Hello.
My name is Matthew Drake.
I'm an obstetric anaesthetist from the National Women's in Auckland
and I'm also the anaesthesia clinical lead to the
Health Quality & Safety Commission's maternity early warning system (MEWS).
My colleagues at the Commission are Gay Austin the midwifery clinical lead
and Suzanne Esson who's the obstetric clinical lead.
Emma Forbes is a quality improvement advisor at the Commission and she's worked on
developing both maternity and the adult early warning systems for New Zealand.
The aim of this presentation is to introduce you to the New Zealand
maternity early warning system, how it came about, why it's an important
and effective national initiative to keep women and their babies safe and how you as
medical staff can make it work.
Whether you work in maternity, medicine, surgery or any other area of acute and hospital care
in New Zealand.
The maternal morbidity working group or MMWG was established in 2016 with the aim to improve the
quality and experience of maternity care for women, babies and their whānau
through robust women's-centered maternal morbidity review and quality improvement.
With this in mind, we established a notification database of pregnant or recently pregnant women
who've been admitted to a high dependency unit or an intensive care unit.
A selection of these cases were then reviewed by a regional multidisciplinary panel -
who were not involved in the case nor had any relationship with the DHB involved.
With a structured tool to determine whether the severity of the morbidity was preventable and which factors
contributed to the severity of the outcome.
In 2018, there were 468 notifications of admissions to high dependency or intensive care across New Zealand,
for 437 women,
either during pregnancy or up to six weeks postpartum,
with similar numbers in the 2017 report.
And for these notifications here's the
spread of the causes for critical care admission for the notifications from the 2018 report.
As you can see the big three are sepsis, hypertensive disorders of pregnancy and postpartum hemorrhage.
Other includes a wide range of other conditions or causes for admission including, but not limited, to
cardiac issues and anaphylaxis and chronic comorbidities.
Multiple conditions includes all women who were admitted with more than one diagnosis.
The first report was published last year focusing on sepsis
and the final report was published in 2019
together with the perinatal and maternal mortality report.
And that focused on peripartum hysterectomy and hypertensive disorders of pregnancy.
Both of these reports are well worth reading
since they bring out some very common themes where
modifiable factors could have been improved.
It will be great if we could reduce the number of women getting so unwell that they need critical care,
both for them and for their families, by optimising the care that they receive.
The resounding conclusion from both reports
is the early recognition of deterioration and
a timely and appropriate response could have prevented
these women being admitted to a high dependency unit or critical care area.
There were three broad modifiable factors that were
brought out in the reviews of the sepsis cases.
These were failure to recognise the severity of illness
in 53 percent of those cases reviewed.
Delay in treatment in 47 percent of cases
and inadequate communication in 47 percent of cases.
If these factors could be reduced this would reduce the severity and amount of morbidity
that women would suffer during pregnancy and the six weeks after birth.
All of the MMWG reviews are consistent with other research both in and outside pregnancy.
They all identify that there is a need to improve
the recognition of the deteriorating pregnant, or recently pregnant woman.
For example, from the MMWG sepsis report,
in half of the 32 cases that were reviewed in-depth,
the multidisciplinary panel felt the severity of the morbidity that occurred
could have been reduced if it had been detected and responded to earlier.
So in order to address this potentially modifiable factor
the maternal morbidity working group
and the Health Quality & Safety Commission have
committed to developing, testing and now implementing
a national maternity early warning system
similar to the adult deteriorating patient work
but customised to the specific needs and physiology of pregnancy.
Once fully embedded, we'll have a standardised approach across the country
which will assist with staff moving between organisations.
It will give us a consistent language to define deterioration
and it will be aligned with the adult deteriorating work
currently being implemented across DHBs.
It will also provide an opportunity for maternity clinical governance
to support a change in culture both within and across services,
to identify and to review patient deterioration with a local lens.
And hopefully lead to a meaningful improvement in care at a local level.
There are three main phases in the response to an unwell patient.
First realising something isn't right
then mobilising the right response
and finally treating the problem.
If you use an objective tool to distinguish
normality from abnormality, such as MEWS
or another track and trigger system
that provides the detection phase of the process.
But that won't be of any benefit until there is a robust process to get the appropriate people to see the patient
within an appropriate time frame.
These people then have to give effective treatment
to further avoid deterioration
and hopefully for the woman to recover
or at least avoid significant morbidity.
At this point I want to stress again that MEWS
is not simply a vital signs chart that's been slightly amended
to cater for younger, normally healthy patients who are
either currently or have recently been pregnant.
The chart is just one part of a recognition and response system.
There's no point recognising deterioration
if it's not supported by an effective and timely response.
In addition to effective recognition and response pathways
there also needs to be some governance process
set in place which remains over time.
Education is a significant initial part of the process
although as time goes on staff will become more familiar with the chart
which is the same wherever they work in New Zealand.
The governance group will need to ensure the full benefits of the system
are being both realised and maintained over time
through both measurement of process and outcomes.
Communication of the 'why' as well as the 'how' is important to take staff with you,
when any new changes occur,
and a two-way dialogue can be really helpful to
understand what's working well and what needs further work to make it work really, really well
for your patient group.
My hospital in Auckland was one of the three test sites
for the first iteration of the maternity early warning system.
So as well as being the anaesthesia lead for the MEWS nationally,
I'm still running the rollout of MEWS in my own hospital.
The system was also tested across the whole hospital in Nelson and Wairau
as well as within the maternity area of Northland DHB.
