Maternal Early Warning Systems

Transcription

1 Maternal Early Warning Systems Mary E. D Alton, M.D. Willard C. Rappleye Professor and Chair, Department of Obstetrics & Gynecology Adina Kern-Goldberger, M.D. M.P.H. Columbia University Vagelos College of Physicians & Surgeons Disclosures I am on the board of Merck for Mothers. Background In many cases in this report, the early warning signs of impending maternal collapse went unrecognized. Rare events Healthy population Physiologic changes of pregnancy 1

2 Existing Joint Commission requirements: Have a process for recognizing and responding as soon as a patient s condition appears to be worsening Develop written criteria describing early warning signs of a change or deterioration in a patient s condition and when to seek further assistance Based on the hospital s early warning criteria, have staff seek additional assistance when they have concerns about a patient s condition Issue 44, January 26, 2010 Maternal Vital Signs Vital Sign Ranges in Pregnancy Pregnant Not Pregnant Temperature Heart Rate Systolic Blood Pressure Diastolic Blood Pressure Respiratory Rate O2 Saturation % % Gabbe, Normal and Problem Pregnancies 2017; Ch 3, Modified Early Obstetric Warning System Parameter RED Trigger YELLOW Trigger Temperature < 35 or > Systolic BP; mmhg <90 or > Diastolic BP; mmhg > Heart rate <40, > , Respiratory rate <10 or > Oxygen saturation <95 Pain score 2 3 Neurological response Unresponsive or responds only to painful stimulus Responds to voice stimulus Contact for 1 RED trigger or 2 YELLOW triggers Swanton, IJOA 2009; 18:

3 MEOWS Implementation Criteria applied to: All post op patients PPH > 500 cc O2 sat < 94% Midwifery/medical concern Patients with spinal/epidural/pca Measurements: q30 min for first 2 hours (q15 min for post op) q2 hours for 4 hours q4 hours If 1 yellow trigger q30 min Swanton, IJOA 2009; 18: MEOWS Validation 673 consecutive obstetric admissions over 2 months (> 20 wks 6 wks PP) 200 patients triggered MEOWS (30%) 78 patients who triggered MEOWS also had morbidity (39%) Singh et al., Anaesthesia MEOWS Validation Study definition of obstetric morbidity: Hemorrhage Pre eclampsia Suspected infection Pulmonary embolus Cerebral venous sinus thrombosis Intracranial bleed Acute asthma Status epilepticus Diabetic ketoacidosis Myocardial infarction Pulmonary edema Anesthetic complications 86 total patients with morbidity [13% of total, 90.7% triggered MEOWS] 43% hemorrhage 31% hypertension 20% suspected infection Singh et al., Anaesthesia

4 MEOWS Validation 89% sensitivity (95% CI 81 95%) 79% specificity (95% CI 76 82%) PPV 39% (95% CI 32 46%) NPV 98% (95% CI 96 99%) Individual Parameters Relative Risk of Morbidity (CI) P Value Heart rate > 100 beats/min 7.0 ( ) < 0.01 Diastolic BP > 90 mmhg 6.6 ( ) < 0.01 Systolic BP > 150 mmhg 5.4 ( ) < 0.01 Respiratory rate > 22 breaths/min 4.8 ( ) < 0.01 Temperate > 38 o C 3.4 ( ) < 0.01 Systolic BP < 90 mmhg 2.4 ( ) < 0.01 Oxygen saturation < 95% 1.3 ( ) 0.56 Pain score ( ) 0.17 Responds only to voice/pain or unresponsive Singh et al., Anaesthesia National Partnership for Maternal Safety: Vital Sign Triggers Committee Consensus based approach to define Maternal Early Warning Criteria (MEWC) Every birthing facility in the United States should adapt tools that identify maternity patients who require urgent bedside evaluation by a These tools also include a differential diagnosis and potential next steps 2 Essential Components Maternal Early Warning Criteria Effective Escalation Policy 4

