High Dependency Care for Obstetric Patients
Content
Section / Content / Page1.0 / Introduction / 3
2.0 / Aims and objectives / 3
3.0 / Management / 3
3.1 / Admission criteria / 3
3.2 / Responsibility of different staff groups / 4
3.3 / Equipment requirements / 5
3.4 / When to involve clinicians from outside the maternity service / 6
3.5 / Criteria for transfer / 6
4.0 / Audit and Monitoring compliance / 7
5.0 / References / 8
1.0 INTRODUCTION
Whilst most pregnancies and births are normal and without complications, there are some occasions when women will require a higher level of care than that normally provided in a general care setting. In these instances the women should be cared for in a suitable environment by staff able to provide the necessary level of care.
Determining what type of care a woman should receive is based on clinical judgement utilising the criteria outlined in the Intensive Care Society’s Standards and Guidelines for the Levels of Critical Care in Adult Patients1.
High dependency Care (ICS Level 2 care)
High dependency care is required for women needing more detailed observation or intervention including basic support for a single failing organ system, extended post-operative care and those stepping down from higher levels of care.
Intensive Care (ICS Level 3 care)
Patients requiring a higher level of care than outlined above will need to be stabilised and transferred to an Intensive Care Unit. For example, women requiring support for 2 or more organ systems, artificial ventilation, renal replacement therapy, risk of sudden catastrophic deterioration.
Although it is acknowledged that the location of the woman should not determine their level of care - it is expected that within the maternity service women requiring high dependency care will usually be cared for on the Delivery Suite. The LGI site has a designated area within the Delivery Suite for providing HDU care, the SJUH site use a fully equipped delivery room to provide the same level of care as in an HDU unit. If a woman needs ICU care she is transferred to general ICU unit at the respective sites providing that a bed is available. In some circumstances it may be necessary to transfer the woman to another unit providing intensive care services.
2.0 AIMS AND OBJECTIVES
The aims and objectives of this protocol are to outline the processes for ensuring that women receive high dependency care / intensive care in a suitable environment. In particular it specifies:
· Admission criteria
· The responsibilities for the different staff groups
· The process for ensuring the availability of equipment in line with national guidance
· Guidance on when to involve clinicians outside the maternity unit
· Agreed criteria for transfer to HDU / ICU outside the maternity unit
3.0 MANAGEMENT
3.1 CRITERIA FOR TRANSFER
3.1.1 Criteria for transfer to high dependency care
These may be met either before or after delivery. The indication for the woman to receive HDU care should be documented in the hospital records or birth record.
All women receiving high dependency care should have observations recorded on a modified obstetric early warning chart (MOEWs) in order that deteriorating condition can be identified.
Patients who are receiving continuous oxygen therapy are not suitable to step down to level 1 care (ward based) and so will need to remain on delivery suite even if otherwise well.
Table 1: Examples of indications
Obstetric Indications / Non-obstetric IndicationsEclampsia
Sepsis
Severe pre-eclampsia
Severe asthma
Major haemorrhage (over 1500mls)
Diabetic ketoacidosis
Thromboembolism
HELLP syndrome
Puerperal sepsis / Transfer from ICU
Other surgical procedures or complications related to surgical condition
Pneumonia/respiratory embarrassment
Hypertension
Renal impairment
Thyrotoxicosis
Cardiac or neurological co-morbidity
Morbid obesity (BMI over 40kg/m2) with co-morbidities
This list is not exhaustive and the need for HDU care should be assessed on an individual basis. When HDU care is required, the midwife/nurse to patient ratio must be no more than one midwife /nurse to two patients.
3.1.2 Discharge Criteria from HDU to Ward
This will be when care can be managed on a maternity ward and must take into account staffing levels, skill-mix and workload on the ward to which the patient is being discharged. A written treatment plan, including clear instructions about the continued level of observation and when to call medical staff, must be documented at the time of transfer. Continued support from the obstetric and anaesthetic staff based on the delivery suite may be required and must be provided. Transfer out of HDU should be a joint obstetric and anaesthetic decision made at consultant level unless exceptional circumstances apply and fulfill the following:
· Patient haemodynamically stable, no further continuous intravenous medication or frequent blood tests required
· No invasive monitoring required
· No active bleeding
· No supplementary Oxygen required
· Patient mobilized.
