1. 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

2. 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

3. 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

4. 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

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

6. 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)

7. 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

8. 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

9. 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?

10. 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?

11. 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
/min
41-60 or /min
<40 or >130/min
Systolic BP
mmhg
mmhg
91-99mmhg
<90 or >161mmhg
Diastolic BP
Up to 90mmhg
mmhg
>110 or <40mmhg
Temperature
38-39
<35 or >40
Assessment / validation
Link with secondary care

12. 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?

13. 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!

14. 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

15. Numerical Obstetric Early Warning Systems

16. National Early Warning System (NEWS)

17. Policy Exemplar Guide
Pragmatic approach
Exemplar versus standardised

18. 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

19. How do you define sepsis in pregnancy?

20. 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

21. 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

22. 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

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

24. Care bundles

25. 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’?

26. 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”

27. 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

28. 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

29. Thank you! Any questions? Phil Banfield – philip.banfield@wales.nhs.uk
Cath Roberts -
Vicki Evans-Park –