5 Revising MEOWS MEWC Parameter RED Trigger YELLOW Trigger Temperature < 35 or > Systolic BP; mmhg <90 or > Diastolic BP; mmhg > Heart rate <40, > , Respiratory rate <10 or > Oxygen saturation <95 Pain score 2 3 Neurological response Unresponsive, pain Responds to vocal stimulus + Oliguria Maternal Early Warning Criteria Systolic BP; mmhg < 90 or > 160 Diastolic BP; mmhg > 100 Heart rate; beats per min < 50 or > 120 Respiratory rate; breaths per min < 10 or > 30 Oxygen saturation; % < 95 Oliguria; ml/hr for 2 hours < 30 Maternal agitation, confusion, or unresponsiveness Patient with hypertension reporting a non remitting headache or shortness of breath 2 Essential Components Maternal Early Warning Criteria Effective Escalation Policy 5

6 Effective Escalation Policy An abnormal parameter requires: 1. Prompt reporting to a or other qualified clinician 2. Prompt bedside evaluation by a or other qualified clinician 3. Ability to activate resources in order to initiate diagnostic and therapeutic interventions 4. Plan for and implementation of diagnostic work up 5. Close follow up of patient s status until: Abnormality resolves, or Parameter judged to be of benign etiology, or Patient is determined to be potentially critically ill and care is escalated (rapid response, higher acuity setting) Bedside Evaluation Maternal mortality reviews illustrate the hazards of phone based management in women developing critical illness Specific expectations for response times should be established at a local level based on available resources Local Implementation 1. Who to notify 2. How to notify them 3. When to activate the clinical chain of command in order to ensure an appropriate response 6

7 Early Warning Breakdowns 1 2 ABNORMAL VITAL SIGN PARAMETERS PREVENT MAJOR MORBIDITY / CRITICAL ILLNESS? 3 Addressing System Barriers Fear of offending or disturbing more senior personnel may need to be addressed Supervisors, service leaders, and hospital administrators must ensure that nurses and other clinicians are rewarded rather than punished or ignored when they call for bedside evaluations Leadership required to establish a normative expectation for prompt bedside evaluation National Partnership for Maternal Safety: Developing a Differential Diagnosis The Vital Signs Triggers Committee also developed differential diagnosis models to help evaluate abnormal vital signs These include: Tachycardia Tachypnea Bradycardia Oxygen desaturation Hypertension Maternal neurologic changes Hypotension Oliguria 7

8 National Partnership for Maternal Safety: Developing a Differential Diagnosis Tachycardia (> 120 bpm): Common diagnoses: Dehydration Hemorrhage Infection Medication side effects (sympathomimetics, beta 2 agonists) Anxiety/pain/panic attack Severe diagnoses (rare, life threatening): Cardiac (cardiomyopathy, heart failure, MI, pericarditis, tachyarrhythmia) Illicit drugs (cocaine, amphetamines) Thromboembolism Concealed hemorrhage (retroperitoneal hemorrhage, abruption, uterine rupture) Amniotic fluid embolism Anaphylaxis Endocrine disorders (pheochromocytoma, hyperthyroidism/thyroid storm) Malignant hyperthermia Vascular emergency (splanchic arterial dissection, aortic dissection) Limitations of MEWC Systolic BP; mmhg < 90 or > 160 Diastolic BP; mmhg > 100 Heart rate; beats per min < 50 or > 120 Respiratory rate; breaths per min < 10 or > 30 Oxygen saturation; % < 95 Oliguria; ml/hr for 2 hours < 30 Maternal agitation, confusion, or unresponsiveness Patient with hypertension reporting a non remitting headache or shortness of breath Do Maternal Early Warning Triggers (MEWTs) Predict Morbidity? MEWT ICU group (n = 50) Controls (n = 50) Odds ratio (95% CI) P value Heart rate > 110 bpm 36 (72) 17 (34) 5.0 ( ) < 0.01 Mean arterial pressure < 65 mm Hg 28 (56) 11 (22) 4.5 ( ) < 0.01 Altered mental state 15 (30) ( ) < 0.01 Temperature 38 C 15 (30) ( ) 0.10 Respiratory rate > 24 breaths/min 9 (18) 3 (6) 3.4 ( ) 0.08 SpO2 < 94% 9 (18) 8 (16) 1.2 ( ) 0.08 Hedriana et al. Int l J. Gynecol Obstet

