August 2016

Maternal Enhanced and Critical Care (MEaCC)

This document provides information and summaries of the following:

1. Maternity Services: Trust Engagement Visit Summary – MECC only - January 2015 2. Y&H Maternity Visits Summary – January 2015 3. Y&H MMM – Project Overview 4. Why MMM? Local and national drivers 5. Y&H MMM task and Finish Group 6. Achievements & Products so far: 7. Y&H CN Events 8. Highlight Report July 2016 – Next Steps 9. Proposed Actions: 10. National Maternity Review 11. Enhanced Care for the Sick Mother: Standards for Maternal Critical Care 2016 12. Maternal Critical Care: Care Worthy of the Name? - Dr AC Quinn and Dr A Cohen 13. Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. 14. BMJ: Maternal CC: what can we learn from patient experience? A qualitative Study 15. MBRRACE

Maternity Services: Trust Engagement Visit Summary – MECC only - January 2015

Models of care vary across the region with size and experience of units and transferability to ICU units being taken into consideration. 10 units offer specific rooms on Labour Ward for enhanced maternity care (high dependency care), with Sheffield having a 4 bedded (plus single en-suite) Advanced Obstetric Care Unit. Smaller units have a lower threshold for transfer and the ease of transfer to ICU is also considered e.g. Bradford require women to be transferred to their trust’s ICU by ambulance and need to plan the transfer accordingly. This may mean they provide a higher level of enhanced maternity care on Labour Ward. 2 units transfer all women for HDU/ICU care and 2 only transfer to ICU for respiratory support.

Training for midwives varied across the region, mainly reflecting the level of enhanced midwifery care provided e.g. Sheffield Jessop Hospital has a 4 bedded area in an Advanced Obstetric Care Unit staffed by a dedicated team with each shift having an RGN and a member of staff trained in Care of the Critically Ill Patient / HDU course. Bradford has midwives who have undertaken a High Dependency Course and aims to have 1 per shift in addition to the Labour Ward Co-ordinator. Calderdale & Huddersfield Trust has introduced an in-house bespoke training programme for caring for ill & early detection of deteriorating obstetric patients with Rotherham discussing funding for a similar programme with Learning beyond Registration (LbR). In total 7 of the 13 trusts either had midwives competency-based trained in caring for the critically ill or were looking at implementing. There appears to be good relationships & communication with the ICU outreach teams, provision of 24 hour anaesthetic cover and obstetric emergency mandatory training for staff.

User feedback specifically for ICU/HDU experience was not offered at any of the 13 trusts. However most units acknowledged that the obstetric consultant / consultant midwife / ICU consultant would discuss care with women, although this was felt to be clinical rather than from an experience perspective. Anaesthetic follow-up was described by 1 trust who would then refer if further discussion was required, but again this was felt to be clinical care rather than a user feedback process. Some bespoke records have an area to complete for documenting a debrief discussion, but this was undertaken on an ad-hoc basis and not specific to the families experience. Birth Afterthoughts (Doncaster & Bassetlaw) and Birth Matters (Leeds) both offer a de-briefing service for all women, but not specific user feedback for Critical Care.

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This area of maternity care will be reviewed in more detail for the Maternal Critical Care Project.

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August 2016

Y&H Maternity Visits Summary – January 2015

Airedale Barnsley Bradford C&H D&B Harrogate Hull Leeds Mid York’s NLAG Rotherham Sheffield York

Feedback y N N Y N ** N N N N N N N

Clear Plan of Care Y N Y N N Y Y Y Y Y Y

Staff trained properly N N *** *** N N N N N Y N Y

Staff Competency N N Prompt N N N Y Y Y N Y

MEOWS or other system/ algorithm

* Y Y Y N Y Y *** Y Y Y

Escalation Process N Y Y N N Y Y MEOWS Y Y Y

Transfer Process N N N N Y Y ** Y Y Y Y

Training AIMS Internal YMETMOET internal YMET YMET YMET YMET/

internal YMET YMET PAR YMET YMET

Training MDT Y Y Y Y Y

* No algorithm – general memo/guidance**more work needed *** Work is ongoing /Improvements expected

Majority of trusts provide debrief for women and F&F but no formal feedback. Care bundle would be useful Skill mix teams (different bands/roles) Smaller Vs Larger Units – One size does not fit all Designated theatre and theatre staffing

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Population and Public Health issues/increase in acuity of women (obesity and complex needs)

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Y&H MEaCC – Project Overview

Background - Saving Mothers’ Lives 2006-2008 (CMACE 2011) identified 70% of direct deaths associated with substandard care (SSC) of the critically ill mother, particularly noted in pre-eclampsia, eclampsia and acute fatty liver where 90% were identified with SSC. The report noted an increase in deaths from sepsis and genital tract infection, with sepsis being the commonest cause of direct maternal death in the UK. During the triennium 2006-2008, there were 261 maternal deaths reported, however for every death there are nine women who develop severe maternal morbidity (RCoA, RCOG, and RCM 2011).

