Document Type: Unique Identifier: GUIDELINE OBS/GYNAE/GUID/0

Document Type: GUIDELINE

Unique Identifier: OBS/GYNAE/GUID/002

Title: High Dependency Care - Including The Criteria For Transfer To HDU/ITU

Version Number: 6

Status: Ratified

Scope: Medical staff and Midwives in Obstetrics

Classification: Organisational

Author/Originator and title: M Broadhead. PD Midwife N Moate. Shift Leader Mr Johnson Amu, Consultant Obstetrician and Gynaecologist

Responsibility: Obstetrics & Gynaecology Directorate

Replaces: Version 5, High Dependency Care - Including the Criteria for Transfer to HDU/ITU OBS/GYNAE/GUID/002

Description of amendments: Amendments throughout

Name Of: Divisional/Directorate/Working Group: Families Division Obstetrics & Gynaecology Policy Group

Date of Meeting: 30/07/2013

Risk Assessment: Not Applicable Financial Implications Not Applicable

Validated by: Women’s Health Departmental Meeting

Validation Date: 09/09/2013

Which Principles of the NHS Constitution Apply? 1 - 4

Ratified by: Clinical Improvement Committee

Ratified Date: 01/10/2013

Issue Date: 01/10/2013

Review dates may alter if any significant changes are made Review Date: 01/07/2016

Does this document meet the requirements of the Equality Act 2010 in relation to Race, Religion and Belief, Age, Disability, Gender, Sexual Orientation, Gender Identity, Pregnancy & Maternity, Marriage and Civil Partnership, Carers, Human Rights and Social Economic Deprivation discrimination? Initial Assessment

Blackpool Teaching Hospitals NHS Foundation Trust ID No. OBS/GYNAE/GUID/002


Revision No: 6 Next Review Date: 01/07/2016

Do you have the up to date version? See the intranet for the latest version Page 2 of 18

1. PURPOSE To ensure women receive high dependency/intensive care in a suitable environment.

2. SCOPE This guideline applies to all staff caring for women who require obstetric care within Blackpool Teaching Hospitals NHS Foundation Trust. 3. GUIDELINE 3.1 Definition of High Dependency Care (HDU) Women who require; • More detailed observations, including;

o basic support for a single failing organ system

o post-operative care

o those stepping down from higher levels of care

• Stabilisation before transfer to Intensive Therapy Unit (ITU) where the following is

required: o support for 2 or more organ systems o artificial ventilation o renal replacement therapy o risk of sudden catastrophic deterioration

3.1.1 Equipment and Facilities All the delivery suite rooms are equipped with Oxygen, Suction and monitoring equipment for the measurement of non-invasive blood pressure. There is also equipment available for monitoring; • ECG

• oxygen saturation • temperature • invasive hemodynamic monitoring • Resuscitation equipment including defibrillator.





3.2 Admission Criteria A delay in recognition of a critical illness contributes to avoidable mortality and morbidity in pregnant women. • All women should have observations recorded on a Modified Obstetric Early Warning

Score Chart, Appendix 1

• The Severely ill pregnant or postnatal woman guideline OBS/GYNAE/GUID/042. And Guidance for when to involve clinicians from outside the Maternity Service. The MOEWS Algorithm, Appendix 2, must be followed

• Examples of indications for the admission to Delivery Suite / HDU / ITU are given in

Appendix 3

3.3 Responsibility And Requirements Of Relevant Staff Groups when transferring a woman to High Dependency Care on Delivery Suite. Once the woman has been identified as requiring HDU/ITU care by the multidisciplinary team (see Severely Ill Pregnant/Postnatal Women ref OBS/GYNAE/GUID/042) the responsibilities of the relevant staff groups are: 3.3.1 The Obstetrician’s Responsibility If the woman’s high dependency care is carried out on Delivery Suite, • Ensure that there is a multidisciplinary approach to decisions regarding care.

• The Obstetrician ST3 or above must complete the ‘’High Dependency Care on

Delivery Suite and Management Plan. Appendix 4. • The initial written Management Plan should include clear instructions about;

o The continued level of observation

o A time for the next patient review

o When to call medical staff. 3.3.2 The Midwife’s Responsibility If the woman’s high dependency care is carried out on Delivery Suite, An Obstetric HDU chart must be commenced. Appendix 5. The record of on-going care will be recorded in the health records. To file the ‘’High Dependency Care on Delivery Suite’ ’form in the health records.