9 Comparison Persistent vs. Isolated MEWTS ICU group Controls Odds ratio Predictive Predictor (n = 50) (n = 50) (95% CI) P value value (95% CI) 2 ISOLATED MEWTs 36 (72) 10 (20) 10.3 ( ) < 0.01 Sensitivity, % 72 (57 83) Specificity, % 80 (66 90) PPV, % 78 (63 89) NPV, % 74 (60 85) 2 PERSISTENT MEWTs 36 (72) 2 (4) 61.7 ( ) < 0.01 Sensitivity, % 72 (57 83) Specificity, % 96 (85 99) PPV, % 95 (81 99) NPV, % 77 (65 87) Hedriana et al. Int l J. Gynecol Obstet Persistent MEWTs 2 or more triggers persistent for 30 minutes or more Persistent triggers in 36 (72%) ICU patients versus 2 (4%) controls Earlier medical intervention might have led to a lesser degree of maternal morbidity for 31 (62%) of ICU patients with at least one MEWT Persistent MEWTs present in most obstetric ICU cases Hedriana et al. Int l J. Gynecol Obstet Proposed MEWT Algorithm MEWTs Sepsis Pathway Cardiopulmonary pathway Hypertension pathway Hemorrhage pathway Abnormal temp + Normal temp + Elevated BPs + Decreasing BPs + Sepsis Severe sepsis or septic shock Hedriana et al. Int l J. Gynecol Obstet

10 MEWT Algorithm Maternal Early Warning Triggers HR>110 bpm, MAP<65 mm Hg, AMS, T 38⁰C, RR>24/min, SpO2 <94% Hedriana et al. Int l J. Gynecol Obstet Proposed MEWT Algorithm MEWTs Sepsis Pathway Cardiopulmonary pathway Hypertension pathway Hemorrhage pathway Abnormal temp + Normal temp + Elevated BPs + Decreasing BPs + Sepsis Severe sepsis or septic shock Hedriana et al. Int l J. Gynecol Obstet MEWT Algorithm: Sepsis Sepsis Pathway Abnormal temp + additional triggers Sepsis Severe sepsis or septic shock Hedriana et al. Int l J. Gynecol Obstet

11 Proposed MEWT Algorithm MEWTs Sepsis Pathway Cardiopulmonary pathway Hypertension pathway Hemorrhage pathway Abnormal temp + Normal temp + Elevated BPs + Decreasing BPs + Sepsis Severe sepsis or septic shock Hedriana et al. Int l J. Gynecol Obstet Limitations of MEWTs MEWT ICU group (n = 50) Controls (n = 50) Odds ratio (95% CI) P value Heart rate > 110 bpm 36 (72) 17 (34) 5.0 ( ) < 0.01 Mean arterial pressure < 65 mm Hg 28 (56) 11 (22) 4.5 ( ) < 0.01 Altered mental state 15 (30) ( ) < 0.01 Temperature 38 C 15 (30) ( ) 0.10 Respiratory rate > 24 breaths/min 9 (18) 3 (6) 3.4 ( ) 0.08 SpO2 < 94% 9 (18) 8 (16) 1.2 ( ) 0.08 Hedriana et al. Int l J. Gynecol Obstet Do MEWTs Reduce Maternal Morbidity? Implementation study in a hospital system (6/29 hospitals) Goal was early and treatment of patients suspected of clinical deterioration Tool addressed the four most common areas of maternal morbidity Sepsis Cardiopulmonary dysfunction Preeclampsia/hypertension Hemorrhage 11

