvement, Severance Hospital, Seoul, Korea, 7Department of Medical IT, Severance Hospital, Seoul, Korea,
8
Department of Obstetrics and Gynecology, Yonsei University, Wonju College of Medicine, Wonju, Gangwon,
Korea, and 9Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea

Address reprint requests to: Ja-Young Kwon, Department of Obstetrics and Gynecology, Yonsei University Health System,
50 Yonsei-ro, Seodaemun-gu, 120-749 Seoul, Korea. Tel: +82-2-2228-2230; Fax: +82-2-313-8357; E-mail: jaykwon@yuhs.ac
Accepted 1 September 2015

Abstract
Objective: To compare the outcomes of postpartum hemorrhage (PPH) episodes before and after
the introduction of a clinical pathway known as the Severance Protocol to save postpartum bleeding
through Expeditious care Delivery (SPEED).
Design: This study was designed as a retrospective analysis.
Setting: The study was conducted in a hospital implementing SPEED.
Participants: The non-SPEED group included 74 patients with PPH who were treated before the
introduction of SPEED, whereas the SPEED group included 155 patients.
Methods: Differences in outcomes were compared between groups.
Main Outcome Measures: Reduction in treatment duration was the primary outcome measure,
whereas uterus preservation was the secondary.
Results: No signicant intergroup differences were observed for hemoglobin levels, hematocrit
values and vital signs upon patients emergency room arrival. The turnaround time for hemoglobin,
mean duration until treatment by obstetricians and gynecologists and duration between chest
radiography ordering and performance signicantly differed between the two groups (SPEED,
10.0 [1.030.0], 3.0 [025.0] and 23.0 [1.086.0] min, respectively; non-SPEED, 17.0 [1.037.0], 12.0
[062.0] and 46.0 [1.0580.0] min, respectively; P < 0.001). Similarly, the mean duration until transfu-
sion of cross-matched red blood cells (SPEED, 77.6 58.6 min; non-SPEED, 103.4 64.4 min;
P = 0.015) and uterus preservation rate (SPEED, 90.1% [136/151]; non-SPEED, 81.7% [58/71];
P = 0.043) also differed signicantly between the groups.

The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved 1
2 Cho et al.

Conclusions: Clinical pathways enable prompt and efcient care for patients experiencing PPH
through faster evaluation and access to red blood cell transfusion, resulting in a decrease in maternal
mortality.

Key words: postpartum hemorrhage, clinical pathway, SPEED

Introduction (from August 2009 to March 2014) were in the SPEED group.
Unstable vital signs were dened as systolic blood pressure of
Postpartum hemorrhage (PPH), which is generally dened as >500 ml
<90 mmHg or diastolic pressure of <60 mmHg, and a heart rate of
of vaginal bleeding within 24 h of delivery, is a major cause of mater-
>100 beats per minute on a patients arrival at the ED.
nal morbidity and mortality worldwide [1] and is associated with
SPEED involved the participation of the department of obstetrics
1.23% of all deliveries in developed countries [25]. From 1995
and gynecology (OBGYN), ED, division of obstetric anesthesiology,
to 2006, a rising trend was observed in the rate of obstetric hemor-
department of radiology, department of laboratory medicine and
rhage cases in the USA [6]. Furthermore, data from Canada, Australia
department of nursing, and the blood bank (Fig. 1). We developed a
and Europe have shown recent increases in PPH rates [7], whereas
standard protocol and CP to expedite diagnosis of PPH and efciently
PPH remains a major cause of maternal mortality in Korea [8]. As
manage PPH in urgent situations. The multidisciplinary team approach
intractable obstetric hemorrhage is associated with a higher risk of
was implemented as follows (Fig. 2).
maternal mortality, timely patient assessment and hemodynamic
When our OBGYN department received a transfer request from a
stabilization via careful monitoring of blood loss amount are critical,
private clinic, patient information, including vital signs, number of
and prompt treatment must be initiated to avoid severe maternal mor-
intravenous (IV) lines, transfusion amount and nil per os (NPO)
bidity and mortality. In order to achieve such goals, expert medical
time, was checked by the OBGYN physician on duty and alerted to
personnel, including obstetricians, emergency medicine specialists,
on-call senior OBGYN physicians and ED physicians. The patient
anesthesiologists and nurses, with abundant experience in managing
was registered on our electronic medical record (EMR) system before
PPH must be involved in patient care. However, there remains an
arrival, and each department involved in SPEED was notied.