3.4 Criteria For Transfer To HDU /ITU Outside Of The Maternity Service Women requiring ITU care are generally transferred to the ITU within the Trust. Following assessment of the woman’s condition, the decision for transfer will be made by the consultant Obstetrician and the Consultant Anaesthetist in liaison with other specialities as required. Woman who require ITU care have usually more than one organ failure including:





• Women requiring advanced respiratory support (ventilation) • Women requiring invasive renal support

• Exacerbation of pre-existing medical problem 3.4.1 The Obstetrician’s Responsibility • The on-call Obstetric Consultant must be notified immediately.

• An obstetrician ST3 or above/ anaesthetist must complete the Referral Request From

Maternity To Critical /High Dependency Care form, Appendix 6.

• The obstetrician must document the plan of care for transfer to HDU/ITU in the health record

3.3.2 The Anaesthetist’s Responsibility • assessing the woman,

• arranging admission to HDU/ITU, • The transfer. 3.3.3 The Midwife’s Responsibility • Provide Antenatal or Postnatal care for the woman as requested by the Obstetrician. 3.3.4 Clinicians outside the Maternity Service • If an additional opinion e.g. medical or surgical is required, a clear assessment and

plan should be written in the woman’s health record following the review along with the doctor’s contact details.

3.5 Guidance On When To Involve Clinicians Outside Of The Maternity Service Transfer out of the maternity unit requires the woman to be assessed jointly by a senior anaesthetist and a senior obstetrician and in some cases other disciplines that have been involved in the woman’s care e.g. renal, cardiac. Senior clinicians from other specialities will be involved in the care of the women where there is: • Failure of more than one organ system

• Disease requiring the expertise of specialist medical teams e.g.

• Renal failure, other than the impairment associated with preeclampsia • Hepatic failure

• Respiratory disease especially that requiring ventilatory support

• Cardiac disease, pre-existing or of recent onset

• Neurological conditions





• Endocrine disease including diabetes mellitus • Non-obstetric surgical problems The outreach team should be consulted if there is a transition to or from the ITU or for help with a specialised problem e.g. high flow oxygen therapy 3.6 Requirements of each staff group when transferring women to HDU/ITU 3.5.1 Responsibilities of Midwife The midwife will accompany the woman during transfer to the HDU / ITU and will complete a nursing/midwife SBAR (Situation, Background, Assessment, Recommendation) handover in the health records. 3.5.2 Responsibilities of Anaesthetist • Liaise with HDU/ITU to arrange appropriate level of care with HDU/ITU and

document in health records.

• Anaesthetist will ensure appropriate equipment for safe transfer, accompany the woman during transfer and document handover of care to HDU/ITU staff.

3.7 Discharge from ITU / HDU / Delivery Suite Discharge from ITU is a consultant level decision and should be back to HDU or the Delivery Suite in the first instance unless otherwise directed. Again the transfer should be made person to person; the woman should be accompanied to the area as there may be significant complications that require a detailed SBAR handover. The woman and her family should be offered a full explanation of the events that led to the need for high dependency care and opportunities for the woman to ask questions and to discuss what happened to her made available. 3.8 Discharge criteria from Delivery Suite / HDU to the Ward This will be when care can be managed on a maternity ward and must consider staffing levels, skill-mix and workload on the ward. A written management plan, including clear instructions about the continued level of observation and when to call medical staff, must be documented in the health record at the time of transfer. Continued support from the obstetric and anaesthetic staff may be required and must be provided. 3.9 Transfer out of HDU / Delivery Suite should be a joint obstetric and anaesthetic decision and fulfil the following: • Patient haemodynamically stable, no further continuous intravenous

• medication or frequent blood tests required

• No invasive monitoring required

• No active bleeding

• No supplementary oxygen required





When transferring a woman from Delivery Suite to the ward, a personal and detailed handover of care should be given from the midwife handing over the care to the receiving midwife using the SBAR tool. 3.10 Process For Monitoring Compliance The process for monitoring compliance is identified at Appendix 7. 4. ATTACHMENTS Appendix Number Title