12 Study Definition of MEWTs Severe (Requires 1 abnormal value) Maternal HR > 130 bpm Respiratory rate > 30/min Mean arterial pressure < 55 mmhg Non Severe (Requires 2 abnormal values) Maternal HR > 110 or < 50 bpm Respiratory rate > 24 or < 10/min BP > 160/110 or < 85/45 mmhg O2 saturation < 90% O2 saturation < 93% Nursing concern Altered mental status Disproportionate pain Temp > 38 or < 36 o C Fetal HR > 160 bpm *Must be sustained for 20 min Do MEWTs Reduce Maternal Morbidity? Pre MEWT Post MEWT Trend P value Deliveries (N) 24,221 12,611 CDC SMM (%) 2.00% 1.60% <.001 Composite morbidity (%) 5.90% 5.10% <0.01 Eclampsia (per 1000 deliveries) <0.01 Hemorrhage (%) 2.90% 2.70% 0.1 Transfusion (%) 0.70% 0.60% 0.5 D&C (per 1000 deliveries) Hysterectomy (per 1000 deliveries) Sepsis (per 1000 deliveries) Do MEWTs Predict ICU Admission? Clinical Pathway Screened positive (N=260) ICU admissions (N=47) Sepsis 71.4% 38% Cardiopulmonary 3.1% 6% Hypertension 14.6% 15% Hemorrhage 7.7% 31% Multiple pathways 2.3% Pathways follow correctly 82.3% Physician intervention time points, <30 and <60 min 71.9% and 83.1% 96.9% sensitivity 99.9% specificity 12.0% PPV 99.99% NPV 12

13 MEWT Flow Diagram MEWT Flow Diagram Maternal Temp, Pulse Ox, HR, RR, BP Normal Assessment [No abnormal triggers] Stop here and continue to monitor Abnormal Maternal Assessment 2 or More Triggers Confirmed (sustained): REQUEST PROVIDER EVALUATION Continue towards Critical Care Assessment Pathway Abnormal Maternal Temp Infection Sepsis Two or more triggers HR>110 and/or MAP<65 Notify, CBC, antibiotics, consider blood culture Test organ dysfunction Severe Sepsis/Septic Shock Notify RRT, ICU transfer and/or consult as appropriate Fluid Resuscitation (within 1 hour) MAP <65 or lactic acid > 4mmol/L Crystalloid Bolus 30mL/kg over 1 hour Goal for MAP>65 and HR<110 13

14 HR>110, MAP<65, O2 Sat 93%, RR>24 or AMS Consider Cardiopulmonary BNP, cardiac enzymes, EKG, echo, spiral CT Cardiomyopathy/CHF Myocardial infarction Pulmonary Edema Pulmonary HTM Pulmonary Embolus/DVT Illicit Drug Use Consults (Anesthesia, Medicine, Critical Care, MFM) Hypertension in Pregnancy SBP>155 and/or DBP>105, MD notified Sustained>160/110 Treatment Indicated Hypertensive Disorders of Pregnancy Protocol Treatment of BP within 1 hour Magnesium Sulfate 4gm Bolus and 2gm per hour, PIH labs, PHI powerplan O2 Sat<93% or RR>24 consider pulmonary edema Cardiopulmonary HR>110, MAP<65, O2 Sat 93%, RR>24 or AMS Consider BNP, cardiac enzymes, EKG, echo, spiral CT Cardiomyopathy/CHF Myocardial infarction Pulmonary Edema Pulmonary HTM Pulmonary Embolus/DVT Illicit Drug Use Consults (Anesthesia, Medicine, Critical Care, MFM) Consider Overlap Hypertension in Pregnancy SBP>155 and/or DBP>105, MD notified Sustained>160/110 Treatment Indicated Hypertensive Disorders of Pregnancy Protocol Treatment of BP within 1 hour Magnesium Sulfate 4gm Bolus and 2gm per hour, PIH labs, PHI powerplan O2 Sat<93% or RR>24 consider pulmonary edema 14