The evaluation ran for three months and included
audit data, written and face-to-face feedback with staff
and further review before a decision was made to implement a slightly amended version
of the MEWS nationally.
In Auckland, I'd introduced a maternity vital signs chart
in isolation a couple of years previously
simply by amending some of the parameters on our existing vital signs chart
and making the escalation pathway a little bit more relevant to maternity.
In reality all I did was introduce a maternity vital signs chart without really looking at
the whole system of early recognition and timely response deterioration.
I didn't audit the effect of implementing this more maternity-specific chart in isolation.
So I can't say whether it made a difference to our outcomes or not.
But this time around I do have some very good data
showing that MEWS as a whole system approach does reduce morbidity.
These are the adult code red calls for the maternity wards
from January 2018 prior to our introduction of the MEWS.
A code red call in Auckland is made when a woman is very unwell
but hasn't yet reached the stage of cardiopulmonary arrest
which is thankfully very rare in maternity.
In June 2018, we were busy getting ready for the national MEWS trial
doing lots of education and making
our escalation processes much more robust.
MEWS was introduced in July and,
against what I expected, the number of code red calls
fell well below the long-term average
even though September and October are traditionally the busiest times of year for maternity units.
This fall seems to have been maintained.
It may be by chance, but as the months go on
I believe this is because we are recognising acute deterioration earlier,
we're making more robust plans for management and review
and therefore preventing so many times that women
deteriorate to the point of needing a code red call.
This is the maternity vital signs chart.
As you can see it's quite similar to the national adult vital signs chart
but it has a green border to distinguish it as the maternity version.
It has eight vital signs instead of seven that contribute to this total score
with both systolic and diastolic blood pressures being recorded and scored separately.
Pain is also recorded on this chart
since this is an observation that should be recorded at the same frequency
as the core vital sign set
and can be a marker of acute illness,
though not in the same objective quantitative way that parameters such as respiratory rate are.
You can see there's also the escalation pathway on the right-hand side
which is developed locally to suit your staffing and resources.
There's a modification box on the bottom right
which allows staff to make temporary or permanent
modifications to the scoring system for a particular patient because of their specific physiology.
Obviously modifications need to be done with care
as inappropriate modifications can hamper recognition of deterioration.
But it's useful whilst waiting for treatment to have an effect
or for a temporary problem like mild hypotension after a spinal anesthetic to wear off.
This is an example of a mandatory escalation pathway from my hospital.
You can see that, as the scores increase, the response is more senior and more rapid.
Like the adult New Zealand Early Warning System
the escalation pathway is a hybrid system using both a total score to determine the response
as well as single parameter triggers.
Pink and blue areas on the vital signs chart automatically trigger a pink or blue response,
regardless of the score.
Though several pink parameters can still add up and trigger a blue response
if the total MEWS adds up to 10 or more.
These single parameter triggers reflect significantly deranged physiology
and merit a more rapid and senior response,
particularly in the younger, fitter maternity population,
who are much more able to compensate for physiological deterioration.
For this reason you can see the total scores
to trigger responses are slightly lower in the MEWS than in the adult EWS,
which are 1–5 and 6–7 in the adult chart
but 1–4 and 5–7 in the maternity chart.
I've already mentioned that MEWS is a whole system that relies predominantly on midwives and nurses
to do the recognition part of the system
but there's also a response part that's
predominantly done by medical staff.
Both the recognition and response parts of the system
have to be effective for MEWS to actually make a difference in outcomes.
Junior doctors are often the first responders
and they always need to be supportive of the process of escalation and be aware that escalation is potentially
an early marker a problem, but occasionally it can just be a false positive.
By the way they should acknowledge and thank the professional who called them
and encourage them to call again in future.
They may also consider discussing completing the parameter modification box on the chart
if that particular physiological derangement is normal for that patient.
It's very important to understand that,
particularly patients in obstetrics who have different
physiology from the majority of the adult population in a hospital,
can compensate for acute illness quite well
and they can often look better than they actually are.
Which is why an objective recognition or response system is so important for maternity patients.
It's also really important that MEWS is not seen solely as a midwifery or nursing initiative
but that it's also a medical initiative, for it to be successful.
Once implemented, MEWS will be for all currently and recently pregnant in-patients
and not just those on the maternity wards.
So pregnant women with appendicitis, fractures and acute asthma
should all be on the MEWS chart
from the time they find out they're pregnant up until six weeks postpartum.
Outside maternity is where then you should make a biggest difference
as it's those areas that aren't used to pregnancy physiology
and where the involvement of the maternity services
can sometimes be forgotten.
During our implementation and evaluation the most difficult group to get involved in the MEWS
has been the medical staff.
There's been lots of barriers including concern the number of calls would increase
as a result of MEWS
or that it somehow removes independent thought.
However, both in my DHB and the other test sites we've actually found the opposite.
Problems are identified earlier, when they're easier to manage, and the feared increasing calls for review
has not actually been borne out in practice.
It's absolutely vital that medical staff model behavior that demonstrates that early recognition and response
to acute deterioration in all adult patients is important, including those in maternity.
You have a very important role to break down the silos between medical specialties
and to make this a common pathway for all pregnant women
regardless of the area of the hospital that they're in.
Your DHB also has an excellent e-learning package that's tailored to three groups of staff.
Nurses outside maternity, nurses and midwives within maternity and medical staff.
Have a look on your own local e-learning platform for more details.
That's all for now, do feel free to drop us an email at either of these addresses if you have any questions.
Thank you very much for watching.