1 Modified Early Warning Score (MOEWS) chart 2 Guidance of when to involve clinicians from outside the maternity

services. Modified Obstetric Early Warning Score Algorithm 3 Examples of indications for the admission to Delivery Suite / HDU /

ITU 4 High Dependency Care On Delivery Suite Form 5 Obstetric Women’s Unit High Dependency Chart 6 Referral request from maternity to critical / high dependency care 7 Process for monitoring compliance 8 Initial Equality Analysis Form

5. ELECTRONIC AND MANUAL RECORDING OF INFORMATION Electronic Database for Procedural Documents Held by Policy Co-ordinators/Archive Office 6. LOCATIONS THIS DOCUMENT ISSUED TO Copy No Location Date Issued 1 Intranet 01/10/2013 2 Wards and Departments 01/10/2013 7. OTHER RELEVANT/ASSOCIATED DOCUMENTS Unique Identifier Title and web links from the document library Obs/Gynae/Guid/020 Hypertension, Pre-Eclampsia, Severe Pre-Eclampsia, Eclampsia

http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-GUID-020.doc

Obs/Gynae/Prot/025 Haemorrhage – Antenatal and post partum http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-PROT-025.doc

Corp/Proc/080 Recording of Basic Observations on Patients http://fcsharepoint/trustdocuments/Documents/CORP-PROC-080.docx

Obs/Gynae/Guid/022 Diabetes in Pregnancy – Management of women with pre-existing diabetes and gestational diabetes http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-GUID-022.doc

Obs/Gynae/Guid/042 Severely Ill Pregnant/Postnatal Women http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-GUID-042.doc



http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-PROT-025.doc

http://fcsharepoint/trustdocuments/Documents/OBS-GYNAE-PROT-025.doc

http://fcsharepoint/trustdocuments/Documents/CORP-PROC-080.docx

http://fcsharepoint/trustdocuments/Documents/CORP-PROC-080.docx









7. OTHER RELEVANT/ASSOCIATED DOCUMENTS Unique Identifier Title and web links from the document library VS505 Obstetric Womens Unit - High Dependency Chart

http://fcsharepoint/divisions/corporateservices/informationgovernance/healthrecords_library/Documents/13-4828%20VS505%20Obstetric-Care%20Chart.pdf

8. SUPPORTING REFERENCES/EVIDENCE BASED DOCUMENTS References In Full National Institute for Health and Clinical Excellence. (2007). Intrapartum care: Care of healthy women and their babies during childbirth. NICE. Available at www.nice.org.uk Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007). Safer Childbirth: Minimum standards for the organisation and delivery of care in labour. London: RCOG Press. Available at www.rcog.org.uk. Royal College of Anaesthetists (2011) Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. July 2011. The Maternal Critical Care Group. http://www.rcog.org.uk/files/rcog-corp/Prov_Eq_MatandCritCare.pdf Association of Anaesthetists of Great Britain and Ireland Obstetric Anaesthetic Association. May 2005. OAA/AAGBI Guidelines for Obstetric Anaesthetic Services, Revised Edition 2005. http://www.aagbi.org/sites/default/files/obstetric05.pdf 9. CONSULTATION WITH STAFF AND PATIENTS Name Designation Dr R Cross Consultant Anaesthetist 10. DEFINITIONS/GLOSSARY OF TERMS 11. AUTHOR/DIVISIONAL/DIRECTORATE MANAGER APPROVAL Issued By Moira Broadhead Checked By Miss June Davies Job Title PD Midwife Job Title Head of Department Date October 2013 Date October 2013




http://www.nice.org.uk/

http://www.rcog.org.uk/

http://www.rcog.org.uk/files/rcog-corp/Prov_Eq_MatandCritCare.pdf

http://www.aagbi.org/sites/default/files/obstetric05.pdf





Appendix 1 Modified Obstetric Early Warning Score Chart - Page 1 of 2 pages









Appendix 2 Guidance of when to involve clinicians from outside the maternity service

Modified Obstetric Early Warning Score Algorithm

This woman could have Sepsis.

