Premier Hospital Engagement Network:
Implementing a Maternal Early Warning
System (MEWS)
Mary E. D’Alton, MD
William C. Rappleye Professor
Chair, Department of Obstetrics & Gynecology
Columbia University College of Physicians &
Surgeons
August 7, 2014
Mary D’Alton, MD, FACOG, is the Willard C. Rappleye Professor and
Chair, Department of Obstetrics and Gynecology at Columbia
University.
Dr. D’Alton received her medical degree from the
National University of Ireland, and completed a
residency in OG/GYN at the University of Ottawa.
She completed a MFM fellowship at Tufts
University School of Medicine and was a Postdoctoral Fellow in Yale University’s Perinatal Unit.
In 2013, she was elected as a member of the
Institute of Medicine (IOM) and was recently
named chair of the Pregnancy Foundation Board.
Objectives
 Provide an overview of the National Partnership for
Maternal Safety.
 Discuss why the Partnership was formed.
 Identify the future activities and deliverables of the
Partnership for:
• Venous Thromboembolism
• Obstetric Hemorrhage
• Hypertension in Pregnancy
 Describe supplemental materials of the Partnership
on Maternal Early Warning Criteria (triggers).
US Pregnancy-Related Mortality
35
Mortality (%)
30
25
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15
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5
0
Berg CJ et al. Obstet Gynecol 2010.
The Burden of
Maternal Morbidity
 Reviewed Nationwide Inpatient
Sample (ICD-9) for 1998-2009
 Severe morbidity 12.9 per 1000
deliveries
• Increase in Shock, Acute Renal Failure,
Pulmonary Embolus, Respiratory
Distress Syndrome, Acute Myocardial
Infarction, Cardiac surgery
 Impacts >50,000 women each year
Callaghan WM et al. Obstet Gynaecol 2012
Factors Increasing Maternal
Mortality and Morbidity
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Maternal age
Obesity
Cesarean delivery
More pregnancies in women with significant
chronic medical conditions
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Hypertension
Pregestational diabetes
Congenital heart disease
Organ transplant
Lessons learned from reviews
 Hemorrhagic death
• 93% of all deaths were potentially preventable.
• Lack of appropriate attention to clinical signs of hemorrhage.
• Failure to restore blood volume, to act decisively with life-saving
interventions.
 Severe Hypertension
• 60% of maternal deaths were potentially preventable.
• Failure to control blood pressure, to recognize HELLP syndrome, to
diagnosis and treat pulmonary edema.
 Pulmonary Embolism
• “Single cause of death most amenable to reduction by systematic
change in practice.”
• Failure to use adequate prophylaxis.
Berg CJ, et al. Obstet Gynecol 2005;106:1228-34
Cantwell R, et al. BJOG 2011 Mar;118 Suppl 1:1-203
Clark, SL. Semin Perinatol 2012;36(1):42-7
Building Consensus
 ACOG-CDC Maternal Mortality/Severe Morbidity Action Meeting
occurred in Atlanta, November 2012
 Participants identified key priorities:
Core Patient Safety Bundles
Obstetric Hemorrhage
Severe Hypertension in Pregnancy
Venous Thromboembolism Prevention in Pregnancy
Supplemental Patient Safety Bundles
Maternal Early Warning Criteria
Facility Review
Family and Staff Support
 6 multidisciplinary working groups were formed
 Work product presented in New Orleans 2013
IHI Evidence-Based Care Bundles
 Concept of bundles developed by Institute for
Healthcare Improvement (IHI)
 Goal: to help health care providers more reliably
deliver the best care for patients
 Provides a structured way of improving processes of
care
 Includes a straightforward set of evidence-based
practices
 When performed correctly and consistently there is
a noted improvement in patient outcomes
IHI. Evidence–Based Care Bundles. Available at: http://www.ihi.org/topics/bundles/
Implementation
 The National Partnership for Maternal Safety
 The Council on Patient Safety in Women’s Health
Care will:
• provide oversight for the implementation of the 3
safety bundles within 3 years
• track implementation throughout the US using
lessons learned from IHI 5 Million Lives Campaign
• provide a platform for facilities to share best
practices
• systematically review the impact of these initiatives
 www.safehealthcareforeverywoman.org
IHI. 5 Million Lives Campaign. Available at: http://www.ihi.org
D’Alton ME, et al. Obstet Gynecol 2014 May;123(5):973-977
The National Partnership for Maternal Safety
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American Academy of Family Physicians (AAFP)
American Association of Birth Centers (AABC)
American Association of Blood Banks (AABB)