Why MEaCC? Local and national drivers

Reducing the level of avoidable maternal morbidities and improving women’s experience during this time has been identified as a national and a local priority as identified in the NHS Outcomes Framework Domain 1: Preventing people from dying prematurely, Domain 3 - Helping people to recover from episodes of ill health or following injury and Domain 4: Ensuring that people have a positive experience of care. .

National Maternity Review – Better Births Enhanced Care for the Sick Mother – Standards for Maternal Critical Care 2016 Y&H Maternity visits Y&H Maternal Enhanced and Critical Care Workshop 3rd March 2016:

Y&H MEaCC task and Finish Group

Y&H Aims & Objectives/outcomes

Aims: What are we aiming to achieve

Within Yorkshire and Humber we need to ensure that pregnant and recently pregnant women who are ill / acutely ill receive consistently high Maternal enhanced and critical care.

Outputs

Benchmarking against MCC Standards

Launch Event of MCC Standards and Y&H Work

Case studies and sharing of good practice

Support the development of trust action plans to meet standards.

Improve/develop tools and resources for Patient Feedback, consultation and engagement

Outcomes

Reduction in the level of avoidable maternal morbidities

Evidence of improved medical management of sick mothers

Improved experience of sick mothers

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Achievements & Products so far:

Initial work has already been undertaken producing the following out puts and outcomes:

Outputs

MEaCC Maternity Service Visits across Y&H

Y&H MEaCC Workshop

Key Document Review and Summaries – assessing current policy & practice

Development of MEaCC Task and Finish Group

Outcomes

Identification of Local, Regional and National Priorities

An understanding of current MEaCC services and management of sick mothers

An understanding of the current and historical experiences of sick mothers and need for further improvement

Y&H CN Events

MEaCC Workshop 3 rd March 2016: The workshop considered national evidence and best practice, the work of the Adult Critical Care Operational Delivery Network (ODN) and the Y&H position, taken from the overview of findings from the maternity service engagement visits. The workshop focused on identifying areas of best practice, priorities, barriers and solutions around each of the 4 key work areas for improvement. Outputs from the workshop were presented to the initial MEaCC Task & Finish Group to inform the project plan and agree actions for the group. Attendance at the workshop included service users, commissioners, LSA, Adult Critical Care ODN and Y&H Provider Trusts

Highlight Report July 2016 – Next Steps

Recommendations and outputs from the T&FG to be collated and draft project/action plan to be developed. Outputs to be circulated for discussion at next meeting 7th October 2016. Draft plan to then be circulated for comment. Communication: highlight report provided to Maternity Clinical Expert Group, Maternity Strategy Group and

Commissioners Forum.

Proposed Actions:

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It is proposed that the Maternal Enhanced and Critical Care Task and Finish group will:Take forward the priority identified in Y&H

Discuss potential solutions/actions Compare against the Enhanced Care for the Sick Mother – Standards for Maternal Critical Care 2016. Identify any gaps and areas for development e.g. Feedback, consultation and engagement of women and

their families.

Benchmark MEaCC Services across Y&H

Rag rate services against:o Enhanced Care for the Sick Mother – Standards for Maternal Critical Care 2016.o Additional Y&H priorities

Highlight areas of good practice (GREEN) – call out for case studies Investigate areas identified as RED – potential solutions/actions

Host MEaCC Launch Event

Keynote speakers Case Study Presentation from areas highlighted as good practice (GREEN from Benchmarking) Workshops focusing on RED areas of benchmarking

Implementation of Standards

Support Trusts to develop action plans Identify resources/tools that would best be developed on a regional level to improve consistency and

reduce variation (this may include support for the development of a national electronic observation tool) Embed benchmarking and quality assurance of services across Y&H (this may include the national drive for

‘Peer Review’)

National Maternity Review

- Maternal mortality in the UK has reduced from 14 deaths per 100,000 maternities in 2003/05 to 9 deaths per 100,000 maternities in 2011/13.

- Maternal mortality has declined progressively over time, to a level of nine deaths per 100,000 maternities in the UK in 2011-13. This number of deaths is too low for variation between different services to be meaningful; however the recent MBRRACE-UK Confidential Enquiry into maternal death found that about half of deaths would have had a different outcome with better care. Late maternal mortality in the period 2011-13 was 14 per 100,000 maternities. Notably, 23% of these deaths were from mental health related causes, with one in seven dying through suicide.

