1. Insert name of presentation on Master Slide Transforming Maternity Services Mini-Collaborative Acutely Deteriorating Woman / Sepsis November 2011 Philip Banfield: Faculty Lead

2. Interactive session About the programme Aneurin Bevan – walking the walk Obstetric early warning systems Sepsis in pregnancy and newly delivered mums Developments at Cardiff & Vale - Rachel Collis Next steps…..

3. 1817 - an obstetric tragedy Term Multiple blood letting 24hr first stage 24hr second stage Stillborn son Gradual deterioration and dies Obstetrician – Richard Croft

5. What are we trying to achieve? OVERALL AIM: To improve experience and outcomes for mothers, babies and their families within Maternity Services Reduce mortality and harm from venous thromboembolism in pregnancy and the postnatal period. Reduce mortality and harm by improving the recognition and response to the acutely deteriorating woman.

6. Care bundles

7. AN/PN admissions to higher level of care in Wales 20092010 Level 27377 Level 34134 PEDW data 2011

8. ‘Providing equity of critical care and maternal care for the critically ill pregnant or recently pregnant woman’ Royal College of Anaesthetists 2011 Every death = 9 severe maternal morbidity Maternal death rate = 14/100,000 Critical care utilisation = 260/100,00 (difficult to ascertain and may be as high as 1200/100,000)

9. Obstetric Early Warning Systems No validated tool Differing modified tools in use across the UK MEOWS (Modified Obstetric Early Warning System) recommended by CMACE in the absence of a validated tool

10. Modified Obstetric Early Warning System (MEOWS) Colour coded Allows a graded response Mostly in use across Wales Associated ‘trigger’ criteria not always clear – nor get the right team Doesn’t provide clear recognition of improvement or deterioration Usage varies – all women or just high risk women

11. Literature Review Allman et al (2010) Royal Gwent – MEOWS being used but recording needs improving, lack of documentation Singh et al (2010) – MEOWs demonstrates high specificity and negative predictive value Tufail et al (2009) - Most critically ill women had early triggers which continued through their illness, time delays in management Kodikara et al (2009) – MEOWS identifies potentially sick women but has high false positive rate, BP trigger values are incorrectly set Carle et al (2010) – Early warning systems can predict obstetric mortality and identify women at risk but obstetric MEWS did not confer additional benefit

13. Aneurin Bevan Health Board

14. Speaking the same language! Early warning system – a tool to aid the recognition and management of a deteriorating woman e.g. MEOWS Track and trigger describes how you use the tool Track – periodic observation of vital signs Trigger – pre-determined criteria ‘trigger’ the summoning for help – timely response, appropriate level of assistance WHAT TO DO AND WHEN TO DO IT !

15. Numerical Obstetric Early Warning Systems

16. Community recognition 4hrly obs on all pregnant women is not an effective use of resources! Community tool – being piloted Links with secondary care tools Screening - are you / is she unwell? Context and expectation – primary care What response should this evoke?

17. National Early Warning System (NEWS) Can we modify this to be sensitive in obstetrics? Chris Subbe

18. Translating MEOWS to NEWS (without modification) <3535-37.3> 37.4-38 >38 AlertVoice P/U 50-100 Conversion White = 0, Yellow = 2 & Red = 3 101-120>12040-49 90-140141-150>15080-89<80 95-100<95 11-2021-28>28<10 ??

19. Additional Triggers in MEOWS 3210123 Diastolic (c) 30-9091-100>100 Urine output (e) <0.5mg/ kg/hr <1ml/kg /hr >1ml/kg /hr Looks unwell NoYes

20. The above maternity ranges have been obtained from the following Obstetric Early Warning Systems NHS Lothian Shrewsbury & Telford MEOWS James Paget Walsall ABAB 3210123 Resp Rate NEWS<89-1112-2021-24>25 Mat range >5-85-109-2021-3025-35>30-36 O2 Sats NEWS<9192-9394-95>96 Mat range < 85- 95 85-9490-9295-100 Supp Oxygen NEWSYESNO Mat Range -------

21. ABAB 3210123 RRNEWS ≤8≤89-1112-2021-24≥25 MEOWS O 2 SatNEWS ≤9192-9394-95≥96 MEOWS Supp O 2 NEWS YESNO MEOWS C 3210123 P NEWS ≤4041-5051-9091-110111-130≥131 MEOWS Syst BP NEWS ≤ 9091-100101-110111-219≥220 MEOWS Diast BP NEWS ------- MEOWS D 3210123 AVPU NEWS AlertVPU MEOWS TempNEWS ≤35.035.1-3636.1-3838.1-39≥39.1 MEOWS UrineNEWS ------- MEOWS

22. Monitoring & data collection Compliance with use of observation chart Alteration of parameters or standards False positives False negatives Escalation Bundle compliance

23. Who is Jessica? Jessica Palmer was a Mum. She died in June 2004, at 34 years old, of childbed fever caused by Group A streptococcus, six days after the uncomplicated birth of her second child.childbed fever

24. How do you define sepsis in pregnancy?

25. Screening for and management of sepsis

26. SEVERE SEPSIS 1.Death related to infection or suspected infection 2.Any woman requiring level 2 or level 3 critical care (or obstetric HDU type care) due to severe sepsis or supsected severe sepsis 3.A clinical diagnosis of severe sepsis

27. Diagnosis of sepsis UK Sepsis Group Audit data – Reading, Manchester, B’ham Welsh Data Validation studies UKOSS reporting

28. Consensus exemplar tools Welsh survey – who, where? Audit data? 10 last ICU admissions and last 3 deaths from all hospitals: Anonymised TPR charts - scores in the 24 hours prior to admission/death Validation studies Identify limits at which point everyone agrees?

29. Escalation and communication Increased surveillance often clear but action to get senior / appropriate staff is not Can we decide at what point the consultant MDT is mobilised Use of structured communication tool Worried: valid at any level - no point score

30. Early and prompt referral to critical care is paramount An anaesthetist and/or critical-care specialist should be involved early Defined local guidance is needed is needed to obtain rapid access to, and help from, critical care specialist Use of outreach/acute care teams – access to unit……. Management of Sepsis

31. Cardiff & Vale Rachel Collis Peter Richardson

32. Focus on Acute deterioration / Sepsis Next steps……… What are we trying to achieve? Agree a validated exemplar early warning system for obstetrics in Wales (although sensitive to local requirements) Work with the National Early Warning System (NEWS) and try to align for use in obstetrics Ensure we agree and understand the language used Find a pragmatic definition of sepsis in pregnancy? Determine if this differs antenatally, in labour or postnatally? Screening tool for sepsis – does it vary with setting or trimester? Clarify the sepsis bundle for use in pregnancy Improved communication and escalation

33. Debate! Programme Manager: Cath Roberts - Maternity.collaborative@wales.nhs.uk Maternity.collaborative@wales.nhs.uk Faculty Lead: Phil Banfield – philip.banfield@wales.nhs.ukphilip.banfield@wales.nhs.uk WebEx – Monday 23 rd January