Danny Challis NSW Perinatal Services Network The parable of the - PowerPoint PPT Presentation

The Deteriorating Maternity Patient Danny Challis NSW Perinatal Services Network

The parable of the Obstetrician and the Cardiologist..

So how is maternity care different? • Well patients – usually good outcomes • Inaccurate tools for fetal welfare assessment • Maternal physiology is different • Differing cultures • Midwifery • GP • Obstetricians • Varied locations – homebirth to quaternary • No tolerance for bad outcomes • Expectations • Impact • Cost of claims

How do midwives see labour and birth? How do midwives see labour and birth?

How do obstetricians see labour and birth?

Moving up the ‘slippery slope’ F etal welfare assessment Prevention Clinical support O bstetric emergencies Outcomes tools Antenatal care / risk N eonatal resuscitation Clinical assessment T raining Clinical Review Continued Pathway/ Treatment guidelines Plan (pre-eclampsia, PPH, Fetal Maternal / fetus Condition distress) Revised Rapid Treatment Response SMOC Plan CTG stickers SNOC Referral Sepsis Pathway/Alert High care unit / ALS facility Diagnostic Error Time Death

Prevention – right time and place • Risk assessment – ongoing • ACMI Guidelines • Appropriate models of care • Continuity models • Service capability • Well defined for planned care • Advice processes • Tiered Maternity Networks - PAL • Transfer processes • PAL/strengthened tiered maternity networks

Maternity VTE risk assessment

Moving up the ‘slippery slope’ F etal welfare assessment Prevention Clinical support O bstetric emergencies Outcomes Antenatal care / risk tools N eonatal resuscitation Clinical assessment T raining Clinical Review Continued Pathway/ Treatment guidelines Plan (pre-eclampsia, PPH, Fetal Maternal / fetus Condition distress) Revised Rapid Treatment Response SMOC Plan CTG stickers SNOC Referral Sepsis Pathway/Alert High care unit / ALS facility Diagnostic Error Time Death

How is fetal deterioration different? • Inaccurate tools • Intermittent auscultation • Electronic fetal heart rate monitoring, • ultrasound • High false positives from heart rate monitoring • Failure to recognise gradual deterioration • Failure to recognise abnormal heart rate patterns • Reluctance to use fetal scalp blood sampling • Chronic vs acute

Electronic fetal heart rate monitoring algorithms and documentation tools 2018-2019 13

Antenatal 14

NSW Pregnancy and newborn Services Network

NSW Pregnancy and newborn Services Network

Are you sure it’s fetal?? NSW Pregnancy and newborn Services Network

Determine risk ► Consideration of background risks when assessing the FHR features ► Introduction of altered calling criteria 18

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Antenatal label ≥ 32 weeks 20

Intrapartum 21

Determine risk Consideration of ► Intrapartum risks ► Fetal reserve ► Graded level of risks 22

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Features ► Baseline ► identifying the rising baseline ► Variability ► Introduction of ‘cycling’ – the normal transition of the fetus through the awake and asleep states. ► Decelerations ► Language change to complicated variables ► Prolonged decelerations – time frames and recognition of recovery 24

Intrapartum label 25

The deteriorating mother: • Maternal Physiology • Healthy and young – late deterioration • Reluctance to recognise rare complications eg peripartum cardiomyopathy • Sepsis esp GAS

Maternal BTF – SMOC & ASSOC

Maternal peripartum BTF - SIOC

Neonatal BTF - SNOC

Moving up the ‘slippery slope’ F etal welfare assessment Prevention Clinical support O bstetric emergencies Outcomes Antenatal care / risk tools N eonatal resuscitation Clinical assessment T raining Clinical Review Continued Pathway/ Treatment guidelines Plan (pre-eclampsia, PPH, Fetal Maternal / fetus Condition distress) Revised Rapid Treatment Response SMOC Plan CTG stickers SNOC Referral SIOC Sepsis Pathway/Alert High care unit / ALS facility Diagnostic Error Time Death

Current FONT – resuscitation, scenarios drills and team training • Neonatal resuscitation • Adult BLS • Maternal collapse • Sepsis • Eclampsia • Shoulder dystocia • Vagina breech delivery • PPH

Sepsis – Maternal and neonatal

Additional neonatal sepsis resources

Monitoring: what do our RCAs tell us?

Top system factors in Maternal and perinatal RCAs

Top three system factors in Maternal and perinatal RCAs

NSW M&N SAFETY SYSTEM 2010 2011 2012 2013 2014 2015 2016 2017 2018 2008 2009 F . O . N . T F . O . N . T F etal welfare PD Between SMOC & revised revision assessment the Flags Policy SNOC revision O bstetric commenced program Directive revised emergencies PD2011_077 launch N eonatal (Adult) Maternal & resuscitation Updated Policy T raining Newborn deteriorating patient Directive Sepsis education BTF BTF PD2013_049 Pathways.v1 program program launch launch (Paeds & (Maternal) Maternal & SNOC) SMOC CTG stickers eMR SMOC & Newborn v1 SNOC Sepsis Policy VERSION 4 ED Sepsis Pathways.v2 Directive Development PD2010_026 Antenatal short stay observation chart (ASSOC)

The future imagined • Neonatal resuscitation training (HETI) • Maternal essential training • Fetal essential training • Team training drills and simulations (Tier II) including DETECT • Library of resources and modules • Responsive escalation, advice, and transfer systems • More usable data to allow better analysis of critical incidents and deaths • Reports to generate priorities and actions

Ongoing challenges • SMO engagement • Team training – identification of appropriate trainers • Equivalence of training/RPL • Culture and human factors work • EMR challenges