- The recognition and care of those with mental health problems around birth is not consistently effective, and a significant number of late maternal deaths have mental health causes.

- Women and families told us that they did not always have confidence that complications would be picked up and staff would understand the impact on women and their families.

- Crucial to rapid identification of complications will be the drawing up and continual review of the personalised care plan.

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- Complications arise, may need care provided by obstetricians, midwives and other specialists in the hospital. This should be offered as soon as complications are identified, and care should be personalised around the needs of the woman and her baby.

- Where a woman suffers a pregnancy or birth related trauma, there should be a multi-professional de-brief and handover between labour and postnatal care, and her personalized care plan should be updated in discussion with the woman.

- Women should be informed of risks and be supported to make decisions which would keep them as safe as possible.

- Staff and teams must continuously measure the quality of their services, they must learn from any serious incidents and mistakes, and seek to constantly improve the quality and outcomes they are delivering.

- When things go wrong, there should be a rapid investigation, support for staff involved, openness and honesty with the family, and provision made for their needs through a rapid resolution and redress system

- In November 2015, the Department of Health announced a new ambition to reduce maternal deaths in England by 50% by 2030.

- Services need to be planned to allow for high quality consultation between professionals and referral from one level of care to another as appropriate.

- Transfers between services should be facilitated by establishing clear referral protocols, although a care pathway needs to be flexible.

- Where a woman suffers a pregnancy or birth related trauma, there should be a multi-professional de-brief and handover between labour and postnatal care, and her personalised care plan should be updated in discussion with the woman to ensure that her physical, psychological and emotional needs are met. This is particularly true of perineal damage where early intervention can make a big difference in long term morbidity. It is important that the mother gets appropriate advice and support.

- There needs to be much greater consistency in the standard of local investigations of perinatal mortality, neonatal mortality, maternal death and serious morbidity. The new Health Safety Investigation Branch (HSIB) should set a common, national standard for high quality serious incident investigations. These should be carried out under the auspices of regional maternity clinical networks to ensure that they are carried out by experienced experts and that the learning is shared widely.

- The review supports the underpinning principles for perinatal mortality review as developed by the Perinatal Mortality Review Task and Finish Group and welcomes the Department of Health’s funding of a standardised nationally accepted tool for perinatal mortality review. The Department of Health should consider how this tool could be expanded to cover neonatal mortality, maternal death and serious morbidity.

- the Department of Health should give serious consideration to the introduction of a “rapid resolution and redress” scheme, similar to the administrative compensation model in place in Sweden

- While staff cannot remove that distress they can ensure that the care families receive is compassionate and does not further add to their grief.

Enhanced Care for the Sick Mother: Standards for Maternal Critical Care 2016

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This document revises the former 2011 standards document: Providing equity of critical and maternity care for the critically-ill pregnant or recently pregnant woman.

- Info graphic page 3

Key messages

- Working in Teams and ‘enhanced maternity care’ (EMC) - EMC is beyond maternity care for women with medical/surgical problems during pregnancy/postpartum but without the severity of illness that requires full CC.

- Focus on early response and recognition of deterioration and closer working between maternity and CC teams.

- Education and training – improving education and training in maternal CC and EMC for all team members

- Obstetric and early warning system ObsEWS – must be applied to all women presenting to acute care services who are known to be pregnant, or within 42 days of delivery.

- Care of the acutely ill mother in a general critical care unit – CC units must have a named lead for MCC to act as a liaison between CC and Obs. Obs team must review all Obs patients admitted to CC unit at least once every 24hrs.

Introduction

- Summary of Standards

- Pregnancy and childbirth is a major life event for women and families

- The same standard of care should be given to women who become acutely unwell or suffer chronic illness, professionals should be trained to the same standards and competencies irrespective of the setting

- Increasingly complex medical and obstetric problems

- For every maternal death at least 70 women develop severe maternal morbidity

- Main ICU admission for recently pregnant women was haemorrhage and respiratory failure for currently pregnant

- Providing high quality care to sicker patients is overstretched, increasingly busy and sometimes underfunded maternity units is challenging

- only 6% of maternity units could provide MCC to the same standard of GCC

- Clear instances of substandard clinical practice, failure to recognise and act upon warning signs in pregnancy, in labour and in new born babies (Kirk up report 2015)

- 2007 it was recommended that maternity units incorporate and early warning system i.e. MEOWS – there is a need for a national approach to revisit, revise and develop a standardised tool for obstetrics.

