This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. Introduction The latest CEMACH Report showed that the early warning signs of impending maternal collapse went unrecognised in many cases. The early detection of severe illness in mothers remains a challenge to all involved in their care. The relative rarity of such events combined with the normal changes in physiology associated with pregnancy and childbirth compounds the problem. Modified early warning scoring systems improve the detection of life threatening illness. *WOW chart replaces all the existing observation charts in obstetric setting. This guideline provides guidance on how and when to use WOW chart & enhanced care WOW chart. This guideline is for use by the following staff groups : All Registered Midwives, Doctors, Student midwives and Medical Students under the supervision of a Registered Midwife and other personnel involved in the clinical care of a women in maternity department. Swati Ghosh Lead Clinician(s) Consultant Obstetrician Approved by Obstetric Guidelines Group on : 20 August 2015 This guideline should not be used after end of: 20 August 2017 Key amendments to this guideline Date Amendment By: 23.08.10 In line with E-z notes requirements for scanning, red has Miss R Imtiaz been changed to peach on the WOW charts. 16.12.11 Agreed by Obstetric CGRM to extend without amendment Miss R Imtiaz for a further period to allow time for review. 01.08.12 Extended for a further period without amendment Miss R Duckett 19.10.12 Amendment to audit standards Miss R Duckett 20/11/14 change to the content. Circulation list updated Val Tristram 29/07/15 Change of term from HDU WOW chart to Enhanced Care WOW chart S Sarkar R Rees WAHT-OBS-099 Page 1 of 8 Version 4
Introduction The latest CEMACH Report showed that the early warning signs of impending maternal collapse went unrecognised in many cases. The early detection of severe illness in mothers remains a challenge to all involved in their care. The relative rarity of such events combined with the normal changes in physiology associated with pregnancy and childbirth compounds the problem. Modified early warning scoring systems improve the detection of life threatening illness. The routine use of WOW chart for all obstetric women will help in the more timely recognition, treatment and referral of women, who have, or are developing, a critical illness. The triggers (yellow and peach) are based on routine observations and are sensitive enough to detect subtle changes in a woman s physiology which will be reflected in a change of score should her condition be improving or deteriorating. However, the detection of life threatening illness alone is of little value. It is the subsequent management that will alter the outcome. Details of Guideline What is a WOW chart? WOW Chart: A4 size (WR1937) Observation chart on front and management plan section at the back Enhanced care WOW chart: A3 size (WR1938). It has 4 parts. 1. WOW observation chart 2. Fluid Balance chart 3. Handover sheet 4. Investigations result record at the back The observations are assigned white, yellow or peach colour. It is the yellow and peach score in addition to the overall clinical situation that will dictate the need to seek help/ advice of more experienced medical staff. Aims of WOW chart: o o To facilitate timely recognition of the patients with established or impending critical illness To empower midwives and trainee medical staff to secure experienced help through the operation of a trigger threshold which, if reached, required mandatory attendance by a more experienced member of staff. Although the majority of patients may benefit from utilisation of WOW charts the clinician s own clinical judgement dictates whether he or she requires the patient to be regularly scored. However, WOW chart is not: o A predictor of outcome o A replacement for clinical judgement o When to use WOW chart? WAHT-OBS-099 Page 2 of 8 Version 4
WOW chart rely on the routine recording and charting of the physiological status of the patient. These are simple observations that can be performed by a midwife, doctor or other trained staff. WOW charts should be used for all obstetric admissions in all clinical settings where observations are required based on clinical presentations. o All antenatal admissions o Intrapartum period: Routine observations in labour will be recorded in a partogram in the yellow birth notes. If a woman requires enhanced care in labour enhanced care WOW chart should be used. o All women requiring enhanced care in delivery suite (antenatal/intrapartum or postnatal) should have their observations recorded on enhanced care WOW chart o All postnatal admissions o It may also be necessary to assess a patient using the WOW chart prior to transferring them to another ward within the hospital or to an external healthcare provider. If decision is made not to use a WOW chart in any of the above situation this should be clearly written in the medical records. NOTE: WOW chart may not be indicated in certain