Trust Guideline for the use of the Modified Early Obstetric Warning Score (MEOWS) in detecting the seriously ill and deteriorating woman.

Transcription

1 A clinical guideline recommended for use In: By: For: Key words: Written by: Supported by: Maternity Services. Obstetricians, Midwives and Midwifery Care Assistants. All women receiving care from maternity services. MEOWS (Modified Early Obstetric Warning Score), call out cascade and MEOWS chart. D.Nirmal S Ardizzone. Dr.J.Corfe Lead Obstetric Anaesthetist, MEOWS development group, Mary Edwards, Critical care outreach team lead, Midwifery Guidelines group, Obstetrics and Gynaecology guidelines group. Approved by: Obstetric Guidelines Committee Reported as approved to: Clinical Effectiveness Committee Guideline Issued: October 2012 Date of approval 08 August 2014 To be reviewed before: 08 August 2017 To be reviewed by: D. Nirmal Guideline supersedes: MID33 v.3/ao13 v.3 Guideline Reg. No: MID33 v.4/ao13 v4 Copy of complete document available from the Trust intranet Page 1 of 9

2 Quick reference guideline The Modified Early Obstetric Warning Score (MEOWS) has been designed to allow early recognition of physical deterioration in parturiate women by monitoring their physiological parameters. MEOWS is a score attributed to these parameters and documented on the MEOWS observation chart. The further away from normal the individual s observations are the higher will be the score. A score 3 triggers the use of a call out cascade giving specific instructions regarding level of monitoring, referral for advice, review, and immediate actions to be considered (See appendix 2). This guideline is for use by all staff undertaking routine physiological observations in both the hospital and the community setting. This guideline should be used in conjunction with the Trust Guideline for the Use of a Critical Illness Risk Assessment Tool (Early Warning Score) in Adult Patients and Recording of Physiological Observations (Guideline no CA2000) Objective This is to provide guidance for staff within the maternity services on recognising and monitoring the obstetric patient using the MEOWS chart. This will enable early recognition of deterioration; advice on the level of monitoring required, facilitate better communication within the multidisciplinary team and ensure prompt management of any women whose condition is deteriorating. Rationale The early detection of critical illness in pregnant women remains a challenge to all professionals involved in their care. The relative rarity of such events combined with the normal changes in physiology associated with pregnancy and childbirth compound the problem. It is recognised that pregnancy and labour are normal physiological events. However, recording of physiological observations is an integral part of maternity care. Regular recording and scoring of these observations will aid the recognition of any changes in a woman s condition. Using the MEOWS chart will prompt early referral to the appropriate practitioner. MEOWS is a way of formalising measurement of physiological variables. The values of the observations are then translated into a summary score which has a critical threshold, above which medical review and intervention is required (see appendix 2 MEOWS call out cascade). It is believed that small changes in the combined physiological variables measured by MEOWS may pick up deterioration earlier than an obvious change in an individual variable. Early detection will trigger subsequent prompt intervention that will either reverse further physiological decline or facilitate timely referral to appropriate personnel. Copy of complete document available from the Trust intranet Page 2 of 9

3 The use of the MEOWS does not demand critical care or define treatment but is a tool to aid the early recognition and management of the deteriorating woman. However no tool can replace the actual physical examination of a woman and clinical assessment of her condition. In some cases maternal collapse occurs with no prior warning, although there may be existing risk factors that make this more likely. Often there are clinical signs that precede collapse. In the last two Saving Mothers Lives reports substandard care was identified where signs and symptoms were not recognised and acted upon. Both reports recommended that a national Obstetric Early Warning Scoring system should be introduced and used for all obstetric women, including those being cared for outside the obstetric setting (CEMACH 2007, CMACE 2011). The use of an early warning score is also supported by NICE in the guideline Acutely Ill patients in hospital: recognition of and response to acute illness in adults in hospital (NICE CG ). The physiological changes of pregnancy may render the existing Early Warning score (EWS) systems inappropriate, (Gopalan PD 2004) and no validated system for use in the pregnant woman currently exists. Because of this, many maternity hospitals have developed their own modified EWS system, and there is continuing work in the UK to try and develop a national obstetrics EWS system (RCOG green top guideline NO: 56 Jan 2011). Appendix 1 shows the MEOWS adapted for use at the NNUH. The MEOWS is calculated by scoring the values of a full set of observations carried out routinely by staff which include; Temperature Systolic blood pressure Diastolic blood pressure Heart rate Respiratory rate Level of consciousness using AVPU scale +/- urine output A - Alert Alert and conscious V - Voice Responds to voice P - Pain Responds to pain U - Unresponsive No response to voice or pain Of all the variables the respiratory rate is the most sensitive indicator. Physiological changes in pregnancy might include: Increase in heart rate by bpm Respiratory rate increases by 2 breaths per minute Blood pressure decreases by 10 mm Hg NB the use of the MEOWS chart does not negate the use of the fluid balance chart. Copy of complete document available from the Trust intranet Page 3 of 9