• Call Consultant Obstetrician • Contact the Anaesthetic

Registrar/Consultant as required. • Depending on the MOEWS consider

critical care referral as per Trust guidelines

Senior Obstetrician, ST3 or above to ensure;

• The consultant Obstetrician is informed.

• Review and document management plan in the health record.

• Multidisciplinary team is involved as appropriate

• Consider transfer to Delivery Suite

MOEWS Calculated

Score = 0 to 2

Antenatal = Daily Observations. Postnatal = at least 12 hourly observations.

Score =3 to 5

Within 30 Minutes you must; Inform Senior Midwife Inform Senior Obstetrician ST3 or above

Score 6 Or Above

Within 15 Minutes you must; Inform Shift leader

Inform Senior Obstetrician, ST3 or above.

Inform the Anaesthetist Transfer to delivery suite

Senior Obstetrician, ST3 or above review within time

frame

YES

NO

At any point, do not hesitate to contact the critical care outreach team for advice and support. The critical care outreach team are contactable via the hospital switch board or by pager 600.





Appendix 3 Examples of indications for the admission to Delivery Suite / HDU / ITU Obstetric Indications

• Eclampsia • Sepsis. Antenatal or Postnatal. • Severe pre-eclampsia • Major haemorrhage more than 1000 mls. • Diabetic ketoacidosis • Thromboembolism • HELLP syndrome

Non-obstetric indications

• Transfer from ITU • Other surgical procedures or complications related to surgical condition • Pneumonia/ respiratory compromise • Hypertension • Renal impairment • Thyrotoxicosis • Cardiac or neurological co-morbidity • Morbid obesity (BMI >40kg/m2) with comorbidities.

This list is not exhaustive and the need for HDU care should be assessed on an individual basis. When close monitoring is required, the midwife to patient ratio must be no more than one midwife to two patients.





Appendix 4. Front FILE IN SECTION 4

Consultant Obstetrician: Date: Time:

Situation -Reason for High Dependency Care and condition of patient

Condition of baby:-

Background (Including Gravida, Parity, Previous medical / obstetric history) Assessment 1. Include Recent Blood Results and If sepsis, culture reports. Reports enclosed Yes / No 2. X-rays/scans (if appropriate) enclosed - Yes / No 3. Invasive monitoring (if any): Arterial Line Yes / No. If yes site:

CVP line Yes / No. If yes site:

Any problems siting CVP : Has post CVP line CXR been done:- Yes / No enclosed: Yes / No (If not why?)

Infusions -------------------------------------------------------------------------------------------------------------------------------------

Other Current Drugs:

Recommendations:

PTO for Management Plan.

Abbreviations used in this document to be listed here with the full description: CVP = Central Venous Line CXR = Chest X-Ray

Write patient details or affix Identification label

Hospital Number: Name: Address: Date of Birth: NHS Number:

HIGH DEPENDENCY CARE ON DELIVERY SUITE





Appendix 4 - Back

Management Plan Time onto delivery Suite ……………………………………………………..

Referring Doctor Print Name and Status: Signature





Appendix 5 - Obstetric HDU Chart





Appendix 6 FILE IN SECTION 4

Consultant Obstetrician: Date: Time:

Situation - Reason for High Dependency Care and condition of patient

Condition of baby:-

Background (Including Gravida, Parity, Previous medical / obstetric history) Assessment 1. Include Recent Blood Results and If sepsis, culture reports. Reports enclosed Yes / No 2. X-rays/scans (if appropriate) enclosed - Yes / No 3. Invasive monitoring (if any): Arterial Line Yes / No. If yes site:

CVP line Yes / No. If yes site:

Any problems siting CVP : Has post CVP line CXR been done:- Yes / No enclosed: Yes / No (If not why?) 4. Infusions --------------------------------------------------------------------------------------------------------------------------------------------

Other Current Drugs: Recommendations: notes enclosed Yes / No Referring Doctor Print Name and Status: Signature

Accepting Doctor Print Name and Status: Signature

Abbreviations used in this document to be listed here with the full description: CVP = Central Venous Line CXR = Chest X-Ray

