The prevalence of anemia in elective surgical patients may be as frequent as 75% in certain populations. A national audit demonstrated that 35% of patients scheduled for joint replacement therapy have a hemoglobin <13 g/dL on preadmission testing. Standard practice currently consists of preadmission testing 3 to 7 days before an elective operative procedure, precluding the opportunity to effectively evaluate and manage a patient with unexpected anemia. Therefore, a standardized approach for the detection, evaluation, and management of anemia in the preoperative surgical setting was identified as an unmet medical need. To address this knowledge gap, we convened a panel of physicians to develop a clinical care pathway for anemia management in this setting. Elective surgery patients should receive a hemoglobin (Hgb) determination a minimum of 30 days before the scheduled surgical procedure. Because the identification and evaluation of anemia in this setting will assist in expedited diagnosis and treatment of underlying comorbidities and will improve patient outcomes, unexplained anemia (Hgb <12 g/dL for females and <13 g/dL for males) should cause elective surgery to be deferred until an evaluation can be performed.

Anemia is a global health issue with disproportionately high prevalence in women. In addition to being an independent risk factor for decreased quality of life and increased morbidity and mortality, anemia in women has been linked to unfavorable outcomes of pregnancy and other issues for children born to anemic women. Iron deficiency is the leading cause of anemia in many populations. Guidelines recommend proactive screening for anemia, particularly in the preoperative setting. Once anemia is diagnosed, treatment should be based on etiology (most commonly, iron deficiency followed, in order of prevalence, by inflammation or chronic disease). Iron supplementation (oral and intravenous) offers safe and effective treatment for anemia associated with iron deficiency. Anemia of chronic disease may be more challenging to treat, and attention must be given to the underlying disease, along with use of hematinic agents. Given its enormous impact on the health and well-being of women and the availability of simple and effective treatment options, anemia should never be left unmanaged.

No abstract

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Healthcare safety and quality are critically important issues in obstetrics, and society, healthcare providers, patients and insurers share a common goal of working toward safer practice, and are continuously seeking strategies to facilitate improvements. To this end, 4 New York City voluntary hospitals with large maternity services initiated a unique collaborative quality improvement program. It was facilitated by their common risk management advisors, FOJP Service Corporation, and their professional liability insurer, Hospitals Insurance Company. Under the guidance of 4 obstetrics and gynecology departmental chairmen, consensus best practices for obstetrics were developed which included: implementation of evidence based protocols with audit and feedback; standardized educational interventions; mandatory electronic fetal monitoring training; and enhanced in-house physician coverage. Each institution developed unique safety related expertise (development of electronic documentation, team training, and simulation education), and experiences were shared across the collaborative. The collaborative group developed robust systems for audit of outcomes and documentation quality, as well as enforcement mechanisms. Ongoing feedback to providers served as a key component of the intervention. The liability carrier provided financial support for these patient safety innovations. As a result of the interventions, the overall AOI for our institutions decreased 42% from baseline (January-June 2008) to the most recently reviewed time period (July-December 2011) (10.7% vs 6.2%, p < 0.001). The Weighted Adverse Outcome Score (WAOS) also decreased during the same time period (3.9 vs 2.3, p = 0.001.) Given the improved outcomes noted, our unique program and the process by which it was developed are described in the hopes that others will recognize collaborative partnering with or without insurers as an opportunity to improve obstetric patient safety.

Clinicians should routinely identify and treat IDA, thereby decreasing its negative impact on health and quality of life of women.

To investigate the effects of frequency and duration of breast-feeding on infants' milk intake and weight gain, two groups of mother-infant pairs were studied during the first month after delivery. Mothers in the control group (n = 24) nursed their infants on a 3- to 4-hour schedule. Those in the experimental group (n = 20) were encouraged to nurse frequently. During the first 14 postpartum days, all mothers recorded the length and time of each breast-feeding. On the 15th and on the 35th postpartum day, milk intake per feeding for 24 hours and infant weight gain from birth were measured. During the first 2 weeks after delivery, mothers in the experimental group nursed more frequently (9.9 v 7.3 feedings per 24 hours; P &lt;.0001). On day 15, their infants took more milk (725 v 502 mL/24 h; P &lt;.0002), and had gained more weight from birth (561 v 347 g; P &lt; .02). On day 35, although mothers in the experimental group were still nursing more frequently (9.8 v 6.8 feedings per 24 hours; P &lt;.01), milk intake and weight gain from birth were not significantly different.

Patients may have differing perceptions about blood transfusions based on their backgrounds, values, education levels, or cultural or religious beliefs, which may or may not be accurate. Unfortunately, despite the fact that transfusions are associated with a number of infectious and noninfectious risks, and in spite of the fact that there are ethical, accreditation, and regulatory requirements to provide information regarding transfusion risks, benefits, and alternatives to patients, transfusion consent remains inconsistently obtained. This can partly be attributed to the fact that clinicians may take on a paternalistic approach to transfusion decisions as well as to the fact that many clinicians have knowledge gaps in transfusion medicine that prevent them from obtaining transfusion consent adequately. As a result, unlike the case with other medical and surgical therapies, most patients are not included in the making of informed decisions regarding the need for transfusion versus alternative therapies, leading to many situations in which the transfusions provide little benefit to them. Recently however, a number of organizations, such as the American Association of Blood Banks and The Joint Commission in the US, have promoted multidisciplinary, evidence-based treatment strategies that aim to minimize the need for blood transfusion, the so-called patient blood management (PBM) protocols. PBM strategies are expected to improve blood utilization through optimization of patients who may need blood transfusions via measures such as preoperative anemia management, intraoperative cell salvage, and improved transfusion guidelines. PBM strategies also focus on enhanced requirements for transfusion education and shared decision making, including informed consent and, thus, promote a patient-centered approach as defined by the Institute of Medicine.