featuring emily hamilton, mdcm...featuring emily hamilton, mdcm senior vice president of clinical...

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Featuring Emily Hamilton, MDCMSenior Vice President of Clinical Research

An experienced obstetrician, Dr. Hamilton is currently an Adjunct Professor of Obstetrics and Gynecology at McGill University, and leads PeriGen’s clinical research team.

She is an internationally-known clinical thought leader on the use of technology to improve obstetric outcomes. She presents her research regularly at obstetric conferences and in peer-reviewed journals.

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Outline

1. Definition2. History 3. US Statistics 4. Obstetrical EWS5. Evolution

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Definition

Early Warning SystemsAlert criteria based on VS (± others) that prompt clinical action

IHI calls them “Scorecards that Save Lives”

• ICU• ER• Anesthesia• Pediatrics • OB

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How do they work? Assessments are routine and repeated periodically e.g. on admission, at

frequent intervals

Results tied to action Physician assessment Calling a rapid response team or Initiating a specific investigation, therapy, or action

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History

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There is an urgent need for the routine use of a national obstetric early warning chart, similar to those in use in other areas of clinical practice, which can be used for all obstetric women which will help in the more timely recognition, treatment and referral of women who have, or are developing, a critical illness.

In the meantime all trusts should adopt one of the existing modified early obstetric warning scoring systems…

Recommendation 10

Growth of OEWS: UK survey 130 OB Units

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Isaacs, RA, Wee MYK, Bick DE, et al. (2015) A national survey of obstetric early warning surveys in the United Kingdom: five years on. Anaesthesia 2014;69:687-9

19%

100%

0%

20%

40%

60%

80%

100%

120%

2007 2013

Infant Mortality Rate in the US among the Highest

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Maternal Mortality Rates in the US is High and Rising

Lancet. 2014 Sep 13;384(9947):980-1004

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Causes of Maternal Mortality in California

Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015 Apr;125(4):938-47.

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Chance to Alter Maternal Mortality

41%

48%

11%

Good to strong

Some

None

Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015 Apr;125(4):938-47.

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Obstetrical EWS

Many Variations

MEWC MEWT MEOWS MEWS IMEWS …

National Partnership for Maternal Safety

Modified Early Warning Criteria

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MEWC

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1.2.3.4.5.6.7.

MEWC

Initiate prompt bedside evaluation

Activate resources to initiate emergency interventions as needed

Mhyre JM, DʼOria R, Hameed AB, Lappen JR, Holley SL, Hunter SK, Jones RL, King JC, DʼAlton ME. The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol. 2014 Oct;124(4):782-6.

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MEOWS - Modified Early Obstetrical Warning System

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MEOWS

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MEOWS

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MEWT any Trigger + Persistence

1. Temp ≤ 36 ≥ 38 2. Pulse Ox ≤ 93%3. Heart rate < 50 < 1004. Systolic BP < 80 > 160 verified 15-20 min 5. Diastolic < 45 > 110 verified 15-20 min6. Altered mental status 7. FHR > 160

Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol. 2016 Apr;214(4):527.e1-6

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MEWT

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Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol. 2016 Apr;214(4):527.e1-6

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Clinical Impact

57

859096

0

10

20

30

40

50

60

70

80

90

100

% Correct Antihypertensive % Correct Mag Sulfate

%Improvements in Care

Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity. Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Am J Obstet Gynecol. 2017 Apr;216(4):

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1.15

2.4

0.62

2

0

0.5

1

1.5

2

2.5

3

Eclampsia per 1000 births Severe Maternal Morbidity per 100 Births

Rate

Improvements in Poor Outcomes

Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity. Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Am J Obstet Gynecol. 2017 Apr;216(4):

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Causes of Medical Error

Lack of Knowledge or Skills is Relatively Uncommon

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Neonatal Encephalopathy Maternal Mortality

Types of Underlying Clinician Factors

Lack of knowledge or skills

Delayed response

Failure to seek help

Communication

Poor recognition of severity

Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015Sadler LC, Farquhar CM, Masson VL, Battin MR. Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia. Am J Obstet Gynecol. 2016

Situational Awareness to Action

1. Collect Data

2. Find Meaning

3. Project Outcome

4. Actions

Sneak Preview of Work in Progress

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PeriWatchTM VigilanceTM

Conclusions: EWS

• Widespread usage across medicine• Wide adoption in UK maternity units• Work intensive• MEWT Associated with clinical improvement in leading US centers• Parts of the EWS process are well suited to computerization to assist clinicians

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Thank you

For more information,please email info@perigen.com or visit www.perigen.com

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