4 Responsibility of relevant staff groups. It is the responsibility of the person carrying out the observations to alert the midwife caring for the woman if the MEOWS score is 3 or more. It is then the responsibility of the midwife to initiate the call out cascade when necessary and to take appropriate action when the MEOWS is 3. Broad recommendations The Process for use of MEOWS Every time a set of observations is performed on ante or post natal women, MEOWS should be calculated and recorded in the hand held records or on the observation chart as applicable. All women presenting to Triage who are having baseline observations carried out should have a MEOWS calculated and documented in the hand held records. Women in active labour do not require regular MEOWS scoring however a score should be attributed to the baseline observations on admission and recorded in the hand held records. Women receiving high dependency care on Delivery Suite should have the MEOWS score documented on the Mega chart. A MEOWS observation chart should be commenced once the Mega chart is no longer being used. All obstetric inpatients must have a full set of observations and a MEOWS calculated at every transfer to a new area (for example on transfer from Recovery to Blakeney ward). The MEOWS chart used in one area should be transferred with the patient to the next area in order to help identify changes in trends of observations. Any woman who triggers a MEOWS of 4 should have their oxygen saturations recorded with each full set of observations. If you are concerned about a woman s condition a MEOWS should be attributed. If you are still concerned regardless of the MEOWS, seek advice. Antenatal: Frequency of observations will depend on the nature of the admission or as indicated by the lead clinician. As a minimum, a full set of observations should be carried out twice daily at least 12 hours apart. MEOWS should be attributed to each of these sets of observations. Delivery Suite: All women should have a set of observations and MEOWS documented in the hand held records on admission to Delivery Suite or to Triage. Currently women who are in Copy of complete document available from the Trust intranet Page 4 of 9

5 labour need not have MEOWS repeated. documented on the partogram as usual. Regular observations should still be Recovery: The theatre care plan will be used in Recovery. The MEOWS chart should be initiated in recovery by the recovery practitioner prior to transfer to midwifery care. The last set of observations taken in recovery should be recorded on both the theatre care and the MEOWS chart. Postnatal: All women should have a full set of observations on admission to the postnatal ward and should have this repeated a minimum of 12 hours apart. A MEOWS score should be attributed to every set of observations. The frequency of observations will depend on the nature of the admission or as indicated by the lead practitioner. All women who have undergone an operative procedure will be having regular observations in accordance with the midwifery guideline for Care Following Operative Procedures (MID28. Community: A MEOWS should be attributed to every set of postnatal observations and documented in the maternal records. If MEOWS >3, observations should be repeated within minutes. If the score remains >3, the midwife should contact Delivery Suite or the GP. Regardless of MEOWS if you are concerned about a woman s condition seek advice. Management of patients in response to MEOWS The call out cascade (see appendix 2) sets out the action to be taken in response to individual MEOWS. This should be followed to ensure the appropriate clinicians are called and appropriate management and care is undertaken. All actions taken must be clearly documented in the handheld records. Guidance on when to involve clinicians from outside of maternity services In the event that a woman deteriorates and becomes seriously ill, it may be appropriate to involve medical staff from other disciplines such as the Critical Care Complex, Haematology, Acute Medicine, Renal Medicine, Cardiology and Surgery. The decision to involve other disciplines should be made by the most senior Obstetric or Anaesthetic staff member involved. The quickest way for the woman to be reviewed by a doctor Copy of complete document available from the Trust intranet Page 5 of 9

6 from another specialty is often by consultant to consultant referral, so early senior involvement is encouraged. Maternity service s expectations for staff training Please refer to the maternity staff training needs analysis (TNA) Clinical audit standards The Maternity Services are committed to the philosophy of clinical audit, as part of its Clinical Governance programme. The standards contained in this clinical guideline will be subject to continuous audit, with multidisciplinary review of the audit results at one of the monthly departmental Clinical Governance meetings. The results will also be summarised and a list of recommendations formed into an action plan, with a commitment to re-audit within three years, resources permitting. Summary of development and consultation process undertaken before registration and dissemination This guideline has been written by Mrs.D.Nirmal, Consultant Obstetrician and S. Ardizzone, Practice Development Midwife, in consultation with Dr. J Corfe, Lead Obstetric Anaesthetist and other members of the MEOWS development group. Distribution list Head of midwifery Clinical midwifery managers Trust Intranet Community team leaders School of Nursing/midwifery Risk manager (Division 3) References/ source documents NICE (2007) Acutely Ill patients in hospital: recognition of and response to acute illness in adults in hospital (clinical guideline 50). London. NICE (2010) Hypertension in pregnancy. The management of hypertensive disorders in pregnancy. (Clinical guideline107) London Lewis G. (ed) The confidential Enquiry into Maternal and Child Health (CEMACH) Saving Mothers Lives: reviewing maternal deaths to make motherhood safer The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH Copy of complete document available from the Trust intranet Page 6 of 9

7 Centre for Maternal and Child enquiries (CEMACE). Saving mothers lives: reviewing maternal deaths to make motherhood safer The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom BJOG 2011 National Patient Safety Agency (2007a) Recognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients. London: NPSA. Maternal collapse in pregnancy and puerperium RCOG green top guideline NO: 56, January 2011 Gopalan PD, Muckhart DJ. The critically ill obstetric patient: what s the score? Int J Obstet Anesth 2004; 13: Copy of complete document available from the Trust intranet Page 7 of 9

8 Guideline for the use of the Modified Early Obstetric Warning Score (MEOWS) in Detecting the Seriously Ill and Deteriorating Woman. Appendix 1 *Ranges adapted from NICE guidance on Hypertension in pregnancy (2010) Temperature range adapted from MEWS obstetrics from Rosie Maternity Hospital, Cambridge University Hospital NHS foundation trust Pulse, Respiratory rate, AVPU, Urine output adapted from NNUH NHS Trust early warning score. Score Temperature <35.C C C >39.C Systolic * BP Diastolic * BP Pulse Respiratory Rate AVPU Alert Responds to Voice Urine output mls/hr <10 <30 Not Measured Responds to Pain If the pulse rate is higher than the systolic blood pressure then score 2 for Pulse Unconsciou s Author/s: D Nirmal, S Ardizzone Date of issue: May 2012 Valid until: May 2015 Guideline Ref No: MID33 v.4/ao13 v.4 Copy of complete document available from the Trust intranet Page 8 of 9

9 Appendix 2 Copy of complete document available from the Trust intranet Page 9 of 9