Background: Iron deficiency (ID) is highly prevalent during pregnancy and may affect up to half of pregnancies with more severe ID affecting approximately 25% of pregnancies. Despite the prevalence of ID in this population, many patients may not be screened during their pregnancy, and the prevalence and severity of ID increases over the course of a pregnancy. Therefore, many patients may remain iron deficient at the time of delivery. Treatment of patients with postpartum ID anemia has with iron repletion therapies have been shown to increase hemoglobin recovery and potentially improve maternal fatigue and depression measures. IV iron repletion is the most efficient way to treat ID in patients with severe iron deficiency anemia (IDA), however oral iron may be appropriate in patients with mild-moderate IDA.

Objective: A quality improvement project to improve screening for ID of patients undergoing Cesarean Section (CS) from 5% to 50%, to improve iron repletion therapy with IV iron while inpatient from 10% to 25%, and to improve oral iron repletion from 13% to 25%.

Methods: Beth Israel Deaconess Medical Center (BIDMC), Boston, MA is an approximately 750 bed quaternary care academic medical center. Approximately 150 CS deliveries are performed each month. Using Slicer-Dicer via the EPIC electronic medical record, approximately 33% of patients with CS deliveries are noted to have a diagnosis code of “abnormal hemoglobin” during their admission. Our primary process measure was the proportion of patients undergoing CS with an abnormal hemoglobin who have a ferritin checked. Outcome measures included the proportion of patients receiving IV iron and the proportion of patients with an outpatient prescription for oral ferrous sulfate. Balancing measures included the monetary cost and nursing administration time required for more IV iron administration. We used the quality improvement methods of process mapping, cause-and-effect (Ishikawa fishbone) diagram, and a multidisciplinary focus group to identify key opportunities for change. The first Plan-Do-Study-Act (PDSA cycle) was an in-person educational talk to the key leaders within the department of obstetrics and gynecology as well as inpatient nursing directors of the antepartum and postpartum floors. We used statistical process control (SPC) p-charts to determine the impact of each process change. The project was supported via the American Society of Hematology Quality Improvement Training Institute.

Results: Between 6/2024 – 2/2025, the baseline proportion of patients undergoing CS who had an abnormal hemoglobin and were screened for ID was 5%. The baseline proportion of patients who received IV iron or oral iron was 10% and 13%, respectively. After the first PDSA cycle between 3/2025 – 5/2025, only 6% of patients were being screened for ID however the proportion of patients receiving IV iron or oral iron increased to 20% and 17%, respectively.

Conclusions: An increase in the proportion of patients receiving iron repletion therapy was seen despite no increase in screening for ID. This may reflect empiric treatment of patients with a high pretest probability of ID anemia. PDSA cycle 2 will focus on optimizing the admission order set to screen patients for ID.

This content is only available as a PDF.
2025
Sign in via your Institution