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urgent need to introduce a standardized, consistent protocol as vari-
ation in medical practice and experience level among healthcare
personnel is inevitable. Therefore, the Joint Commission Sentinel
Alert has recommended the introduction of protocols to address
maternal morbidity and mortality due to PPH [9].
PPH, which is considered a bloody business, requires immediate
care from different medical specialties. In addition, because it is a crit-
ical situation, PPH management in the emergency department (ED)
can be chaotic, and a lack of coordination often culminates in miscom-
munication, redundant calls, inconsistent care, inefcient use of
manpower and in-hospital time delay.
The use of computerized physician order entry (CPOE)-based
stroke team approach has been shown to aid in reducing the time inter-
val between a patients arrival and therapy [10]. Therefore, we have
established and implemented a patient safety protocol utilizing the
CPOE and physician alert system to facilitate a multidisciplinary clin-
ical pathway (CP) for PPH management. Such a system, known as the
Severance Protocol to save postpartum bleeding through Expeditious
care Delivery (SPEED), was developed in Severance Hospital in 2009.
The purpose of this study was to determine the effectiveness of CP by
comparing treatment characteristics and clinical outcomes before and
after the implementation of this program.
Methods
The CPOE system specically designed for PPH management, known
as SPEED, was implemented in Severance Hospital in 2009. In the pre-
sent study, we retrospectively reviewed the medical records of all
patients with PPH transferred to our institution between January
2007 and March 2014. This study was approved by the institutional
review board of Yonsei University Health System.
Seventy-four patients with PPH who were treated before the imple-
mentation of SPEED (from January 2007 to July 2009) were included
in the non-SPEED group, whereas 155 patients managed with SPEED
The on-duty OBGYN physician was instructed to wait for the
patient at the emergency room (ER) and assess her condition upon
arrival. The decision to activate SPEED was made by the OBGYN
physician after patient assessment. If the patient was eligible for
SPEED, the OBGYN physician clicked the SPEED check box at the
upper corner of her EMR window and selected the activation icon.
Once the SPEED program was activated, the patients name was high-
lighted in pink color, and a text message was sent to every SPEED team
member automatically. Consequently, every department involved
could easily and promptly recognize this patient. At the same time,
patient vital signs were evaluated, and the need for monitoring, oxy-
gen supply, two or more IV lines or blood product transfusion was
determined.
A predesigned set of orders named the SPEED orders was given,
and details about blood product preparation were coordinated with
the blood bank. The patients blood sample collected in a container
labeled SPEED was sent to a laboratory using air shooter. SPEED in-
volved the emergency release of O-negative red blood cells (RBCs) and
if time permitted, cross-matched blood products were provided as or-
dered. A senior OBGYN physician, an obstetric anesthesiologist and a
radiologist were also notied about the patients condition simultan-
eously. A pre-anesthesia screening was performed, including blood
test, urine test, chest radiography and electrocardiography. We em-
powered priority to relevant departments to process results for a
SPEED patient, and laboratory technicians sent preliminary results
via text messages to the treating OBGYN physician.
The treatment planuterotonics only, balloon tamponade, pelvic
arterial embolization (PAE) or cesarean hysterectomywas deter-
mined based on the patients vital signs and blood test results. The
SPEED program was deactivated after the treatment plan was deter-
mined. Specically, when the patient left the ER to undergo surgery
or any procedure or be admitted to the intensive care unit, the
OBGYN physician deactivated the program. Deactivation was com-
pleted by clicking the SPEED checkbox on the patients order window
Managing postpartum hemorrhage 3

Figure 1 Network for PPH management at our institution. OBGYN: obstetrics and gynecology.