There is a named consultant anaesthetist responsible for all HDU patients 24 hours per day.
When transferring a woman from HDU to the postnatal ward a personal handover of care should be given from the midwife handing over care to the receiving midwife utilising the SBAR principle for communication. This should be person to person the woman should be accompanied to the postnatal ward as there may be significant complications that require a more detailed handover and should always be done face to face to the receiving midwife by either a midwife , nurse or doctor.
3.1.3 Criteria for transfer to ICU Care
Women requiring ICU care are generally transferred to an ICU within the Trust. Following assessment of the woman’s condition, the decision for transfer will be made by the Consultant Obstetrician and the Consultant Anaesthetist in liaison with other specialties as required. The reason for transfer should be clearly documented in the Hospital records and/or birth record
Women who may require ICU care have usually more than one organ failure including:
· Women requiring advanced respiratory support (ventilation)
· Women requiring invasive renal support
· Women requiring inotropic support would be considered
· Exacerbation of pre-existing medical problem.
Plans would be made between the Consultant Obstetric anaesthetist, Consultant Obstetricians and the Intensive Care Consultant again using the SBAR principle for communication. On going care for these women must include daily conference between these key personnel.
Discharge from ICU is a consultant level decision and should be back to an obstetric HDU in the first instance unless otherwise directed. The outreach team may need to provide advice and support following discharge from ICU but this will be at the discretion of the Consultant Anaesthetist and Consultant Obstetrician and will depend on the original indication for admission to ICU. Again the transfer should be made person to person the woman should be accompanied to the HDU area as there may be significant complications that require a more detailed handover and should always be done face to face to the receiving midwife by either a midwife, nurse or doctor.
3.2 Responsibilities of the different staff groups
The table below outlines the key roles and responsibilities of staff involved in the care of women requiring level 2 care or above.
ROLE / RESPONSIBILITIES / DocumentationObstetricians / Attend & review woman at least 3 times/24hours (as a minimum on ward rounds at change of shift)
review of investigations and actions as appropriate
communicate with other staff about plan of care and escalate if more senior review required
Respond to an abnormal MOEWs score
Discussing care with woman and/or partner
Liaise with MDT regularly regarding appropriate level and place of care
Be aware of transfer criteria as stated in guidance and arrange transfer as appropriate / Individual plan of care in hospital records
Document discussions in records
Document discussions in hospital records
Document reason for change in level of care and personnel required to undertake transfer
Anaesthetists / Ensure patient is physiologically stable and that appropriate monitoring is in place
Be immediately available to review woman if her condition deteriorates
Liaise with ICU/outreach team if woman requires level 3 care
Accompany woman to ICU and handover care to receiving team / Document plan of care (may be part of ward round documentation from obstetric team as above)
Document discussions in hospital records
Document handover of care including name of person taking over care
Midwifery Staff / To undertake physical observations for women and report any change in score to medical staff
To provide support for women and their partners/family
photocopy birth records and hospital records if transferring outside the Trust
Accompany woman to ICU and handover care to receiving team / Documentation on the MOEWs chart
Document handover of care including name of person taking over care using SBAR sticker or SBAR headings
3.3 Equipment requirements
HDU care should be conducted in the appropriate care setting with staff skilled and trained in this area. The basic equipment available in both the HDU and in delivery suite rooms to provide HDU care is:
· equipment available to monitor vital signs including, pulse, blood pressure, and oxygen saturation (eg SPACELAB / Dynamap)
· Oxygen supply with masks and tubing
· Suction with Yankauer catheter and tubing with various size suction catheters
· Ambubag and masks of different sizes.
· Emergency intubation equipment and drugs (on Crash trolley)
· Minitrach tracheostomy set (on crash trolley)
· Assorted cannula for intravenous access / drip stands
· Wound dressings , tape
· Gloves (Sterile / unsterile in various sizes) / Aprons
In addition there is daily stock check of drugs and fluids.
Equipment and algorithms required for resuscitation and care of HDU patients are included in Trust Basic HDU Competencies document.