- In 2011 sepsis was identified as the lead cause of maternal death, rising comorbidities and increased sepsis rates, organism virulence and antibiotic resistance means that maternity services need to keep close links with all CC resources and new initiatives in our hospitals.

- Unified approach for managing the sick mother is required, including a national early warning score and rapid response system for obstetric patients, electronic data collection and evidence based information to inform future developments in this area, mirroring GCC.

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- Avoid working in silos

- If obs patients are excluded from generic policies instituted in our acute hospitals this should be a carefully considered decision.

The document

- recommended all members of the team are familiar with all sections however some are aimed at specific groups

- Each section has standards and/or recommendations as defined in the Guidelines for the provision of intensive care services 2015. These standards must be followed by UK maternity and critical care services

- Standards are expected to be in place but where they are not an action plan must be developed with clear timeline for implementation

- Recommendations should be routinely in place, implantation of recommendations is seen as good practice

- Observance of both standards and recommendations will be subject to peer review to inform commissioners and CQC

- In time where appropriate recommendations may evolve into standards

Implementation

- Integral to successful implementation of early warning systems is improving education and training in MCC for all members of the team.

- Section 1 describes a new level of care ‘enhanced maternal care’ and the accompanying framework document (App 1) this aims to address the variation in pre and post registration midwifery education, this is not a designated critical care level of nursing .

- Also recommending changes to medical, midwifery and nursing training.

- Must ensure all specialities (Anea’ Obs and CC) include MCC in their specialist programmes

- An intercollegiate curriculum must be developed for speciality training in which a common knowledge base and consistency in delivering care will be shared.

- Introduction of innovative education methods

- Adequate number of staff should be available with the knowledge and skills to detect deterioration and escalate intensity, deliver high quality care to a critically ill mother at any stage between home care and receipt of maximum supports in level 3 CC unit.

- Maternity and CC networks throughout the country must work together and consider how to implement models of care for diff configuration of services.

- Must listen to patients experience to help shape services, need to cast the net widely to involve all who may contribute to this process.

- This compliments many aspects highlights in the NMR which signal the need for: safer, multi professional care working across boundaries.

- Ensure standards are implemented through high quality audit and peer review.

Standards & Recommendations

- Section 1: Delivering Care and Working in Teams10

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- Section 2: Obstetric Early Warning Scores, ObsEWS

- Section 3: Acutely ill mother in a designated General Critical Care

- Section 4: Recognising, Transferring and Clinical Responsibility outside of Maternity

- Section 5: Patient Reflections

- Section 6: Education

- Section 7: Monitoring Standards and Quality Indicators

- App 1: Enhanced Maternity Competency framework for midwives caring for ill and acutely ill women

- App 2: Obstetric Early Warning System (ObsEWS) scores

- App 3: Patient satisfaction, patient feedback, EMC patient satisfaction survey and patient/relative survey

Section 1: Delivering Care and Working in Teams

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Section 2: Obstetric Early Warning Scores, ObsEWS

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Section 3: Acutely ill mother in a designated General Critical Care

Section 4: Recognising, Transferring and Clinical Responsibility outside of Maternity

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Section 5: Patient Reflections

Section 6: Education

Midwives

Critical Care Nurses

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Critical Care Outreach

Doctors

Multidisciplinary Skills Training

Section 7: Monitoring Standards and Quality Indicators

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Maternal Critical Care: Care Worthy of the Name? - Dr AC Quinn and Dr A Cohen

Increased no’s of sick mothers with complex problems are being seen on isolated MCC units.

MCC units operate outside the guidance of CC environment and manage a wide spectrum of critically ill obstetric patients and mothers who may or may not have had a high risk pregnancy.

The Obstetrics Anaesthetist is a key player in developing a model of care

Scope of the Problem

Increasing numbers:

- A significant no. of MCC deaths linked to suboptimal care

- Increase in deaths from sepsis and genital tract infection

- Lack of recognition of signs of sepsis and lack of guidelines of its management were highlighted.

More complex cases:

- Complex medical and obstetrics problems

- For every death at least 9 women who develop severe maternal morbidity

- The main obstetric cause of ICU admission in ‘recently pregnant’ was haemorrhage

- Pneumonia was main cause in ‘currently pregnant’

- The incidence of level 2 care (ICS Classification) can be up to 20 times level 3 care needs and this is usually delivered within the maternity unit.

Critical Care training for midwives, obstetricians, Obstetrics Anaesthetists:

- Midwives are no longer nurses (3-4 year degree)

- Strong focus on studying ‘normality’ in pregnancy

- UG curriculum doesn’t not address specialised training to look after CC patients

- Compounded by a national shortage of midwives and a higher proportion of maternity support workers.