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Figure 2 Process for managing a patient with PPH at our institution. Abbreviation: NPO, nil per os; EM, emergency medicine; ER, emergency room; OBGYN,
obstetrics and gynecology; RBC, red blood cells; PLT, platelet; BUN, blood urea nitrogen; Cr, creatinine; AST, aspartate aminotransferase; ALT, alanine
aminotransferase; PT, prothrombin time; PTT, partial thromboplastin time; EKG, electrocardiogram.

and selecting the deactivation icon. Subsequently, the pink highlight
on the SPEED patients name disappeared, and a text message about
deactivation was sent to every SPEED team member automatically.
We compared maternal characteristics between the SPEED and non-
SPEED groups using the MannWhitney U-test or Fishers exact test
(categorical variables) and two-sample t-test or one-way ANOVA (con-
tinuous variables). Statistical signicance was determined by P-values of
<0.05, and all statistical analysis was performed using SPSS version 20.0
(SPSS Institute, Chicago, IL).
Results
In total, 229 patients with PPH were referred to our institution from
private clinics during the study period. Of these, the SPEED program
4 Cho et al.

Table 1 Demographic and clinical characteristics

Variable SPEED group (n = 155) Non-SPEED group (n = 74) P-value

Age (years) 32.8 3.8 30.8 4.2 <0.001

Gestational age (weeks+days) 38+6 (35+241+1) 38+3 (34+641+6) 0.709
Parity ( primigravida) 82 (52.9%) 42 (56.7%) 0.554
Placenta previa 12 (7.7%) 1 (1.3%) 0.048
Mode of delivery 0.002
Vaginal delivery 107 (69.0%) 38 (51.3%)
VBAC 0 4 (5.4%)
Elective cesarean section 33 (21.3%) 15 (20.3%)
Emergency cesarean section 15 (9.7%) 17 (23.0%)
Etiology of PPH 0.287
Cervix or vaginal laceration 25 (16.2%) 5 (6.8%)
Uterine atony 100 (64.5%) 45 (60.8%)
Placenta previa and accreta 18 (11.6%) 11 (14.9%)
Retained placenta
Others 12 (7.7%) 13 (17.5%)
Treatment prior to transfer <0.001
None 28 (18.1%) 2 (2.7%)
Vaginal packing 10 (6.5%) 6 (8.1%)
Bakri tube insertion 21 (13.5%) 0 (0)
Cesarean hysterectomy 4 (2.6%) 3 (4.1%)
Uterotonics 89 (57.4%) 59 (79.7%)
Othersa 3 (1.9%) 4 (5.4%)
Transfusion in referring clinics 86 (55.5%) 31 (41.9%) 0.134
Cardiopulmonary resuscitation 3 (1.9%) 2 (2.7%) 0.659
Initial mental state 0.471

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Alert state 147 (94.8%) 69 (93.2%)
Drowsy state 7 (4.5%) 3 (4.1%)
Comatose state 1 (0.7%) 2 (2.7%)
Initial vital signs 0.195
Mentally alert, stable vital sign 96 (61.9%) 37 (50.0%)
Mentally alert, unstable vital sign 52 (33.6%) 33 (44.6%)
Drowsy, unstable vital sign 7 (4.5%) 4 (5.4%)
Systolic blood pressure (mmHg) 106.3 23.7 109.7 24.6 0.309
Diastolic blood pressure (mmHg) 65.8 14.9 64.8 17.9 0.680
Pulse rate (/min) 101.4 22.4 100.3 21.4 0.724
Initial lab values
Hb (g/dl) 9.9 2.2 9.7 2.4 0.460
Hct (%) 29.4 6.4 28.1 7.0 0.162
PLT (103/l) 177.0 87.6 194.4 112.4 0.203
PT (INR) 1.4 1.4 1.3 0.9 0.494
PTT (sec) 39.2 33.0 37.1 24.4 0.624