situations including: o Women attending the unit for counselling or discussion with the consultant who do not require any vital signs monitoring. o Postnatal women who have been discharged but staying in the ward because of the baby. Frequency of the observations recorded on WOW chart should be decided on an individual basis. In low risk women not requiring medical input this will be decided by the midwife looking after the woman. The required frequency of observations should be documented on the management plan at the back of WOW chart. The management plan should be updated as necessary and signed when the woman is reviewed. In high dependency patients the frequency of observation required and the management plan should be documented in patient s case notes. t all patients will require every part of the WOW observation chart to be completed e.g. some observations are specific to postnatal period and will not be done antenatally. How to respond to WOW score? o If there is one orange/red and/or two yellow scores at any time on the WOW observation chart doctor should be contacted. o See appendix 2 for WOW pathway. o NOTE: Pain score is explained in appendix 1 below. Appendix 1 : PAIN SCORE ON MOVEMENT Pain 0 Mild pain which can be tolerated 1 Moderate pain causing some distress 2 Severe pain worse pain possible 3 WAHT-OBS-099 Page 3 of 8 Version 4
Appendix 2 WOW PATHWAY 1 or 2 yello in obs scoring 1 yell + other obs normal Call O&G SHO on-call Continue monitoring. Repeat WOW observations as per medical instructions. Has SHO responded within 10 minutes / are you happy with the advice? Ensure O2 Call O&G registrar on-call for advice Has registrar responded within 10 minutes / are you happy with the advice? Call Obstetrics Consultant on-call Patient improves with intervention Involve the anaesthetist + may need urgent referral to surgical /medical team as indicated Continue WOW observations as per medical advice WAHT-OBS-099 Page 4 of 8 Version 4
Monitoring Tool This should include realistic goals, timeframes and measurable outcomes. How will monitoring be carried out? Who will monitor compliance with the guideline? Page/ Section of Key Document Key control: Checks to be carried out to confirm compliance with the policy: How often the check will be carried out: Responsible for carrying out the check: Results of check reported to: (Responsible for also ensuring actions are developed to address any areas of non-compliance) Frequency of reporting: WHAT? HOW? WHEN? WHO? WHERE? WHEN? Page 3 WOW chart used for all obstetric patients where any observation required Page 3 Appropriate escalation when WOW score 2 or more Page 3 Enhanced care WOW chart used appropriately Audit Annual Audit midwife Clinical Governance Annually References Saving mothers Lives (2003-2005) - CEMACH report Dec 2007 WAHT-OBS-099 Page 5 of 8 Version 4
Contribution List Key individuals involved in developing the document Name Designation Swati Ghosh Consultant Obstetrician Sally Millett Clinical director of anaesthetics Judi Barratt Clinical Midwife Specialist Valerie Tristram Supervisor of Midwives/Clinical Pathways/Guidelines Lead Circulated to the following individuals for comments Name Designation Mr S Agwu Mrs P Arya Mrs A Blackwell Miss R Duckett Mrs S Ghosh Mr J Hughes Consultant Obstetrician/Gynaecology Miss M Pathak Mrs J Shahid Miss D Sinha Miss L Thirumalaikumar Mr A Thomson Mr J Uhiara R Fletcher Clinical Pharmacist M Stewart Matron/Supervisor of Midwives P Jones Delivery Suite Manager, WRH User representatives (LW Forum) C Finneran L Ratcliffe D Stokes S Tyrrell J Willis Members of Guideline Circulation Group for discussion with their Peers Caroline Carter Joint Community Team Leader WRH Kealey Derby Evesham Community Midwife Heloise Doherty Redditch Community Midwife Sophie Guarnieri Midwife WRH Melanie Hurdman CMW Team Leader Worcs (SOM) Barbara Kavanagh CMW Team Leader Redditch Claire Layton CMW Team Leader Evesham Jennifer Martin Delivery suite Manager Alex Sara pain Deputy ward manager PNW WRH Sally Talbot Deputy Delivery Suite Manager Alex Maria Pearman Midwife Alexandra Hospital Michelle Tongue DAU manager Alexandra Hospital (SOM) Helen Walker Community Midwife Kidderminster Jo Walters Midwife ANC Alexandra Hospital Jane Wardlaw Midwife ANC KTC Rachel Williams Midwife WRH Circulated to the chair of the following committee s / groups for comments Name Committee / group WAHT-OBS-099 Page 6 of 8 Version 4
Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. / Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Pregnant women only Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? N/A Pregnant women 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources. WAHT-OBS-099 Page 7 of 8 Version 4
It is the responsibility of every individual to check that this is the latest version/copy of this document. Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue / 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: ne If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-OBS-099 Page 8 of 8 Version 4