London Maternal Mortality Learning and Sharing event Date
London Maternal Morbidity & Mortality Working Group 8th September 2016
Session Seven Delays in care along the pathway and out of hours support Date
Rachel Thomas Patient Safety & Risk Manager King’s College Hospital NHS Foundation Trust 8th September 2016
Delays in care along the pathway and out of hours support
Seven cases – contributory factors were identified as delays in care and lack of out of hours support 3
Reasons for delay Delays included o implementation of care plans o access to appropriate senior professionals o access to specialist procedures (e.g. CT scanning) o appropriate transfer to clinical areas o recognition of high risk status o access to appropriate management 4
Delays in access • Access to senior obstetric and other clinical teams when serious maternal illness was identified • Ensuring care management plans were acted on promptly • Taking women to theatre • Taking urgent blood samples • Interpretation of blood samples • Commencement of appropriate medication • Calling senior clinical staff out of hours • Poor communication between clinical teams • Key clinical information omitted from patient handover 5
Delays in triage care • Five cases involved delays in triage o Specific cases included:
o Lack of information for midwife to appropriately assess the woman o Delay in identifying a high risk woman o Would have been more appropriate for LAS to have taken the woman to A&E
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Triage services • Identified triage services set up alongside labour wards in some units • Using the A&E system, triage is used to identify women in established labour or presenting with other issues when admission is required • Some triage services signpost women who require obstetric day assessment unit and midwifery-led birth centres • Triage has also been used to alleviate traffic and workload for labour ward
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Case Study 30 year old European National - All antenatal care abroad – staying with relatives in the UK 22:00 - 33w admitted via LAS to maternity triage with lower back pain and abdominal pain BP 152/87 rechecked 164/93 using Entonox FH√ Temp normal P=60 RR 21 BP recheck 151/72 SHO informed for Co-dydramol 23:24 CTG patient uncomfortable LOC 23:45 For booking bloods taken Sister-in-Law translating 00:15 SHO GPST1 review. Speculum – os closed, FFN test normal. Uterus tender and non-irritable. Increased pain due to pain due to UTI? PLAN – urinanalysis + repeat obs + repeat CTG. BP 160/70 d/w SPR
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• 00:35 CTG discontinued “suspicious” to be repeated (no timeframe) Urinanalysis – blood +++, proteinurea and trace leucocytes • 01:20 d/w SpR (ST7) re BP 160/70 Plan – admit to A/N ward. 30 minute BP check. If remains elevated for labetalol. PET screening bloods and urine for PCR and MSU • 1:30 BP 170/80, CTG restart p=72. MEWS started= 1 red score. For immediate referral to SpR and 15 obs (30 min obs carried out and SpR NOT informed) MSU√ PCR not ordered • 02.00 – another red score on MEWS (BP 160/80) SpR NOT informed • 02:15 Booking bloods taken plus LFTs U&Es and CRP • 02:30 BP 160/80 Red MEWS score. CTG normal and discontinued • 03:30 BP d/w SpR. Not for antihypertensives but continue half hourly obs. Admit to A/N ward. Not yet reviewed. • 03:10 discussion regarding appropriateness of transfer to ward. ? Needs 1:1 care on LW
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• 03:20 complaints of headache and co-dydramol given. BP 160/80 1 Red score • 03:42 Bloods received by lab (taken 02:15). Transfer to AN ward • 04:20 BP 184/104 P=53 SHO asked to review • 04:30 attempt to transfer to LW. SHO reviewed Nifedipine 10mgs prescribed d/w SpR. Results Platelets 43 ALT likely to be high but sample haemolysed. SpR informed, Anaesthetic SpR informed. Realised no PCR – urgent re-request. • 04:45 repeat bloods • 05:00 BP 145/75 • 05:15 transfer to LW • 05:20 MDT review – diagnosis of pre-eclampsia Plan – steroids, IV access, antihypertensives, fluid balance to start, continuous CTG, 15 min obs, potential to expedite delivery • 05:50 platelets d/w lab. No platelets in hospital then one pool found (was allocated to another patient). Replacement platelets needed as a priority from Colindale Plan – not transfuse at this time and may need for cover for C/S
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• 06:30 ALT 1121 (normal range 1-34); plts 30; bilirubin 57 Plan – PET bloods + mag sulph, NNU review, restrict fluid intake, prep resus trolley, HELLP • 07:06 Obs consultant informed. Nil by mouth. Steroids√ BP 148/92 P=70 • 07:30 First dose of Mag Sulph given • 07:45 CTG pathological for previous hour. Reviewed by Consultant. Diagnosis severe pre-eclampsia and HELLP. d/w Sister-in-law hospital and regional liver unit informed • 08:09 2 pools platelets ordered BP 142/90 p=80 • 08:20 Consent taken for surgery • 08:45 reviewed by Anaesthetist. Patient not responding to questions. Reports frontal headache. Decision for EMCS in main theatre as likely to need ITU • 09:20 arrive in theatre. Drowsy and agitated. Unable to transfer herself to table. • 09:30 1st pool platelets given • 09:55 GA • 10:01 C/S commenced • 10:08 :Livebirth
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1 RBC; 2 FFP; 2 pool platelets, 2x cryoprecipitate 11:55 CS finished EBL 800mls 12:40 still intubated, difficulty in rousing 12:50 pupils checked – grossly unequal
Learning Points • Escalate when MEOWS charts trigger – no escalation to Cons Obs until 8 hours after admission • Commence MEOWS chart on admission • Prompt escalation needed re ordering of platelets • Delay in recognition and diagnosis of PET and HELLP • Delay in performing CS by 2.5 hours • Delay in starting mag sulphate and ordering platelets • Haemolysed blood results need to be reviewed and clinical picture taken into account
