Research Article: Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study

Date Published: August 20, 2019

Publisher: Public Library of Science

Author(s): Jameel Abdulrehman, Andrea Lausman, Grace H. Tang, Rosane Nisenbaum, Jessica Petrucci, Katerina Pavenski, Lisa K. Hicks, Michelle Sholzberg, Kathleen Rasmussen

Abstract: BackgroundIron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.Methods and findingsIn order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael’s Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%–14.11%]; post-intervention 10.6% [95% CI 9.6%–11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group.ConclusionsThe introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.

Partial Text: Iron deficiency (ID) in pregnancy is a common problem that can have serious consequences. At baseline, 9% to 11% of teenage girls and women of child bearing age in developed countries have ID [1]. Individuals from lower income and of minority groups are more commonly affected [1]. The risk of ID increases during pregnancy due to an increase in maternal iron requirements to accommodate the expansion of maternal red blood cell (RBC) mass, development of the placenta and fetus, and the loss of blood associated with labor and delivery [2]. Unfortunately, women cannot meet these iron demands through food intake alone and must rely upon iron stores [3]. If the stores are suboptimal, secondary anemia ensues [4]. ID is the most common cause of anemia in pregnancy [3,4]. ID anemia (IDA) is associated with preterm delivery, cesarean delivery, RBC transfusions, low birth weight, 5-minute Apgar score <7, neonatal intensive care unit admission, and long-term effects on mental and psychomotor development in the child [2,5–8]. One year after implementation of the paper-based IRON MOM toolkit, we found a large increase in the frequency of ferritin testing as an almost 10-fold increase in the mean monthly rate of ferritin testing in the obstetric clinics at our institution. There was a lower risk of an antenatal hemoglobin below 100 g/L and a lower proportion of women receiving an RBC transfusion during pregnancy and postpartum. Source: http://doi.org/10.1371/journal.pmed.1002867

 

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