Data presented in the table are n (%), except where indicated otherwise.
VBAC, vaginal birth after cesarean; PPH, postpartum hemorrhage; Hb, hemoglobin; Hct, hematocrit; PLT, platelet; PT, prothrombin time; INR, international
normalized ratio; PTT, partial thromboplastin time; sec, seconds.
a
Uterine artery bleeding, omental bleeding, disseminated intravascular coagulation, arteriovenous malformation.

was activated for 155 patients. Demographic characteristics were not
signicantly different between the two groups, except age, delivery
mode and treatment prior to transfer (Table 1). The most common
cause of PPH was uterine atony in both groups, and there was no sig-
nicant difference with regard to the etiology of PPH. Uterotonics ad-
ministration was the most common treatment performed prior to
transfer, and it was performed in 79.7% (59/74) and 57.4% (89/
155) of the patients in the non-SPEED and SPEED group, respectively
(P < 0.001). The percentage of patients transferred without any treat-
ment was higher for the SPEED group (28/155, 18.1%) compared
with the non-SPEED group (2/74, 2.7%). This might be because pri-
vate clinics started to transfer PPH patients quickly after the SPEED
program became widely known. Intrauterine tamponade with a
Bakri balloon catheter was used in 13.5% (21/155) of the cases in
the SPEED group, but not in any case in the non-SPEED group, mainly
because Bakri balloon tamponade was only made available in Korea
in 2009 (P < 0.001). There were no signicant differences in vital signs,
including pulse rate, blood pressure, hemoglobin level, hematocrit
concentration, platelet count, prothrombin time and partial thrombo-
plastin time at the time of arrival between the two groups (Table 1).
The turnaround time for hemoglobin shortened from 17 to 10 min
after SPEED implementation (P < 0.001) (Table 2). In addition, the
time interval between an OBGYN physician being notied and actual
patient encounter reduced to 3 min (range, 025), and the duration be-
tween chest radiography ordering and performance reduced to 23 min
(range, 186) in the SPEED group (P < 0.001). Furthermore, although
transfusion with O-negative RBCs commenced within 30 min in both
groups, the turnaround time for cross-matched RBC transfusion was
shorter in the SPEED group (77.6 58.6 min) than the non-SPEED
group (103.4 64.4 min) (P = 0.015). In total, 127 (81.9%) SPEED
Managing postpartum hemorrhage 5

Table 2 Comparison of laboratory values and management course between the two groups

Variable SPEED group (n = 155) Non-SPEED group (n = 74) P-value

Turnaround times for Hb (min) 10.0 (1.030.0) 17.0 (1.037.0) <0.001

Duration between an OBGYN physician being notied and patient being seen (min) 3.0 (0.025.0) 12.0 (0.062.0) <0.001
Duration between ordering and performance of chest radiograph (min) 23.0 (1.086.0) 46.0 (1.0580.0) <0.001
Duration between ordering and transfusion of Rh-O (min) 21.4 12.7 24.5 17.2 0.750
Duration between ordering and transfusion of cross-matched RBCs (min) 77.6 58.6 103.4 64.4 0.015

Data in the table are presented as mean SD or median (range).

Hb, hemoglobin; Hct, hematocrit; OBGYN, obstetrics and gynecology; Rh-O, O-negative; RBCs, red blood cells.

Table 3 Transfusion frequency and amount of blood products At our institution, SPEED was introduced because delayed attention
transfused and treatment of PPH patients arriving at the ER could result in severe
morbidity and mortality. Previously, at our institution, every process
Variable SPEED group Non-SPEED group P-value
(n = 155) (n = 74) had to be veried in order to minimize the risk of miscommunication
between departments, avoid ignorance of procedures or treatments dur-
Frequency of 127 (81.9) 61 (82.4) 0.927 ing rapid patient assessment and ensure prompt procedure and treat-
transfusion ment decision-making. Therefore, there was a need to improve our
Rh-O 43 (33.9) 6 (9.8) <0.001 procedures for PPH management. In addition, we intended to prevent
Cross-matched 108 (85.0) 57 (93.4) 0.100 delay in the workow with respect to processing of laboratory test re-
RBCs
sults or preparing of blood products for transfusion owing to excessive
FFP 53 (34.2) 27 (36.5) 0.733
demand from other departments. With the SPEED program, we could
Amount of units transfused initiate treatment promptly and provide early intervention to reduce the
RBC units 4.9 (0.030.0) 4.4 (0.023.0) 0.839 amount of transfused blood products and prevent progression to life-

