1. Call Facilitator : Phil Banfield & Cath Roberts
Monday 23rd January 2012
Transforming Maternity Services Mini-Collaborative Obstetric Early Warning System/Sepsis
Call Facilitator : Phil Banfield & Cath Roberts
Insert name of presentation on Master Slide

2. Agenda 1 Welcome and introductions 2
Outlining the challenge/purpose of call 3
Obstetric Early Warning System – charts and scores 4
Sepsis – screening and bundle 5
Next steps 6
Any other business

3. Purpose of Call
Overall Aim is to develop exemplar tools to be used by Health Boards in the absence of ‘working’ tools.
Clarify the issues and constraints raised during development of the tools and circulation of the Draft documents

4. Introduction – Early warning Systems
Early Warning Systems are intended to identify sick women and initiate the right action, at the right time by the appropriately skilled clinicians, at a time when treatment might make a difference.

5. Identified Recommendations – Obs EWS
Agree and understand the language used with early warning systems.
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. 1. Obstetric National Early Warning System Prior to testing these tools, can you suggest any changes to the following?
What would be the best name – ONEWS, NEOWS or any other suggestions?

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

7. 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 – eg all women or just high risk women

8. National Early Warning System (NEWS)

9. 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)
** Singh et al (2012) A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS)

12. Recommendations
Maternity Units to continue using their existing observation tracking charts eg. MEOWS/MEWS but eventually work towards a national standardised version.
To agree necessary amendments to the parameters of the trigger scoring system of NEWS in relation to obstetrics and for the tool to be available for implementation following testing.
To agree necessary amendments to the Alert and Review sections of NEWS escalation guidance in relation to obstetrics and for the tool to be available for implementation following testing.
To agree on a name for the obstetric national early warning system.

13. Feedback – Obs EWS Generally received positively Typo’s!
NEWS – (correction) plans to implement across Wales by April 12 (rather than 2013).
Needs further clarification around usage – when, where?
AVPU – useful?
Looks/feels unwell……….scoring worried?

14. All-Wales Consensus Policy Exemplar Guide (PEG)
SEPSIS
All-Wales Consensus Policy Exemplar Guide (PEG)
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?
Can you live with the advice suggested?

15. Sepsis in Pregnancy
Known or suspected infection AND Systemic Inflammatory Response Syndrome (SIRS).
Defined as the presence of TWO or more of the following:
Temperature >38◦c or <36◦c
White blood cell count >20 or <4
Respiratory rate >20/min or lactate >2mmol/l
Heart rate>100bpm

16. History or signs of new infection
Prolonged ruptured membranes or offensive liquor
Unexplained fetal tachycardia in the absence of a maternal tachycardia
Recent delivery / offensive lochia
Breast redness and / or tenderness / mastitis
Fetal demise
Cough / sputum / chest pain
Adbo pain / distension / diarrhoea
Line / IVI access infection
Endocarditis
Catheter or Dysuria
Headache with neck stiffness

17. Objective measures used in the diagnosis of sepsis applied to pregnancy
Temperature <36°C or >38.3°C
Heart rate > 100 bpm
Respiratory rate >24/minute
Acutely altered mental state
Wbc >20 or <4 x 109/l
Hyperglycaemia in the absence of (known) diabetes

18. Signs of organ dysfunction in Pregnancy
Systollic BP < 90mmHg or MAP < 65mmHg
Urine output < 0.5mm/kg/hr for 2hrs
INR > 1.5 or aPPT >60s
Bilirubin > 34µmol/l
Lactate > 2mmol/l **
New need for oxygen to keep SpO2 > 90%
Platelets < 100 x 109/l
Creatinine > 170mmol/l
** There appears to be a consensus emerging from the steering group, learning sessions and mini-collaborative that this is the most sensitive investigation in assessing the severity of sepsis for use in pregnancy. Although most ITUs will have ready access to this test, many Labour Wards do not (although SBCUs usually do). It is recommended that any maternity unit dealing with HDU level pregnant women should have immediate access to blood gas machines that can provide a rapid assessment of serum lactate levels.

19. Consensus questions for Sepsis diagnosis and management
The areas for agreement divide into 5 areas:
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?
Can you live with the advice suggested?

20. Cwm Taf Obstetric Sepsis Screening Tool

22. BCU Sepsis Six Bundle Compliance

23. (Based on the general version)
Obstetric SEPSIS CARD
(Based on the general version)

24. Feedback re sepsis Well received Typo’s!
Differences between sepsis tool/card
CRP – is there a role for this?
INR – Haematologist input
Bilirubin ? >30 or 34?

25. Next Steps.......... Further feedback….(appreciate short timescale )
2nd Draft of Papers to Nat Steering Group 31/1/12
Research proposal – Obs EWS
Testing of sepsis tool
Next WebEx – date…

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