Write patient details or affix Identification label

Hospital Number: Name: Address: Date of Birth: NHS Number:

REFERRAL REQUEST FROM MATERNITY TO CRITICAL/ HIGH DEPENDENCY CARE





Appendix 7 – The Process For Monitoring Compliance

Minimum requirement to be monitored Process for monitoring e.g. audit

Responsible individual/ group/ committee

Frequency of monitoring

Responsible individual/ group/ committee for review of results

Responsible individual/ group/ committee for development of action plan

Responsible individual/group/ committee for monitoring of action plan and Implementation

a) Responsibilities of relevant staff groups

Audit Of 1% Of Health Records Of Woman Who Delivered Who Required HDU/ITU Care

Consultant Obstetric Lead for Labour Ward / Divisional Clinical Governance Group

Annual




b) Process for ensuring the availability of medical equipment in line with national guidance



Annual Consultant Obstetric Lead for Labour Ward / Divisional Clinical Governance Group



c) Guidance for staff on when to involve clinicians outside the maternity service






d) Agreed criteria for transfer to HDU/ITU within or outside the maternity service










Appendix 8 – Equality Impact Assessment Form

Department Organisation Wide Service or Policy Guideline Date Completed: July GROUPS TO BE CONSIDERED Deprived communities, homeless, substance misusers, people who have a disability, learning disability, older people, children and families, young people, Lesbian Gay Bi-sexual or Transgender, minority ethnic communities, Gypsy/Roma/Travellers, women/men, parents, carers, staff, wider community, offenders. EQUALITY PROTECTED CHARACTERISTICS TO BE CONSIDERED Age, gender, disability, race, sexual orientation, gender identity (or reassignment), religion and belief, carers, Human Rights and socio economic/deprivation.

QUESTION RESPONSE IMPACT Issue Action Positive Negative

What is the service, leaflet or policy development? What are its aims, who are the target audience?

The Procedural Document is to ensure that all members of staff have clear guidance on processes to be followed. The target audience is all staff across the Organisation who undertakes this process.

Raise awareness of the Organisations format and processes involved in relation to the procedural document.

Yes – Clear processes identified

Does the service, leaflet or policy/ development impact on community safety • Crime • Community cohesion

Not applicable to community safety or crime

N/A N/A

Is there any evidence that groups who should benefit do not? i.e. equal opportunity monitoring of service users and/or staff. If none/insufficient local or national data available consider what information you need.

No N/A N/A

Does the service, leaflet or development/ policy have a negative impact on any geographical or sub group of the population?

No N/A N/A

How does the service, leaflet or policy/ development promote equality and diversity?

Ensures a cohesive approach across the Organisation in relation to the procedural document.

All policies and procedural documents include an EA to identify any positive or negative impacts.

Does the service, leaflet or policy/ development explicitly include a commitment to equality and diversity and meeting needs? How does it demonstrate its impact?

The Procedure includes a completed EA which provides the opportunity to highlight any potential for a negative / adverse impact.

Does the Organisation or service workforce reflect the local population? Do we employ people from disadvantaged groups

Our workforce is reflective of the local population.

Will the service, leaflet or policy/ development i. Improve economic social conditions in

deprived areas ii. Use brown field sites iii. Improve public spaces including

creation of green spaces?

N/A

Does the service, leaflet or policy/ development promote equity of lifelong learning?

N/A

Does the service, leaflet or policy/ development encourage healthy lifestyles and reduce risks to health?

N/A

Does the service, leaflet or policy/ development impact on transport? What are the implications of this?

N/A

Does the service, leaflet or policy/development impact on housing, housing needs, homelessness, or a person’s ability to remain at home?

N/A

Are there any groups for whom this policy/ service/leaflet would have an impact? Is it an adverse/negative impact? Does it or

None identified





could it (or is the perception that it could exclude disadvantaged or marginalised groups?

ACTION: Please identify if you are now required to carry out a Full Equality Analysis No (Please delete as

appropriate) Name of Author: Signature of Author:

Moira Broadhead Date Signed: July 2013

Name of Lead Person: Signature of Lead Person:

Date Signed:

Name of Manager: Signature of Manager

June Davies Date Signed: July 2013