15 Obstetric Hemorrhage Management of Obstetrical Hemorrhage Protocol HR>110, MAP<65 bleeding or recent surgery Move to Stage 3 Activate MTP, CBC and DIC panel, OB and Anesthesia to bedside Limitations of MEWTs Severe (Requires 1 abnormal value) Maternal HR > 130 bpm Respiratory rate > 30/min Mean arterial pressure < 55 mmhg Non Severe (Requires 2 abnormal values) Maternal HR > 110 or < 50 bpm Respiratory rate > 24 or < 10/min BP > 160/110 or < 85/45 mmhg O2 saturation < 90% O2 saturation < 93% Nursing concern Altered mental status Disproportionate pain Temp > 38 or < 36 o C Fetal HR > 160 bpm *Must be sustained for 20 min Comparison of Maternal Early Warning Systems Parameter MEOWS MEWC MEWT Temperature Red: < 35 > 38 or < 36 or > 38 Yellow: Systolic BP Red: < 90 or > 160 < 90 or > 160 > 155 or < 80 Yellow: or Diastolic BP > 100 > 105 or < 45 Mean arterial pressure Severe: < 50 Heart rate Red: < 40 or > 120 Yellow: or < 50 or > 120 > 110 or < 50 Severe: > 130 Respiratory rate Red: < 10 or > 30 Yellow: < 10 or > 30 > 24 or < 12 Severe: > 30 O2 saturation < 95 < 95 < 93 Severe: < 90 Urine output < 35 cc/hr (for > 2 hrs) Pain score (0 3) Yellow: 2 3 Neurological Red: Unresponsive to pain Agitation, confusion, Altered mental status response/ Yellow: Unresponsive to vocal unresponsiveness; with stimulus preeclampsia and unremitting headache or shortness of breath Fetal heart rate > 160 (if suspected infection) Requirement for triggering system 1 red or 2 yellow triggers 1 trigger 2 triggers > 20 min or 1 severe trigger Zuckerwise et al. Semin Perinatol

16 Parameter MEOWS MEWC MEWT Temperature Red: < 35 or > 38 Yellow: > 38 or < 36 Systolic BP Red: < 90 or > 160 Yellow: or < 90 or > 160 > 155 or < 80 Diastolic BP > 100 > 105 or < 45 Mean arterial pressure Heart rate Red: < 40 or > 120 Yellow: or Severe: < 50 < 50 or > 120 > 110 or < 50 Severe: > 130 Respiratory rate Red: < 10 or > 30 Yellow: < 10 or > 30 > 24 or < 12 Severe: > 30 O2 saturation < 95 < 95 < 93 Severe: < 90 Urine output < 35 cc/hr (for >2 hrs) Zuckerwise et al. Semin Perinatol Goals for Continued Response Improvement Protocolize responses Focus on cardiopulmonary and sepsis pathways Prevention of delayed diagnosis of cardiopulmonary events and sepsis Tachycardia Consider some elimination of some parameters Hypotension (poor predictor) Tachypnea (poor predictor) Mental status changes (late sign) Outside of OB: SIRS SIRS SEPSIS SEVERE SEPSIS SEPTIC SHOCK MODS Two or more of the following criteria: Temp >38º or <35º Heart rate >90bpm RR >20 or AP CO2 <32 mm Hg WBC >12,000; <4,000mm 3 or more than 10% of immature forms With documented infection Sepsis associated with organ dysfunction, hypoperfusion or hypotenstion Sepsis with refractory hypotension to appropriate reanimation and hypoperfusion manifestations Failure of two or more organs so homeostasis cannot be sustained without support Bone et al. Chest

17 Outside of OB: SOFA System Respiratory: PaO2/FiO2 Coagulation: Platelets Liver: Bilirubin Cardiovascular: MAP, Pressor requirement Central Nervous System: Glasgow Coma Scale Renal: Creatinine or Urine Output (per day) Score > 400 < 400 < 300 < 200 < 100 > 150 < 150 < 100 < 50 < 20 < > 12.0 MAP > 70 MAP < 70 Dopamine < 5 or dobutamine (any dose) Dopamine or epinephrine <0.1 or norepinephrine <0.1 Dopamine > 15 or epinephrine > 0.1 or norepinephrine > < 6 Cr < 1.2 Cr Cr Cr or UOP < 500 Cr > 5.0 or UOP < 200 Vincent et al. Intensive Care Med Outside of OB: qsofa RR>22 SBP<100 SIRS vs. SOFA vs. qsofa SIRS SOFA qsofa Resp Rate PaO2/FiO2 Ratio Resp Rate WBC Bands % Heart Rate Temp PaCO2 Glasgow Coma Scale Mean Arterial Pressure Administration of Pressors Serum Cr or Urine Output Bilirubin Platelets Glasgow Coma Scale Systolic Blood Pressure Seymour et al. JAMA

