Are you feeling well? Community Bundles

Marie Lewis

Donna Owen

Powys Local Health Board

Aim of Call

The overall aim for this call is to begin the process of agreeing a'minimum standard for community referral' (in response to physiological observations) so that this does not just rely on the midwives experience and interpretation of the situation.

Transforming Maternity Services Mini collaborative: Community Model

The community bundle is made up of three aspects similar to the four care bundles within Transforming Maternity Services.

Pre-Admissions: All women have adequate history taken and recorded in their hand held records including BMI, Medical conditions, Obstetric History and VTE risk assessment. Plan for frequency of observations.

Recognition: Routine maternal observations carried out as per local guidelines. Risk assessments repeated as appropriate and any changes recorded within the hand held records. Early warning score used as trigger for full set of observations and referral if necessary.

Response: Communication with all members of the team using the SBAR format. Referral to appropriate place for further care and investigation. Immediate care if necessary prior to and during transfer. Mechanism for recording findings, actions and follow up.

When implementing the community bundle organisations need to consider local processes for referral from community to acute settings, the acceptable timeframe and communication process feeding back to community from the acute setting.

Recognition:

Community midwives are key players in recognising when deterioration or deviation from norm occurs.

The early warning score does not replace clinical judgement but is designed to aid community midwives in decision making, consistency and documentation.

All women at every opportunity should be asked about their wellbeing. And the EWS recorded.

Full set of observations:

Recognition:

At each contact, the healthcare professional should ask the woman about her health and wellbeing. Any symptoms reported by the woman or identified through clinical observations should be assessed. [NICE CG 37]

When a woman reports feeling unwell a full set of observations should include:

“ Are you feeling well?”

Community Early Warning Score Aide

memoir:

Looks/feels well

Yes No

Trigger for recording physiological

observations and recording Early

Warning Score.

Score

0 1 2 3

Respirations 9-20 /min 21-24/ min 25-29/ min <8 or >30/

min

Pulse 61-100/min 101-110/min 41-60 or 111-

129/min

<40 or

>130/min

Systolic BP 100-

140mmhg

141-

160mmhg

91-99mmhg <90 or

>161mmh

g

Diastolic BP Up to

90mmhg

91-99mmhg 100-

109mmhg

>110 or

<40mmhg

Temperature 36-37.9 35.1-35.9 38-39 <35 or >40

Early Warning Score

Record full set of Observations on

locally agreed documentation/chart.

EWS Calculated

Score 0

Continue routine

care

Score 1-2

Repeat full set of

observations in 30

mins

Score2

Discuss with appropriate

Health professional

Score 3-4

Attend Obstetric

care within 2

hours

Score >5

Emergency

transfer

Think: Blood pressure readings in isolation need to be considered in relation to local

Hypertension guidelines.

The Early warning score aims to support professional decision making. Health

professionals should always use their professional judgement and refer to an

appropriate person if they are concerned about the wellbeing of the mother.

Recognition:

Where indicated women should be referred to an appropriate setting and a full plan of care recorded.

To aid communication and documentation the SBAR format is recommended.

Addressograph

Date:

Time Left:

Time Arrived:

Transfer from:

Transfer to:

Arranged with

(Name)

Maternal Transfer Document

Situation: Reason

Background: Gravida: Para: EDD: Gestation:

Relevant medical/obstetric history

Assessment: - Clinical Impression/Actions/observations

Recommendation: including your requests and expected time frame

Midwife: Date: Time:

Thresholds and triggers for referral

NICE Postnatal care guidelines

LIFE-THREATENING CONDITIONS IN WOMENEmergency Action: Life threatening or potentially life threatening situationsUrgent Action: Potentially serious situation, which needs appropriate action

Non-Urgent Action: Continue to monitor and assess

Possible Sign/Symptom Evaluate For Action

Sudden or profuse blood loss, or blood

loss and signs/ symptoms of

shock including tachycardia,

hypotension, hypofusion, change

in consciousness

Postpartum Haemorrhage Emergency Action

See All Wales Birth Centre Guidelines

Offensive vaginal loss, tender

abdomen

Genital Tract Sepsis Urgent Action

Refer to GP

Fever ›38c, shivering, abdominal pain,

and/or offensive vaginal loss

Infection/Genital Tract Sepsis Emergency Action

Refer to DGH

Severe or persistent headache Pre-eclampsia/ Eclampsia Emergency Action

Diastolic is greater than 90mm Hg and

accompanied by another

sign/symptom of pre-eclampsia

Pre-eclampsia/Eclampsia Emergency Action

Refer to DGH

Diastolic is greater than 90mm Hg and

NO other sign/symptom, repeat

BP within 4hrs and re-evaluate for

signs of pre-eclampsia

Pre-eclampsia/Eclampsia Urgent Action

Refer to GP if BP remains ›90mm Hg

and NO signs of pre-eclampsia

Shortness of breath or chest pain Pulmonary Embolism Emergency Action

Refer to DGH

Unilateral calf pain, redness or

swelling

Deep Vein Thrombosis Emergency Action

Refer to DGH

Common Health Problems in Women

Health Problem Action

Baby Blues If symptoms not resolved after 10-14 days, assess for postnatal depression, and if symptoms

persist evaluate further – Refer to Local Maternal Mental Health Policy (Urgent action)

Perineal Pain, discomfort,

stinging,

offensive odour or

Dyspareunia.

Offer to assess the perineum. Evaluate for signs of infection, inadequate repair, wound

breakdown or non healing (Urgent Action).

Advise use of topical cold therapy and paracetamol( if not contra-indicated), but if neither are

effective consider oral or rectal non-steroidal anti-inflammatory drug (Non Urgent Action)

Dyspareunia In cases of Perineal trauma offer to assess the perineum (See above).

Advise water based lubricant If problem persists evaluate further (Non Urgent Action ref GP

Headache Advise women who have had epidural/spinal anaesthesia to report severe headache.

Check Blood pressure For tension/migraine headaches offer advice on relaxation and avoiding

factors associated with headache

Persistent Fatigue Ask about women’s general well-being and offer advice on diet, exercise and planning activities.

Consider Haemoglobin level if clinically indicated

Backache If persistent refer to GP

Constipation Assess diet and fluid intake. If changes in diet are ineffective advise use of a gentle laxative

Haemorrhoids If haemorrhoids are severe, swollen or prolapsed, evaluate for referral to GP (Urgent Action).

Otherwise advise dietary measures to avoid constipation and use of haemorrhoid

cream. If not resolved within two weeks refer to GP.

Faecal Incontinence Assess Severity, duration and frequency. Refer as appropriate (Urgent Action)

Urinary Incontinence Teach the woman to do pelvic floor exercises. Complete continence assessment and refer as

appropriate

Urinary Retention

(within 6 hours of

birth)

Advise methods of assisting urination such as taking a warm bath or shower. If this doesn’t work

assess bladder volume and consider catheterisation (Urgent Action).

Over to you:

How would the early warning score work for you?

What are your current thresholds for referral?

What are the current pathways for referral?

Is it possible to devise a minimum best practice trigger and pathway tool?