Transforming Maternity Services Mini-Collaborative SEPSIS Tuesday 18th October 2011 Transforming Maternity Services Mini-Collaborative SEPSIS Call Facilitator : Phil Banfield Insert name of presentation on Master Slide

Agenda 1 Welcome and introductions 2 Outlining the challenge 3 Recognition – community & hospital 4 Deterioration 5 Escalation and Communication 6 Monitoring & data collection 7 Next steps 8 Any other business

Introduction CMACE 2006-8 Report (2011) Mortality overall declining – about 11/100,000 Sepsis leading direct cause - 26 (about 11 / million) Further 12 deaths (diagnosis flu virus) April 09-Jan 10

CMACE Report Findings (2006-2008) RARE Many - early warning signs unrecognised Issues re: support and backup Clear lack of clinical knowledge Challenge as deterioration can be rapid

AN/PN Admissions to higher level of care - Wales 2009 2010 Level 2 73 77 Level 3 41 34 PEDW data 2011

Obstetric Anaesthetists Survey 2009 All UK maternity units 71% return rate Need a validated early warning system for obstetrics PLUS associated training, skills and resources (Swanton et al 2009)

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

Normality GPs see ill pregnant women all the time Political imperative is driving ‘normality’ Unacceptable to ‘medicalise’ low risk women in normal pregnancy Recognition of abnormality, transfer and treatment needs to be clearly defined and rapid

The key questions – for the collaborative Is she ill? Is she getting better – or worse? At what point do you call for help? At what point do you transfer? At what point does the MDT kick in? Do our care bundles need changing? How do we monitor compliance and improvement?

Community recognition 4hrly obs on all pregnant women is not an effective use of resources! Community tool – being piloted Screening - are you / is she unwell? What response should this evoke?

Community Tool Assessment / validation Link with secondary care Community Early Warning Score Aide Memoir Score 1 2 3 Looks/feels well Yes No 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 >161mmhg Diastolic BP Up to 90mmhg 100-109mmhg >110 or <40mmhg Temperature 36-37.9 35.1-35.9 38-39 <35 or >40 Assessment / validation Link with secondary care

Tracking well versus ill In hospital, we can do obs Great work being done in many hospitals Numerical Graphical Colour coded RCOG / OAA review of Critical Care What sort of consensus is needed?

Speaking the same language! Early warning system – a tool to aid the recognition and management of a deteriorating woman eg 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!

Modified Obstetric Early Warning System (MEOWS) Recommended by CMACE (in the absence of a validated tool) Colour coded Allows a graded response Mostly in use across Wales Associated ‘trigger’ criteria not always clear Doesn’t provide clear recognition of improvement or deterioration Usage varies – all women or just high risk women

Numerical Obstetric Early Warning Systems

National Early Warning System (NEWS)

Policy Exemplar Guide Pragmatic approach Exemplar versus standardised

Sepsis What are we trying to achieve? Review existing work on sepsis and critically ill women in pregnancy Agree a validated 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

How do you define sepsis in pregnancy?

Sepsis – non-pregnant Temp > 38°C or < 36°C Heart rate > 90bpm RR > 20/min PaCO2 <32mmHg (4.3kPa) + WCC: >12 x 106/l or <4 x 106/l or 10% immature/band forms + Presence of infection

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

Clinical diagnosis of severe sepsis – a guide Usually 2 or more of the following: Temp >38oC or < 36oC on 2 occasions at least 4hrs apart Heart rate >100bpm on 2 occasions … Resp rate > 20/min on 2 occasions … WBC > 17x109/l or < 4x109/l or with immature band forms, measured on 2 occasions

Diagnosis of sepsis UK Sepsis Group Audit data – Reading, Manchester, B’ham Welsh Data Validation studies UKOSS reporting Research – SAIL dataset - Swansea

Care bundles

Escalation and communication Increased surveillance often clear but action to get senior / appropriate staff is not Is there a point at which we agree that one / more than one consultant is called? Can we decide at what point the consultant MDT is mobilised – before ‘in extremis’?

Monitoring & data collection Compliance with observation chart Escalation False positives False negatives Alteration of parameters or standards “Data, Data, Data. I cannot make bricks without clay”

Next steps Finalise what questions we don’t know the answers for Agree what need to agree and what needs flexibility Agree constant feedback and sharing – this is naturally evolving LS3 Delphi Exercise

Remember Important to use care bundles for recognition Essential to respond appropriately Helpful to monitor compliance and outcomes Trying to get everyone to a place they wish to be by March 2012

Thank you! Any questions? Phil Banfield – philip.banfield@wales.nhs.uk Cath Roberts - Maternity.collaborative@wales.nhs.uk Vicki Evans-Park – victoria.evans-park@wales.nhs.uk