To ensure the availability of all necessary and functioning equipment, an inspection is undertaken on a daily basis by the duty Operating Department Practitioner (ODP) and/or Delivery Suite Midwife. If any defects/ faults are found in the equipment at inspection then it is removed from service and reported promptly to Medical Physics (LGI ext: 23492, SJUH ext 66167). A note will be made in the communication book and the information passed on at each shift change so that all staff are aware. Extra equipment is available in the theatre store cupboard if required. This equipment is checked on a regular basis by Medical Physics
3.4 Guidance on when to involve clinicians outside the maternity unit
Transfer out of Obstetric HDU care requires the woman to be assessed jointly by a senior anaesthetist and a senior obstetrician and in some cases other disciplines that have been involved in the woman’s care e.g. renal, cardiac. Senior clinicians from other specialties will be involved in the care of women where there is:
1. Failure of more than one system
2. Disease whose management is out-with the expertise of the obstetric or anaesthetic team
e.g. i renal failure, other than the impairment associated with pre-eclampsia
ii hepatic failure
iii respiratory disease especially that requiring ventilatory support
iv cardiac disease, pre-existing or of recent onset
v neurological conditions
vi endocrine disease including diabetes mellitus
vii non-obstetric surgical problems
The referral will be at Consultant level and ideally such women will be reviewed by the Consultant from the appropriate specialty. The reason for referral and who the referral is made to should be documented in the Hospital records and/or Birth record
The outreach team should be consulted if there is a transition to or from the ICU or for help with a specialised problem e.g. high flow oxygen therapy.
Once the patient is deemed to have stabilised sufficiently to be nursed on a postnatal ward, this will be communicated to the midwife responsible for her care as well as the co-ordinating midwife. There should be a clear plan of on-going care and observations documented on the MOEWS chart once the HDU chart is no longer necessary.
4.0 AUDIT AND MONITORING COMPLIANCE
A clinical incident report will be completed for all women admitted to intensive care or transferred to high dependency care outside the maternity unit. Each case will be reviewed at the weekly risk management meeting who will decide if any further action is required including a level 2 investigation.
A multidisciplinary annual audit will be carried out in accordance with the Maternity Services Audit Plan. Auditable standards include:
· Number of women cared for in HDU
· Length of stay
· Admission and discharge criteria
· involvement of clinicians outside the maternity service
· responsibilities of different staff groups
· availability of medical equipment
· documentation requirements
Audit results will be presented at the Women’s Services Clinical Governance and Audit meeting and an action plan developed as necessary. A lead will be appointed for monitoring of the action plan, including re-audit, and the status of the action plan reported to the Women’s Services Clinical Governance and Risk management Forum quarterly. Audit results will be included in the Maternity quarterly risk management report and any resulting changes disseminated via the Maternity Services Forum, Team Leaders Forum, Supervisor’s Forum.
5.0 Evidence Base
ICNARC (Obstetric) 2010
The Joint Standing Committee of the RCoA and RCOG, in collaboration with the OAA, commissioned ICNARC to introduce fields for “currently pregnant” and “recently pregnant” into their well established Case Mix Programme from February 2006. http://www.oaa-anaes.ac.uk/content.asp?ContentID=323
Sabir N, Vaughan DJA, Lucas DN, Chan I, Bhuptani S, Robinson PN. A survey of obstetricians' knowledge of aspects of acute care in maternity HDU patients. Int J Obstet Anaesth 2009; 16: S21.
Swanton RDJ, Al-Zawi S, Wee MYE. Obstetric Early warning scoring systems- an OAA approved national postal survey IJOA 2008 O14
Srinivas K, Yadthore S, Collis RE. Obstetric high dependency facilities: a survey of current practice. Int J Obstet Anaesth 2007;16: S45.
Rathinam S, Khan A, Rupasinghe M. Preparation of midwives for high risk care: viewpoint of the midwife (Abstract). Int J Obstet Anesth 2007; 16: S50.
Harrison DA, Penny JA, Yentis SM, Fayek S and Brady AR. Case mix, outcome and activity for obstetric admissions to adult,general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database Critical Care 2005 Vol 9 No Suppl 3