American Hospital Association (AHA)
American College of Nurse-Midwives (ACNM)
American College of Obstetricians and Gynecologists (ACOG)
Association of Maternal and Child Health Programs (AMCHP)
Association of State and Territorial Health Officials (ASTHO)
Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN)
California Maternal Quality Care Collaborative (CMQCC)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare and Medicaid Services (CMS)
Cynosure
Florida Perinatal Collaborative
Health Resources and Services Administration (HRSA)
Hospital Corporation of America (HCA)
National Association of Nurse Practitioners in Women’s Health (NPWH)
The Preeclampsia Foundation
Premier
PULSE of New York
Society for Maternal and Fetal Medicine (SMFM)
Society for Obstetric Anesthesia and Perinatology (SOAP)
The Joint Commission (TJC)
The Council
Formed in late 2011, the Council on Patient Safety in Women’s Health Care brings
partner and subspecialty organizations together with patients under the central goal of
improving health care for all women.
Mission
Continually improve patient safety in women’s health care through multidisciplinary
collaboration that drives culture change
Vision
Safe health care for every woman
Purpose
The Council on Patient Safety in Women’s Health Care’s purpose is to reduce harm to
patients by fostering:
• Investigation to better understand the causation of harm
• Programs and tools to implement patient safety initiatives
• Education to promote patient safety
• Dissemination of patient safety information
• A health care culture of respect, transparency, and accountability
Council Membership
Obstetric Hemorrhage Safety Bundle
READINESS
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Hemorrhage Cart with Procedural Instructions
Rapid access to hemorrhage medications
Established response team
Establish massive transfusion protocols
Unit education, regular unit-based drills (with debriefs)
RECOGNITION
• Assessment of hemorrhage risk
• Measurement of CUMULATIVE blood loss
• Active Management of 3rd Stage of labor
RESPONSE
• Unit-standard, stage-based OB Hemorrhage Emergency Management Plan with checklists
• Support program for patients, families and staff for all significant hemorrhages
REPORTING/SYSTEMS LEARNING
• Establish a culture of Huddle for high risk patients and Post-event Debriefs
• Review all serious hemorrhages for systems issues
• Monitor outcomes and process metrics in Perinatal QI committee
Modified from Elliott Main, M.D.
Preeclampsia/ Severe HTN Safety Bundle
READINESS
• Make severe hypertensive protocol familiar and easy to implement (i.e. Order sets)
• Rapid access to key medications (eliminate need to go to pharmacy)
• Unit education, regular unit-based drills (with debriefs)
RECOGNITION
• Proper blood pressure recording
• Application of the 2013 ACOG hypertension diagnosis categories
RESPONSE
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Unit-standard, Severe Hypertension and Eclampsia Management Plans with checklists
Delivery planning based on ACOG Hypertension category
Postpartum and Post discharge planning for close supervision
Support program for patients, families and staff for all ICU admissions
REPORTING/SYSTEMS LEARNING
• Establish a culture of Huddle for high risk patients and Post-event Debriefs
• Review all Severe Hypertension/ICU cases for systems issues
• Monitor outcomes and process metrics in Perinatal QI committee
Modified from Lynn Simpson, MD, Burton Rochelson, MD and ACOG District II
Venous Thromboembolism Safety Bundle
READINESS
• Thromboembolism risk assessment tools with recommendations for prophylaxis for:
• Outpatient prenatal care
• An antepartum admission
• A delivery hospitalization
• Discharge home after a delivery
RECOGNITION
• Tools to assess thromboembolism risk at all time points during pregnancy:
• Medical, obstetrical, and demographic risk factors thromboembolism
• Recommendations for safe administration of neuroaxial anesthesia
RESPONSE
• Protocols for dosing of prophylactic and therapeutic pharmacologic anticoagulation
• Recommendations for mechanical thromboprophylaxis
REPORTING/SYSTEMS LEARNING
• Establish hospital-level protocols for obstetric thromboembolism prophylaxis
• Review all thromboembolism events for systems issues
• Monitor outcomes and process metrics
 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
D’Alton ME, Obstet Gynecol 2014;123:973-7
Background
• “In many cases in this report, the early warning
signs of impending maternal collapse went
unrecognized.”