18 SIRS Fails Obstetric Patients 913 Chorio 575 +SIRS criteria 5 Sepsis 4 ICU transfers 1Maternal death Test Characteristics of SIRS Sensitivity (%) 100 Specificity (%) 37.2 Positive Predictive Value 0.9 Negative Predictive Value 100 Lappen et al. Am J. Obstet Gynecol Bowyer, et al, Aust N Z J Obstet Gynaecol, cases, 328 controls Most common causes of sepsis: Chorioamnionitis 20 (24.4%) Endometritis 19 (23.2%) Pneumonia 9 (11.0%) Most commonly found pathogens: E. coli 12 (14.6%) Other Gram negative rods 8 (9.8%) Group A Streptococcus 6 (7.3%) Bauer, et al, Anest Anal,

19 SENSITIVITY SPECIFICITY SIRS qsofa MEWC Bauer, et al, Anest Anal, 2018 Sepsis in Obstetrics Score The Sepsis in Obstetrics Score (SOS) was an attempt to identify obstetric patients with concern for infection at risk of ICU admission and mortality This was developed in a cohort of already sick pregnant patients Scoring rubric similar to SOFA and is based on SIRS as well as REMS (Rapid Emergency Medicine Score) and APACHE II (an ICU mortality scoring system) Sepsis in Obstetrics Score (SOS) Rubric Variable HIGH ABNORMAL NORMAL LOW ABNORMAL Score Temp (C) > Systolic Blood Pressure Heart Rate > < > < 70 Resp Rate > <5 < 119 SpO2 > 92% 90 91% 85 89% < 85% WBC > < Immature neutrophils > 10% < 10% Lactic acid >4 < 4 Albright et al. Am J. Obstet Gynecol

20 SOS Outcomes Data Variable SOS >6 (N = 48) SOS < 6 (N = 802) P Value Admission to ICU (N, %) 8 (16.7) 1 (0.1) < 0.01 Admission to telemetry 16 (33.3) 16 (2.0) < 0.01 unit (N, %) Length of hospital stay in 4.4 (2.9) 2.8 (1.6) < 0.01 days (Mean, SD) Positive blood cultures 12 (30.8) 12 (8.5) < 0.01 (N, %) Fetal tachycardia (N, %) 18 (60.0) 77 (12.9) < 0.01 Albright et al. Am J. Obstet Gynecol SOS Outcomes Data Variable Area Under the Curve SOS Score 0.97 Temperature 0.78 Heart rate 0.94 Systolic blood 0.93 pressure Respiratory rate 0.80 SpO Leukocyte count 0.89 % Immature 0.74 neutrophils Lactic acid 0.72 Albright et al. Am J. Obstet Gynecol Experience at Columbia MEWS is an excellent means of auditing clinical response by: Medical assistants Nursing Residents Fellows and Attendings MEWS has helped: Identify issues/challenges with timely evaluations at our own institution Establish expectations for care 20

21 Experience from Columbia Relatively high screen positive rate Some vital sign parameters perform better than others, leading to alarm fatigue Hypotension generally poor predictor House staff frustrated fielding calls for BPs in the high 80s Majority of clinically relevant alerts were for hypertension Hypertensive responses: Significant improvement in timely response Nurses trained to administer IV medications Take Home Points Numerous Maternal Early Warning and Sepsis Scoring Systems have been developed to address the unique physiology of OB patients These are generally based on: Temperature Blood pressure Heart rate Respiratory rate/o2 sat Neurologic status There is variability in the cut-offs for all of these metrics: Tachycardia: >100 to > 130 Tachypnea: > 24 to > 30 Hypotension: MAP < 50 or <55 or <65, sbp < 80 or < 90, dbp < 45 or < 50 Many MEWS criteria are actually not EARLY warnings: MAP < 65 Altered mental status Conclusion Early warning systems clearly have benefit in identifying patients that require prompt attention in the general obstetric patient population Research needed to refine which parameters should be included Standard protocols for evaluation are a technology opportunity EPIC has a module for multi parameter scoring systems Local implementation depends on hospital type, provider staffing, and patient population Continued audit is necessary to assess barriers 21

22 Maternal Early Warning Systems Mary E. D Alton, M.D. Willard C. Rappleye Professor and Chair, Department of Obstetrics & Gynecology Adina Kern-Goldberger, M.D. M.P.H. Columbia University Vagelos College of Physicians & Surgeons 22