Obstetric Early

Warning System

Learning

session 4

29th May 2012

Recognising & responding

to acute illness

Sepsis

• Agree and understand the language • Agree the normal/abnormal physiological

parameters for obstetrics in order to devise an effective trigger system.

• Agree effective accompanying escalation guidance.

• Work with the National Early Warning System

(NEWS) and explore its alignment for the use in obstetrics.

• What would be the best name – ONEWS, NEOWS or any other suggestions?

AIM of Paper – Obs EWS

Obstetric Early warning system

PREVIOUSLY……..

Modified Obstetric Early Warning System (MEOWS)

•Recommended by CMACE in the

absence of a validated tool

•Colour coded

•Mostly in use across Wales

•Associated ‘trigger’ (escalation)

criteria not always clear

•Doesn’t provide clear recognition of

improvement or deterioration

•Usage varies across Wales – e.g. all

women or just high risk women

PREVIOUSLY……..

Agreeing the Physiological Parameters in obstetrics -

What is normal/abnormal?

• MEOWS

• Existing numerical obstetric early warning systems

• NEWS

• Work undertaken with maternity clinicians (Nov 11)

• Specific physiological differences in pregnancy

• Report: Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman (Royal College of Anaesthetists, 2011)

What has informed this work?

Attempting to adapt NEWS to Obstetrics

Feedback – Obs EWS

• OVERWHELMING FEEDBACK THAT THE SERVICE

DOES NOT CURRENTLY REQUIRE A ‘NEW’

OBSTETRIC EARLY WARNING SERVICE – would need

validating so wouldn’t be available immediately.

• Singh et al (2012) A validation study of the CEMACH

recommended modified early obstetric warning system

(MEOWS) - provided further validation.

Where next?

• Need to remind ourselves: ‘what are we trying to achieve?’ improve the recognition of and response to acutely ill women

• What EWS are you currently using? 5/6 using MEOWS

• Process compliance measured via bundles.

• Can you demonstrate that tool is effective?

• Outcome measures that demonstrate the effectiveness of the early warning tool you use.

• Robust escalation guidance is key appropriate, timely

response

Outcome Measures

Reviewing cases will also highlight issues with your Early

Warning System.

Multi-disciplinary Review

Denominator: all women triggered as having severe sepsis requiring a response in one month.

Numerator: the number of women within above set that

were transferred to high dependency unit, delivery

suite or critical care within that month.

Calculate as a percentage by dividing the numerator by

the denominator and multiplying the result by 100.

This needs to include women transferred to Labour

Ward for one to one care, High dependency unit

or ICU.

Number of women escalated to

higher level of care

Monthly number of calls for a response to women who

have been assessed as being of medium or high risk of acute deterioration.

Number of calls for rapid response

to medium and high risk acute illness

(depending on local guidance and

which track and trigger system

is used)

Operational DefinitionMeasure Name

You will need to ensure that you

have robust escalation systems

Cwm Taf

EWS

Recommendations

• Maternity Units to continue using their existing observation tracking charts/EWS eg. MEOWS.

• To locally agree escalation guidance that is explicit (RCA / RCOG).

• Demonstrate effectiveness of tool.

• How to guide will be updated to reflect this.

SEPSIS Previously………

The questions

• How do we define sepsis in pregnancy?

• Is sepsis defined the same at all stages of pregnancy and the puerperium?

• Is there a simple screening tool for sepsis in pregnancy?

• Can general advice be given on the management of sepsis in pregnancy? In other words, is the general ‘sepsis six’ care bundle appropriate for use in pregnancy or are modifications necessary?

How have we answered these

questions?

•Reviewed the current evidence

•Explored what is already happening

•Confidential enquiry

•Consultation with the service

•New RCOG Guidance

How do we define sepsis

in pregnancy?

• Sepsis: infection plus systemic manifestations of infection.

• Severe sepsis: sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion.

• Septic shock: the persistence of hypoperfusion despite adequate fluid replacement therapy.

RCOG (2012)

• Do we know the answer to this question?

Is sepsis defined the same at all stages of pregnancy and the puerperium?

Is there a simple screening tool for sepsis in pregnancy?

Can general advice be

given on the management

of sepsis in pregnancy? In other words, is the general

‘sepsis six’ care bundle appropriate for use in

pregnancy or are

modifications necessary?

“SEPSIS SIX”

Can general advice be

given on the management

of sepsis in pregnancy? In other words, is the general

‘sepsis six’ care bundle appropriate for use in

pregnancy or are

modifications necessary?

“SEPSIS SIX”

PLUS TWO

Communication

Sepsis Bag

Antibiotic Therapy

Measuring Effectiveness

Process

% compliance to Sepsis Six Bundle

Outcome Measures

Multidisciplinary reviews – learning from cases of sepsis that occur

Number of calls for rapid response to medium and high risk acute illness (depending on local guidance and which track and trigger system is used)

Monthly number of calls for a response to women who have been assessed as being of medium or high risk of acute deterioration

Number of women escalated to higher level of care - needs to include women transferred to Labour Ward for one to one care, High dependency unit or ICU

Sepsis Mortality

Outputs

• Updated How to

Guide June 2012

• PEG: Recognition of

the deteriorating pregnant woman and

escalation to

appropriate care

• PEG: Sepsis in

pregnancy