are you feeling well? community bundles · 2015-11-14 · baby blues if symptoms not resolved after...
TRANSCRIPT
Are you feeling well? Community Bundles
Marie Lewis
Donna Owen
Powys Local Health Board
Aim of Call
The overall aim for this call is to begin the process of agreeing a'minimum standard for community referral' (in response to physiological observations) so that this does not just rely on the midwives experience and interpretation of the situation.
Transforming Maternity Services Mini collaborative: Community Model
The community bundle is made up of three aspects similar to the four care bundles within Transforming Maternity Services.
Pre-Admissions: All women have adequate history taken and recorded in their hand held records including BMI, Medical conditions, Obstetric History and VTE risk assessment. Plan for frequency of observations.
Recognition: Routine maternal observations carried out as per local guidelines. Risk assessments repeated as appropriate and any changes recorded within the hand held records. Early warning score used as trigger for full set of observations and referral if necessary.
Response: Communication with all members of the team using the SBAR format. Referral to appropriate place for further care and investigation. Immediate care if necessary prior to and during transfer. Mechanism for recording findings, actions and follow up.
When implementing the community bundle organisations need to consider local processes for referral from community to acute settings, the acceptable timeframe and communication process feeding back to community from the acute setting.
Recognition:
Community midwives are key players in recognising when deterioration or deviation from norm occurs.
The early warning score does not replace clinical judgement but is designed to aid community midwives in decision making, consistency and documentation.
All women at every opportunity should be asked about their wellbeing. And the EWS recorded.
Full set of observations:
Recognition:
At each contact, the healthcare professional should ask the woman about her health and wellbeing. Any symptoms reported by the woman or identified through clinical observations should be assessed. [NICE CG 37]
When a woman reports feeling unwell a full set of observations should include:
“ Are you feeling well?”
Community Early Warning Score Aide
memoir:
Looks/feels well
Yes No
Trigger for recording physiological
observations and recording Early
Warning Score.
Score
0 1 2 3
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
>161mmh
g
Diastolic BP Up to
90mmhg
91-99mmhg 100-
109mmhg
>110 or
<40mmhg
Temperature 36-37.9 35.1-35.9 38-39 <35 or >40
Early Warning Score
Record full set of Observations on
locally agreed documentation/chart.
EWS Calculated
Score 0
Continue routine
care
Score 1-2
Repeat full set of
observations in 30
mins
Score2
Discuss with appropriate
Health professional
Score 3-4
Attend Obstetric
care within 2
hours
Score >5
Emergency
transfer
Think: Blood pressure readings in isolation need to be considered in relation to local
Hypertension guidelines.
The Early warning score aims to support professional decision making. Health
professionals should always use their professional judgement and refer to an
appropriate person if they are concerned about the wellbeing of the mother.
Recognition:
Where indicated women should be referred to an appropriate setting and a full plan of care recorded.
To aid communication and documentation the SBAR format is recommended.
Addressograph
Date:
Time Left:
Time Arrived:
Transfer from:
Transfer to:
Arranged with
(Name)
Maternal Transfer Document
Situation: Reason
Background: Gravida: Para: EDD: Gestation:
Relevant medical/obstetric history
Assessment: - Clinical Impression/Actions/observations
Recommendation: including your requests and expected time frame
Midwife: Date: Time:
Thresholds and triggers for referral
NICE Postnatal care guidelines
LIFE-THREATENING CONDITIONS IN WOMENEmergency Action: Life threatening or potentially life threatening situationsUrgent Action: Potentially serious situation, which needs appropriate action
Non-Urgent Action: Continue to monitor and assess
Possible Sign/Symptom Evaluate For Action
Sudden or profuse blood loss, or blood
loss and signs/ symptoms of
shock including tachycardia,
hypotension, hypofusion, change
in consciousness
Postpartum Haemorrhage Emergency Action
See All Wales Birth Centre Guidelines
Offensive vaginal loss, tender
abdomen
Genital Tract Sepsis Urgent Action
Refer to GP
Fever ›38c, shivering, abdominal pain,
and/or offensive vaginal loss
Infection/Genital Tract Sepsis Emergency Action
Refer to DGH
Severe or persistent headache Pre-eclampsia/ Eclampsia Emergency Action
Diastolic is greater than 90mm Hg and
accompanied by another
sign/symptom of pre-eclampsia
Pre-eclampsia/Eclampsia Emergency Action
Refer to DGH
Diastolic is greater than 90mm Hg and
NO other sign/symptom, repeat
BP within 4hrs and re-evaluate for
signs of pre-eclampsia
Pre-eclampsia/Eclampsia Urgent Action
Refer to GP if BP remains ›90mm Hg
and NO signs of pre-eclampsia
Shortness of breath or chest pain Pulmonary Embolism Emergency Action
Refer to DGH
Unilateral calf pain, redness or
swelling
Deep Vein Thrombosis Emergency Action
Refer to DGH
Common Health Problems in Women
Health Problem Action
Baby Blues If symptoms not resolved after 10-14 days, assess for postnatal depression, and if symptoms
persist evaluate further – Refer to Local Maternal Mental Health Policy (Urgent action)
Perineal Pain, discomfort,
stinging,
offensive odour or
Dyspareunia.
Offer to assess the perineum. Evaluate for signs of infection, inadequate repair, wound
breakdown or non healing (Urgent Action).
Advise use of topical cold therapy and paracetamol( if not contra-indicated), but if neither are
effective consider oral or rectal non-steroidal anti-inflammatory drug (Non Urgent Action)
Dyspareunia In cases of Perineal trauma offer to assess the perineum (See above).
Advise water based lubricant If problem persists evaluate further (Non Urgent Action ref GP
Headache Advise women who have had epidural/spinal anaesthesia to report severe headache.
Check Blood pressure For tension/migraine headaches offer advice on relaxation and avoiding
factors associated with headache
Persistent Fatigue Ask about women’s general well-being and offer advice on diet, exercise and planning activities.
Consider Haemoglobin level if clinically indicated
Backache If persistent refer to GP
Constipation Assess diet and fluid intake. If changes in diet are ineffective advise use of a gentle laxative
Haemorrhoids If haemorrhoids are severe, swollen or prolapsed, evaluate for referral to GP (Urgent Action).
Otherwise advise dietary measures to avoid constipation and use of haemorrhoid
cream. If not resolved within two weeks refer to GP.
Faecal Incontinence Assess Severity, duration and frequency. Refer as appropriate (Urgent Action)
Urinary Incontinence Teach the woman to do pelvic floor exercises. Complete continence assessment and refer as
appropriate
Urinary Retention
(within 6 hours of
birth)
Advise methods of assisting urination such as taking a warm bath or shower. If this doesn’t work
assess bladder volume and consider catheterisation (Urgent Action).
Over to you:
How would the early warning score work for you?
What are your current thresholds for referral?
What are the current pathways for referral?
Is it possible to devise a minimum best practice trigger and pathway tool?