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transfused, n
FFP units 2.0 (0.032.0) 2.2 (0.032.0) 0.770
transfused, n
Data presented in the table are n (%), mean SD or median (range).
Rh-O, O-negative; RBC, red blood cell; FFP, fresh frozen plasma.
and 61 (82.4%) non-SPEED patients subsequently received blood pro-
ducts (Table 3). The frequency of O-negative RBC transfusion increased
from 6 patients (9.8%) to 43 patients (33.9%) after initiation of the
SPEED program.
The management strategies and outcomes after the introduction of
SPEED in our institution are presented in Table 4. First, the duration
from patient arrival at the ER to the rst actual treatment reduced
from 86 to 76 min (P = 0.015). Second, there were signicant differences
between the two groups in terms of management techniques, such as
uterotonics, use of Bakri balloon tamponade, PAE or cesarean hysterec-
tomy (P = 0.022). Furthermore, the number of patients who underwent
PAE reduced from 51.4% (38/74) to 47.7% (74/155), and that of hyster-
ectomy cases from 20.3% (15/74) to 9.7% (15/155) in the SPEED group
after the availability of Bakri balloon tamponade. Finally, the rates of
uterus preservation were 90.1% (136/151) and 81.7% (58/71) for the
SPEED and non-SPEED groups, respectively, and the rate of cesarean
hysterectomy tended to decrease in the SPEED group (P = 0.043).
Discussion
It is crucial that quality of care be analyzed to enhance the level of care
and implement improved medical care to benet patients [1115].
Thus, the ultimate objective of this study was to evaluate the effective-
ness of a standardized protocol on PPH management. Fast and multi-
disciplinary approaches are essential for achieving favorable outcomes
for PPH. Our results indicated that the time from patient arrival to ac-
tual diagnosis and treatment decreased after SPEED implementation,
and such a reduction resulted in favorable patient outcomes.
threatening conditions, such as disseminated intravascular coagulation.
In this study, the turnaround time for cross-matched RBCs decreased in
the SPEED group possibly because of a consensus to quickly process all
requirements for a SPEED patient by all departments involved. The
need for treatment protocols to manage PPH has been recognized
worldwide, and comprehensive protocols have been introduced in
many institutions [16, 17]. In the USA, multidisciplinary protocols
for the effective treatment of maternal hemorrhage and training for
management of obstetric hemorrhage are mandatory in the states of
New York and Illinois [18]. Shields et al. [19] reported that a protocol
for management of obstetric hemorrhage reduced blood product util-
ization and improved patient safety. More importantly, after a standard
protocol was implemented, the clinical knowledge of medical staff
members improved remarkably, and they were less stressed when
encountering obstetric hemorrhage cases. In 2004, Rizvi F et al. [20]
reported faster detection and treatment of PPH after the development
of guidelines for PPH management and medical staff training.
The number of patients without any treatment prior to transfer in-
creased in the SPEED group because these patients were sent from pri-
vate clinics promptly after the SPEED system was deployed. In
addition, the Bakri balloon tamponade, which presently is the only in-
strument specically designed to treat PPH and was introduced in
Korea in 2009, was used as one of the treatments prior to transfer
in the SPEED group.
We hypothesized that the transfusion of O-negative RBCs in-
creased in the SPEED group because the turnaround time for cross-
matched RBCs was longer than that for O-negative uncross-matched
RBCs. In order to avoid over usage of O-negative uncross-matched
RBCs, we further claried that up to two units of O-negative RBCs
could be used in the CP. Gutierrez et al. [21] reported that massive
transfusion protocol (MTP) could provide early access to blood pro-