- Obstetric trainees do little general medicine training

- There is minimal MCC in obstetric core curriculum

- Obstetrics Anaesthetist have undergone training in intensive care medicine (ICM)

- In Aug 2012 it became possible to train only in ICM

- OA’s will still receive ICM training but will not be trained to deliver the same level of CC as future ICM specialists

- MCC is a subspecialty where many disciplines are required to define their remit, limitations and professional standards

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- Clinical staff looking after MCC unit should have suitable training, maintained CPD, allocated time in their job plans and work with the rest of the hospitals CC Service.

- Recognise variations in local models nationally but underline the need for standards to be met.

Current Evidence

MCC Unit models

- ‘Critical care without walls’ CC patients should receive same standard of treatment no matter where they are in the hospital.

- Unfortunately funding and initiatives for CC training was not taken up by obstetrics many hospitals

- Maternity units often function as a separate site within the hospital with their own guidelines managing majority of MCC cases

- Many models of different sizes depending on size of unit, some transfer all MCC patients others manage certain cases especially pre-eclampsia and massive haemorrhaging

- Often larger units manage CC patients in their own units

- Auditing Standards: A pilot scheme in Yorkshire

- CC networks in 27 regions around the country

- Since 2010 Yorkshire CC has supported a MCC group that meets 4 times a year – this group along with Y&H Networks carried out benchmarking against a number of factors from PECCM

- An audit was carried out in 15 trusts and as a result an action plan of recommendations was developed including:

o Improved education around sepsis

o Ensure early warning scores and protocols for escalation are in place and regular audit of obstetric areas to encourage compliance

o Encourage obstetric staff to attend a course with ABCDE approach to recognise acutely ill patients e.g. ALERT, AIM, PROMPT, REACTS

o Promote links between obstetrics departments and critical care/outreach

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Areas for Improvement

Critical Care Funding

- Current payment by results in maternity does not account for intensity of nursing care in critically ill patients (unlike in CC Units), changes in NHS Funding may address this and identify funding to establish and support high maternal quality CC teaching and training.

Workforce Planning

- A trust MCC forum should be established with in the delivery suite including clinical, managerial leads and implementation team with documentation and policy to span both.

- Clear links with intensive care and outreach

- MCC numbers should be audited and outcomes on all levels including analysis of critical incidents

- Regular MDT meetings to review sever maternal morbidity cases

- At least on member of midwifery/nursing staff should be available per shift and free to focus complete attention on sick mother.

- Identifying a lead obstetrician for MCC is key with combined ward rounds or clinics for high risk patients and those returning after critical illness in pregnancy or childbirth.

Teaching and Training

- OA’s have several resources to maintain their skills, the deficits often lie in the midwifery and nursing level on the maternity ward – this needs addressing

o Training in early recognition of acutely ill or deteriorating patient

o Competent in recording MEOWS as suggested in NICE and escalating using track and trigger system

- Need to encourage obstetricians to develop an MCC subspecialty interest with rotations in ICU during training.

Summary

- Safe environment is vital

- Patients requiring high level organ support, Level 3 care should be provided in a general ICU

- Suitably trained obstetricians are best placed to lead the development of MCC

- Look at different international models patients requiring higher level of care go to main HDU/ICU – good to recognise advantages and disadvantages of this

- Adequate time and resources should be identified and added to job plans

- Promote links between MCC and critical care particularly re training

- Need to recognise patients as ‘low-risk’ may subsequently deteriorate on a PN Ward

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Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman.

Background, Aims and Data

- Summarise in one place existing standards and recommendations relevant to the care of the pregnant or recently pregnant critically ill woman for maternity and critical care.

- ‘Childbirth is a major life event for women and their families. The few women who become critically ill during this time should receive the same standard of care for both their pregnancy related and critical care needs, delivered by professionals with the same level of competences irrespective of whether these are provided in a maternity of general critical care setting.’

- Growing need to collate, standardise, share and learn re CC

- New and recurrent themes emerging I.e., increased incidence of sepsis particularly in ethnic groups

- For every death 9 women develop sever maternal morbidity

- Aim of this document is to review evidence base and provide examples of models of care

- The report provides data around maternal deaths and refers to Confidential Enquiry into Maternal Death Report 2006-2008 and the ICNARC – Intensive Care National Audit and Research Centres and Case Mix Programme re: female admission to adult general CC Units.

