2022 Quality Report

Hospital Quality Improvement Showcase - Ascension Wisconsin

Anemia of Pregnancy

Reduction of severe maternal morbidity was identified as a priority project for the perinatal service line for Ascension Wisconsin. Analysis showed that blood transfusion was the most common morbidity encountered. Approximately 70% of the patients with a blood transfusion required only 1-2 units of blood and had minor blood loss during their delivery hospitalization. Further analysis revealed that many of these patients were anemic at the time of admission, which prompted a closer look at the diagnosis and treatment of iron deficiency anemia during pregnancy. 

The primary goal of this work was to ensure that women were treated adequately for iron deficiency anemia during pregnancy so they would have normal hemoglobin levels at the time of delivery. A normal hemoglobin level will both allow the patient to tolerate a normal blood loss as well as have the energy to interact with and care for her newborn. 

We defined success as an increase in the number of women with a hemoglobin greater than 11 g/dL on admission and a reduction in 1- and 2-unit blood transfusions. Additionally, we monitored the number of patients who required a 1- or 2-unit blood transfusion each month across Ascension Wisconsin. 

While also monitoring the admission hemoglobin levels for patients experiencing a hemorrhage event, a clear link between anemia on admission and the need for blood transfusion after a hemorrhage was determined. This graph shows the admission hemoglobin values and the need for a blood transfusion of any number of products after the hemorrhage event. All of the patients with normal hemoglobin values on admission had significant total blood loss before transfusions were needed. 

Severe maternal morbidity review teams analyzed individual patient cases. It was identified that many patients who received a blood transfusion were not coded for the procedure. By March 2021, all transfusion procedures were coded to accurately reflect care regardless of insurance type, which allowed for accurate monitoring of process improvement. The review teams counted the number of blood products used for each case and identified the need for improved treatment of iron deficiency anemia during pregnancy. An algorithm was created that includes close monitoring of lab values and progression to IV iron infusions when oral supplementation is determined to be inadequate. 

Ambulatory leaders were engaged to disseminate the anemia algorithm. After several months, further strategies were developed to verify that the algorithm was being followed. The clinics developed anemia of pregnancy tracking tools to monitor the treatment provided during the pregnancy and identify ongoing opportunities to enhance the care provided. An anemia of pregnancy treatment protocol was agreed upon by obstetric providers, and ambulatory nursing staff were empowered to enact the protocol orders when needed. 

The work is ongoing, but there have been many successes throughout utilizing iterative rapid cycle process improvement. Patients are being closely monitored for anemia throughout their pregnancies. There has been a substantial increase in the number of patients who receive IV iron. More obstetric providers are now ordering IV iron therapy instead of referring patients to hematology, which increases timely infusion. Additionally, through engagement of the Ascension Maternal Health Social System Initiative, patients have received navigation assistance to help break down barriers in access to care. 

The graph below shows IV iron infusion data from one ambulatory setting: 

Throughout this project so far, there are several key lessons learned:
  • A small team that meets frequently is crucial for keeping momentum towards reaching goals.
  • Partnership is needed between the ambulatory and inpatient settings to maximize best outcomes for patients.
  • Leverage technology by using shared tools to organize, collaborate and share results.
  • Consistent procedure coding is necessary to accurately document the patient care provided.
  • Providing real case feedback to providers demonstrates how their work impacts patient outcomes.