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

Publisher: Public Library of Science Country of Publication: United States NLM ID: 101231360 Publication Model: eCollection Cited Medium: Internet ISSN: 1549-1676 (Electronic) Linking ISSN: 15491277 NLM ISO Abbreviation: PLoS Med Subsets: MEDLINE

Original Publication: San Francisco, CA : Public Library of Science, [2004]-

Quality Improvement*; Anemia, Iron-Deficiency/*complications ; Pregnancy Complications/*diagnosis; Anemia, Iron-Deficiency/diagnosis ; Anemia, Iron-Deficiency/therapy ; Controlled Before-After Studies ; Critical Pathways ; Erythrocyte Transfusion ; Female ; Ferritins/blood ; Humans ; Perinatal Care/methods ; Pregnancy ; Pregnancy Complications/therapy

Background: Iron 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 Findings: In 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.
Conclusions: The 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.
Competing Interests: The authors have declared that no competing interests exist.

Hematol Oncol Clin North Am. 2011 Apr;25(2):241-59, vii. (PMID: 21444028)
J Clin Pharm Ther. 2002 Aug;27(4):299-309. (PMID: 12174032)
Transfusion. 2015 Dec;55(12):2799-806. (PMID: 26246160)
Acad Pediatr. 2013 Nov-Dec;13(6 Suppl):S38-44. (PMID: 24268083)
Transl Res. 2017 Feb;180:68-76. (PMID: 27593097)
BMJ Qual Saf. 2016 Dec;25(12):e7. (PMID: 27076505)
Hematology Am Soc Hematol Educ Program. 2015;2015:146-51. (PMID: 26637714)
J Pediatr. 2012 Jun;160(6):1027-33. (PMID: 22244466)
Br J Haematol. 2012 Mar;156(5):588-600. (PMID: 22512001)
Obstet Gynecol. 2008 Jul;112(1):201-7. (PMID: 18591330)
J Pediatr. 2002 Feb;140(2):165-70. (PMID: 11865266)
MMWR Recomm Rep. 1998 Apr 3;47(RR-3):1-29. (PMID: 9563847)
Qual Saf Health Care. 2003 Feb;12(1):47-52. (PMID: 12571345)
BMJ Qual Saf. 2017 Jul;26(7):572-577. (PMID: 27986900)
BMJ Qual Improv Rep. 2017 Jun 23;6(1):e000009. (PMID: 28824807)
Cochrane Database Syst Rev. 2015 Jul 22;(7):CD004736. (PMID: 26198451)
Qual Manag Health Care. 2004 Jan-Mar;13(1):17-32. (PMID: 14976904)
J Pediatr Adolesc Gynecol. 2016 Dec;29(6):628-631. (PMID: 27262832)
JAMA. 1997 Mar 26;277(12):973-6. (PMID: 9091669)
Blood. 2017 Feb 23;129(8):940-949. (PMID: 28034892)
N Engl J Med. 2015 May 7;372(19):1832-43. (PMID: 25946282)
Am J Clin Nutr. 2016 Oct;104(4):1052-1060. (PMID: 27581469)
Am J Clin Nutr. 1992 May;55(5):985-8. (PMID: 1570808)
BMC Fam Pract. 2017 Feb 28;18(1):31. (PMID: 28241787)

9007-73-2 (Ferritins)

Date Created: 20190821 Date Completed: 20200109 Latest Revision: 20200309

20250114

PMC6701755

10.1371/journal.pmed.1002867

31430296