- Diagnosis precipitating admission to CCU are predictable and include:

o Massive haemorrhage

o Eclampsia

o Sepsis

o Thromboembolism

o Acute organ dysfunction (renal, hepatic, cardiac, respiratory, neurological)

o Anaesthesia related morbidity (aspiration, anaphylaxis and muscle relaxant related problems.

- The required level of CC each woman will need to receive will be dependent on which organ requires support and the level of such support.

- The report states that is excellent data available regarding maternal death rates and CC utilisation, however, rates for women who require a higher level of monitoring or single organ support is more difficult to quantify.

What is Maternal Critical Care?

- MCC, HDC and high risk maternity care are not interchangeable, the term CC having a more precise definition

- DH doc Comprehensive CC recommends that HDC and IC be replaced by CC and proposes that a care required by an individual be independent of location ‘critical care without walls’

- Care is divided into 4 levels, dependent on organ support and the level of monitoring required independent of diagnosis:

o Level 0 – patients whose needs can be met through normal ward care

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o Level 1 – patients at risk of their condition deteriorating and needing a higher level of observation or those recently re located from higher levels of care

o Level2 – patients requiring invasive monitoring/intervention that includes support for a single failing organ system (excluding advanced respiratory support)

o Level 3 – patients requiring advanced respiratory support (mechanical ventilation) alone or basic respiratory support along with support of at least one additional organ. The nature of organ support is captured using the CC minimum data set (CCMDS).

- The advantage of using this dataset to reflect organ supporting maternity units is obvious. A standardised platform will provide accurate data and facilitate comparative audit, utilising the case mix program.

- This approach has been beneficial as it has allowed some level 2 care to be delivered in alternate locations with the proviso of competent staff with appropriate clinical expertise to manage the clinical situation, either with or independently of CC staff, an example of such care would be women requiring invasive cardio monitoring and intervention for pre-eclampsia or massive haemorrhage on delivery.

- Thus MCC can be distinguished from High risk obstetric because:

o Fetal issues are excluded

o maternal risk factors of obstetric complications that require closer observation, but, not support of an organ system , are also outside the term

Care of the critically ill parturient in different settings

- CC or obstetrics management outside designated speciality specific areas is always challenging. The NSF for CYP and Maternity requires consultant led services have adequate facilities, expertise, capacity and back up for timely and comprehensive obstetric emergency care, including transfer to ITU

- Commissioners, maternity and CC services must design care pathways at a local level which insure that a critically ill parturient accesses equitable care for both components, irrespective of location.

- Pathways should include:

o Keeping mum and baby together where possible

o Defined escalation arrangements

o Take into account – local configuration, size and complexity of maternity and CC services

o Suitable area and equipment

o Input from Anaesthetists and obstetricians

o Staffed by team of midwives with additional training

o Arrangements for input from other disciplines and allied professionals where required

o CC skills on labour ward through outreach or other arrangements with CC services

o Transferring women to a general level 2 unit with local arrangements for providing obstetric and midwifery input

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Standards for recognition and care of the acutely ill parturient

- NICE guidelines of care of critically ill must be implemented

- Physiological track and trigger systems should be used to monitor all antenatal and postnatal admissions.

- Following labour and delivery obs should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease.

- Frequency of monitoring should increase if abnormal physiology is detected.

- Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to acutely ill patient appropriate to the level of care they are providing.

- Education should be provided to staff so they have these competences and assessed to ensure they can demonstrate them.

- A graded response strategy for patients identified as being at risk of clinical deterioration should be agreed and delivered locally

- Low score 1-3: increased frequency of observations and midwife in charge alerted

- Medium score 4 - 5:urgent call to team with primary medical responsibility for patient, simultaneous call to personnel with core competencies for acute illness, such as CC outreach team, hospital-at-night team, specialist trainee in anaesthesia, obstetrics, acute medical or surgical speciality.

- High Score 6 +: emergency call to team with critical care competencies and maternity team

Competencies for recognition and care of the critically ill parturient within the maternity service

- The acute care competencies are defined with in the DH document ‘competencies for recognising and responding to Acutely ill patients in hospital (DH 2008).

- Competencies are targeted at staff involved in care of CIP but maybe adapted for use in other settings e.g. maternity

- They define the KSA required for safe and effective treatment and care along the chain of response...

Non clinical staff recorder recogniser primary responder secondary responder tertiary responder (critical care)

- It is likely that one staff group or banding will cover more than one role in the chain e.g. recogniser may also fulfil role of primary responder or on occasion’s recorder.

- Obstetricians and midwifery staff providing this care should have additional training in the care of the critically ill women to achieve the relevant competencies.