• Causes:
− Rare events.
− Healthy population.
− Physiologic changes of pregnancy.
MEOWS
• Vital Sign Triggers
• “Contact doctor if
one red or two
yellow scores at
any one time.”
Swanton, IJOA 2009; 18: 253-7
MEOWS Triggers
• Response initiated for one red or two yellow
triggers:
Parameter
Red Trigger
Yellow Trigger
Temperature
< 35 or >38
35-36
Systolic BP; mmHg
<90 or >160
150-160
Diastolic BP; mmHg
>100
90-100
Heart rate
<40, >120
100-120, 40-50
Respiratory rate
<10 or >30
21-30
Oxygen saturation
<95
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Pain score
-
2-3
Neurological response
Unresponsive, pain
Voice
Singh et al. Anesthesia. 2012
A Validation System of MEOWS
Outcomes
• Hemorrhage
• Asthma exacerbation
• Preeclampsia
• Status epilepticus
• Infection
• Diabetic ketoacidosis
• Pulmonary embolus
• Myocardial infarction
• Central venous sinus
thrombosis
• Pulmonary edema
• Stroke
• Anesthesia complications
• Other
A Validation System of MEOWS
673 patients scored
200 (30%) triggered an evaluation
86 (13%) met criteria for morbidity
Sensitivity 89% (95% CI 81-95%)
Specificity 79% (95% CI 76-82%)
PPV 39% (95% CI 32-46%)
NPV 98% (95% CI 96-99%)
Singh et al. Anesthesia. 2012
Council Subcommittee on
Vital Sign Triggers
 Every birthing facility in the United States should
adapt tools that identify maternity patients who
require urgent bedside evaluation by a physician.
 These tools also include differential diagnoses and
potential next steps.
National Maternal Safety Initiative
Two Essential Components
Maternal
Early Warning
Criteria
Effective
Escalation
Policy
MEWS in ACOG District II
• Series of meetings in 2013 with leaders
from academic centers across New York
State.
• MEWS criteria and scoring was reviewed
and modified.
• Criteria identified when an obstetric
patient should be seen promptly by a
senior provider.
Variations in Criteria
MEOWS Criteria
MEWS Criteria
Systolic BP; mmHg
Diastolic BP; mmHg
Heart rate; bpm
Respiratory rate; bpm
Oxygen saturation; %
Oliguria; mL/hr x 2h
Maternal agitation, confusion, or
unresponsiveness
<90 or >160
>100
<50 or >120
<10 or >30
<95
<35cc/hour
x 6 hours
Variations in Criteria
MEOWS Criteria
MEWS Criteria
Systolic BP; mmHg
Diastolic BP; mmHg
Heart rate; bpm
Respiratory rate; bpm
Oxygen saturation; %
Oliguria; mL/hr x 2h
Maternal agitation, confusion, or
unresponsiveness
<90 or >160
>100
<50 or >120
<10 or >30
<95
<35cc/hour
x 6 hours
Parameters to alert physician
Abnormal Vitals
Values
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
<35
Neurologic: Maternal agitation, confusion, or unresponsiveness
Adapted from Singh et al. 2012
Differential Diagnosis
Common diagnoses
Rare but life-threatening diagnoses
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Hypertension (SBP>160 or DBP>100)
Hypotension (SBP<90)
Tachycardia (HR>120)
Bradycardia (HR<50)
Tachypnea (RR>30)
Bradypnea (RR<10)
Hypoxemia (SpO2<95% on room air)
Oliguria (<35 cc/hr for >2 hrs)
Confusion, agitation, or unresponsiveness
Two Essential Components
Maternal Early
Warning
Criteria
Effective
Escalation
Policy
Effective Escalation Policy
An abnormal parameter requires:
1. Prompt reporting to a physician or other
qualified clinician.