ducts, including RBCs, plasma and platelets, for PPH patients, and
MTP could improve outcomes of patients presenting with major
obstetric hemorrhage. Our protocol also emphasized the importance
of transfusion therapy for acute management of PPH. Therefore, since
6 Cho et al.
Table 4 Comparison of management and outcomes between the two groups
Variable SPEED group (n = 155)
Mean duration until treatment initiation (min) 76.0 (1.0276.0)
Management
Uterotonics only 34 (21.9)
Bakri balloon tamponade 28 (18.1)
Pelvic arterial embolization 74 (47.7)
Cesarean hysterectomy 15 (9.7)
Othersa 4 (2.6)
Outcomes
Uterus preservation 136/151 (90.1)
Cesarean hysterectomy 15/151 (9.9)
Duration in the ER (min) 86.0 (10.01170)
ICU admission 54 (34.8)
Duration of ICU stay (days) 2.0 (1.07.0)
Duration of hospital stay (days) 4.0 (1.0103.0)
Data presented in the table are n (%), mean SD or median (range).
ER, emergency room; ICU, intensive care unit.
a
Repair of cervical laceration and vaginal laceration, manual removal of retained placenta or transferring to other hospitals.
the SPEED protocol included O-negative blood transfusion in the
early phase, the use of O-negative blood increased, and the ability
to start transfusion early resulted in enhanced maternal outcome. In
terms of patient management upon arrival at the ED, 11% of patients
were treated with Bakri balloon tamponade for PPH. If these patients
were presented before the introduction of Bakri balloon tamponade,
additional treatment such as PAE might have been necessary to control
bleeding. The reduced utilization of PAE aided in the decrease of
procedure-related complications and medical expense.
In terms of outcomes, more patients showed good recovery, and
the uterus preservation rate was higher in the SPEED group. When a
patient arrived at the ER and a treatment plan involving uterotonics
only, Bakri balloon tamponade, PAE, cesarean hysterectomy or others
was decided, we also evaluated to see whether any further treatment
was necessary. Additionally, the proportion of patients who needed
further treatment after the initial management at our institution was
18.1% (28/155) in the SPEED group (data not shown). Further treat-
ments included PAE (11%, 17/155), hysterectomy (1.3%, 2/155) and
others (5.8%, 9/155) such as bleeding vessel ligation, abdominal wall
hematoma evacuation or methotrexate treatment for retained pla-
centa. Among the patients who underwent PAE for further treatment,
the primary treatment was uterotonics in ve cases and Bakri balloon
tamponade in eight. Three of these eight cases involved temporary
usage of Bakri balloon tamponade after PAE was chosen as the pri-
mary treatment. Re-embolization was necessary in two cases, and
two other cases needed embolization after cesarean hysterectomy
was decided as the primary management.
In conclusion, our results showed that laboratory tests were per-
formed promptly, and the time from patient arrival to rst consult-
ation with the physician decreased after SPEED was introduced.
This might have resulted in the increased uterus preservation rate ob-
served after SPEED was implemented. Development of comprehensive
protocols and implementing of such protocols in the involved depart-
ments enabled the standardization of treatment for PPH and maxi-
mized the efciency of the multidisciplinary team approach.
Acknowledgements
The authors thank the SPEED team staff, Ofce of Quality Improvement, blood
bank, Ofce of Medical Insurance Affairs, Department of Medical IT,
Non-SPEED group (n = 74) P-value
86.0 (13.0188.0) 0.015
20 (27.0)
0 (0)
38 (51.4)
15 (20.3)
1 (1.3)
0.043
58/71 (81.7)
13/71 (18.3)
138.0 (20.0440.0) 0.008
17 (23.0) 0.069
3.0 (1.012.0) 0.680
4.0 (1.054.0) 0.125
Department of Medical Records and Billing, Departments of Laboratory Medi-
cine, Radiology, Emergency Medicine and Anesthesiology.
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