- The competencies required (See Appendix 7 of document) focus primarily on the clinical and technical aspects of care and the delivery of effective patient management, but they are not exclusive.

- They assume the possession and application at every level of complementary generic competence such as record keeping, team working, interpersonal skills, and clinical decision making.

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- Of particular note in this context is the ability to rapidly access hospital information systems and retrieve patient information, such as blood results and X-rays.

Implementing Competencies

- Maternity services should define which of their staff on each one of the chain of response roles and ensure that they have suitable training and assessment of competencies requires.

- Implementing competencies will need a system wide approach with effective leadership and rigorous change management from board to ward, this may include the following

o Identifying a designated clinical and managerial lead and implementation team who will secure all training provision

o Monitoring and reporting outcomes

o Critical incident analysis, peer supervision, regular MDT review meetings

o Incorporation of education and training in induction and ongoing provision

o Making sure resources and equipment are in place

o Adapting local policies to support people meeting the policies

o Developing team working, assertiveness and inter-professional working relationships

Workforce Development

- Lead professionals in maternity services have a responsibility to ensure staff are deemed competent in the early recognition of acutely ill and deteriorating patients and are able to perform the initial resuscitation of such patients.

- Whichever course is selected, assessment of competencies is essential.

Transfer to ward from critical care

- After the decision to transfer a patient from a critical care area to the maternity ward has been made, she should be transferred as early as possible during the day

- Both critical care and receiving maternity ward teams should take shared responsibility for the care of the patient being transferred.

Transfer from Critical care area from a maternity unit

- Such transfers need to satisfy the ICS Standards for ‘Guidelines for the transfer of the critically ill adult’ and need to be accompanied by an additional plan addressing the maternal, fetal and postnatal needs of the patient

- All maternity sites must have the facilities and staff to resuscitate, stabilise and transfer critical care patients.

- Transfer equipment should be dedicated for transfer only

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- The transfer should take place with an appropriately trained practitioner

The acutely ill parturient in a general critical care area

- The overarching principle in managing the acutely ill pregnant woman id the optimal management of the condition, including essential imaging and medication, is paramount, the fetus is always secondary to this.

The maternity and general critical care interface

- Wherever a pregnant woman is receiving care there must be a fundamental principle that her pregnancy care is continued and integrated into care plans and that this continues throughout the postnatal period.

- The multiple care givers have to ensure that the needs of the critical care do not overshadow the needs of the woman and her family in regard to midwifery of obstetric care.

- The pregnant woman being cared for in a general critical care area requires daily review by an MD Team including a named obstetric consultant and named senior midwife.

- The individualised patient management plan should include care during the antepartum, intrapartum and postpartum periods with significant midwifery input for normal midwifery care

- The maternity team role includes discussing any specific obstetric conditions with the critical care tea, for example pre-eclampsia, which may be obscure by the woman’s current medical emergency.

- The woman’s named midwife should be informed of admission to critical care

- Units should consider having a dedicated link midwifery team, who are contactable and who will ensure regular and as needed midwifery input. They are well placed in maintaining contact with both baby and mother, who may be in different care environments, and therefore interlink the separate care plans.

- As these women are critically ill there should be regular communication between midwives, obstetricians and neonatologists as more complex aspects of obstetric care are considered.

- Whilst the critical care staff are experienced in communicating and updating family members there are different needs and information that the family require from midwives e.g. emotional and social support, potential preparation for premature delivery, a baby in special care.

- The family should know how to contact a midwife and the midwife should have an opportunity to make a connection with the family.

Auditable standards/outcome Indicators

- Effectiveness

- Safety

- Improving healthcare outcomes and prevention

- Patient experience

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August 2016

BMJ: Maternal CC: what can we learn from patient experience? A qualitative Study

- For every Maternal Death, 9 women develop severe maternal morbidity.

- CC in the context of pregnancy poses distinct issues for staff and patients e.g. breastfeeding support, separation from new-born.

- The findings are presented in 3 themes: being in CC, being a new mother in CC and follow up and after CC.

- Case Mix Programme which covers 90% of Adult CC units across England, Wales and Norther Ireland.

- Being in CC is almost always unforeseen and a frightening experience for women and their families.

- Long term psychological and emotional impact of maternal morbidity. – Fear, shock, disempowerment, anxiety and flashbacks.

- Little research of the service gap between maternity and CC Unit and the optimum location with the hospital for the sick patient.

- Lack of research about the competencies needed by maternity staff

- Support needed for partners and families

Waking up/understanding why they are there/being in ICU

- Women reported waking in ICU/HDU was often frightening particularly with patients with many different types of trauma.