2. Prompt bedside evaluation by a physician or
other qualified clinician with the ability to
activate resources in order to initiate
emergency diagnostic and therapeutic
interventions as needed.
Effective Escalation Policy (cont.)
An abnormal parameter requires:
3. Plan for and implementation of diagnostic workup.
4. Close follow up by senior provider 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).
Why Bedside Evaluation?
 Maternal mortality reviews have illustrated
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
Need to define:
1. Who to notify
2. How to notify them
3. When and how to activate the clinical chain
of command in order to ensure an
appropriate response
Experience at Columbia
 MEWS initiated August 1st, 2013 for all
antepartum and postpartum patients.
 Goal: Evaluation by a senior provider (senior
resident, fellow, or attending) within 15 minutes
of abnormal parameter being reported.
 Education programs provided to Medical
Assistants, Nursing, Residents and Senior
Providers
 MEWS provides clear expectations for reporting
and evaluation of potentially critically ill patients
Early Warnings
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ABNORMAL VITAL SIGN
PARAMETERS
PREVENT
MAJOR MORBIDITY /
CRITICAL ILLNESS?
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Experience at Columbia/
Preliminary data
• Breakdowns in system can occur on any
level:
− Medical/nursing assistants notifying nursing of
abnormal parameters
− Nursing notifying providers
− Providers evaluating patients
− Correct diagnostic assessment
− Follow up of diagnostic evaluation
Early Warnings
1
ABNORMAL VITAL SIGN
PARAMETERS
PREVENT
MAJOR MORBIDITY /
CRITICAL ILLNESS?
2
3
Early Warnings
1
ABNORMAL VITAL SIGN
PARAMETERS
PREVENT
MAJOR MORBIDITY /
CRITICAL ILLNESS?
2
3
Early Warnings
1
ABNORMAL VITAL SIGN
PARAMETERS
PREVENT
MAJOR MORBIDITY /
CRITICAL ILLNESS?
2
3
Experience at Columbia
• Majority of alerts (>80%) were for the
following parameters:
− Oliguria
− Severe-range hypertension
− Tachycardia
• The protocol has thus far been associated
with:
− Timely bedside evaluations.
− Timely administration of antihypertensives.
− Timely workup for severe anemia in patients
with oliguria and tachycardia.
Moving Forward
 Robust data on improvements in process
measures and outcomes.
 “Lessons learned” from implementation
and education for a maternal early
warning system.
 Can decision support be used to help
midlevel providers (nurse practitioners,
midwives, junior residents) evaluate these
patients effectively?
Moving Forward
 Can MEWS responses be protocolized to
avoid delays in diagnosis and treatment?
• Severe-range hypertension
⁻ Is it necessary or beneficial to wait for a senior
provider evaluation before treatment?
⁻ Simple algorithms for management:
o ACOG District II
o Hospital Corporation of America
• Patient with tachycardia
⁻ Should any patient with new onset tachycardia
(HR >120) not have a CBC performed?
Key Points
 Delays in diagnosis contribute to a large
portion of preventable maternal deaths.
 Maternal Early Warning Criteria can identify
potentially critically ill patients and establish
standards for prompt evaluation and close
follow-up.
 Local implementation will depend on hospital
type, provider staffing, and patient
population.
 Significant research opportunities exist.
Thank you for presentation materials:
Alex Friedman MD, Columbia University
Jill Mhyre MD, University of Michigan
Council Website
www.safehealthcareforeverywoman.org