- For many women it took a while to understand why they were in ICU/HDU

- Some women were not aware of how critically ill they were/had been

- Women and their partner would sit trying to piece together what happened.

- Further evidence and patient stories include

- Many women find the experience in CC as humiliating and distressing

- Women state the importance of kindness and support from the staff looking after them

- The importance of staff communicating and explaining things to partners and family members

Being a new mother in critical care

- Separation from new baby is one of the hardest things

- Missing ‘firsts’ i.e. nappy changes…not being able to hold baby etc.…

- Not all units allow baby to visit due to mum being too sick or risk of infection.

- Women spoke with great sadness about missing baby’s special moments

- Women appreciate when ICU staff are able to help them visit their babies.

- Breastfeeding is often difficult to establish and often a cause of great distress to mothers

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August 2016

- Often new mother in CC feel it is really important to breastfeed

- Support for establishing breastfeeding/expressing was not consistent across ICU/HDUs

- Women were grateful for supportive understanding around how hard breastfeeding would be after obstetric emergency.

Transfer out of Critical Care

- Women are often pleased to transfer as it is a sign of recovery however the transfer can often be the hardest part of a woman’s experience

- Staff were often unsure of best place to transfer back to e.g. delivery, maternity…

- Women often reported transfer being hard due to still feeling very weak, the trauma of almost dying, being expected to just pick up and start looking after a new baby

- Found a lack of understanding from staff outside of CC about what they have been through

- Not being able to look after themselves never mind a new baby

- Being on a ward with other new mums who have been through birth with little or no complications could be upsetting.

- Some women appreciated their own room.

- Most women found the ICU follow up really helpful.

Discussion

- While the fundamental principle that where ever a woman is receiving care her pregnancy care continues and is integrated, however highlights the challenges of the interface between maternity and critical care.

- Support for health care professionals and continuity of care during birth is imperative for women experience

- Transferring out of ICU can cause ‘relocation stress’ and depression for the general ICU population.

- Physical and emotional morbidities that can affect women who have required maternal critical care.

- ICU acquired weakness can have far reaching consequences for the patient.

- The surviving mother may have difficulties caring for her baby and the rest of her family.

- Where transfer was received well women felt supported during their recovery and caring for their baby

‘While critical illness maybe uncommon, it is a potentially devastating complication in pregnancy. The obstetric population is changing, increasingly presenting clinicians with, older mothers with pre-existing disorders and advanced chronic medical conditions.’

See study for :

- Methodology

- Results

- Limitations.

- References

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August 2016

MBRRACE

- MBRRACE UK – collaboration is responsible for running the: National Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP).

- Aims: Deliver national surveillance and confidential enquiries to: o Assess quality and safety of maternity and infant health serviceso Support improvements in service qualityo Produce evidence based recommendations and good practice pointso Influence clinical practice, service provision, health policy and clinical education.

- Surveillance and confidential enquiries of all maternal deaths- Confidential enquiries of a rolling programme of serious maternal morbidity

- Evidence of review of maternal death o Saving Lives, Improving Mothers care 2019-12 – CE of deaths from sepsiso Saving Lives, Improving Mothers care – confidential enquiry into maternal deaths and

morbidity 2019-13 – CE of deaths from maternal mental health.

- Maternal Death o Currently no standardised toolkit for local review of maternal death although a subgroup of

the Women’s Health Patient Safety Expert Group has started work on the development after the release of the MBRRACE UK Report 2014.

- Out of a total 225 records included in the forthcoming report (2016):o 100 records (44%) did include serious incidents reports (or equivalent)o 81 records (36%) did not include a reporto 40 records (18%) were unavailableo 4 records (2%) are uncertain.

- We are currently planning a systematic assessment of local review.- Information about undertaking a review – See document.

- External input into reviews : recently published study looked at the methods used for conduct of local review of care of women with sever maternal morbidity and to compare lessons identified for future care through local and external reviews (confidential enquiry)

- Carried out in 6 randomly selected consultant led maternity units in England- Include 33 women who had severe maternal morbidity- Local review conducted for 28 women (85%) but methods, staff involved and reports of the outcomes

were variable. 4 reports included root cause analysis- Patient involvement 1 5 local reviews- Action plans for 14 and 3 included a recommendation to audit subsequent change in clinical practice.- External reviews highlighted improvements in care that may have made a difference for 11 women.- Quality of reviews can be clearly improved- Reviews should be multidisciplinary and generate an action plan; implementation of

recommendations should be audited.

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August 2016

- Improvements in local reviews could be made by standardising training or development is national protocols

- Further evaluation should be undertaken to establish if there is added value of including and external perspective.

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