Introduction of a modified obstetric early warning system -(-MOEWS-)- at an Ethiopian referral hospital: a feasibility assessment

Early warning tools and clinician 'agency' for strengthening safety culture: An integrative review

AIM

Identify and analyse literature investigating nurses' and midwives' use of early warning tools during the care of adult inpatients.

DESIGN

An integrative literature review.

METHODS

Whittemore and Knafl's (2005) framework guided this integrative review. PubMed, CINAHL, EMCARE and Google Scholar were systematically searched. The authors assessed the methodological quality of 21 papers meeting inclusion criteria and thematically analysed key data.

RESULTS

Three main themes were identified, each with further sub-themes.

CONCLUSION

Early warning tools operate within various systems and cultural contexts. However, their potential for improved patient safety may be hindered. Protocols influencing tool usage may make nurses and midwives distanced from patients and their expertise. For early warning tools to enhance patient safety, assessing their integration into practice is crucial to maximizing effectiveness.

IMPACT

This review emphasizes the importance of integrating human relationships with early warning tools for patient safety.

PATIENT OR PUBLIC CONTRIBUTION

This integrative literature review does not include patient or public input.

IMPLICATIONS FOR PRACTICE/POLICY

Adapting early warning tools to balance standardization for safety and efficiency and promoting nurses' and midwives' expertise and autonomy is required to optimize delivery of quality care and uphold patient safety.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used.

Immediate postpartum care in low- and middle-income countries: A gap in healthcare quality research and practice

The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.

Barriers to effective management of primary postpartum haemorrhage following in-hospital births in northwest Ethiopia: healthcare providers' views using a qualitative approach

Background

Data showed that postpartum haemorrhage contributed to over 40% of in-hospital deaths of Ethiopian women. However, little is known about the barriers to effective management of primary postpartum haemorrhage. This study aims to explore the views and experiences of maternity healthcare professionals about the barriers to managing primary postpartum haemorrhage following in-hospital births in northwest Ethiopia using the ‘Three Delays’ model as a conceptual framework.

Methods

A qualitative descriptive study was employed at two tertiary referral hospitals between December 2018 and May 2019. Forty-one maternal healthcare providers, including midwives, midwifery unit managers, and obstetricians, participated in this study. Individual face-to-face interviews, focus group discussions, and self-administered open-ended questionnaires were used to collect data. A framework analysis approach was used for the qualitative data analysis. Themes were identified based on the Three Delays model of ‘delay the decision to seek care’, ‘delay arrival at a health facility’, and ‘delay the provision of appropriate and quality care’.

Results

Participants reported several modifiable issues when managing primary postpartum haemorrhage, and all were linked to a delay in receiving appropriate and quality care due to limited resources. Five sub-themes were identified: ‘workforce’, ‘communication issues between healthcare providers’, ‘systemic issues’, ‘education, training, and resourcing issues’, and ‘lack of identification and referral’.

Conclusion

Maternal healthcare providers in these hospitals require training in managing a birthing emergency. In addition, the birth units need adequate supplies and continuous essential services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05071-6.

Early warning systems in maternity care: A qualitative evidence synthesis of maternity care providers' views and experiences

OBJECTIVE

To gain insight and understanding, from the perspective of maternity care providers, on the use and application of maternity early warning systems (MEWS) in clinical practice.

DESIGN

A qualitative evidence synthesis was conducted. MEDLINE, CINHAL, Web of Science Core Collection and Maternity and Infant Care (MIDIRS), from inception to March 2021, were searched for eligible studies. Grey literature sources were also searched for unpublished studies. The methodological quality of included studies was assessed by at least two reviewers using an Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre quality assessment tool. Thomas and Harden's thematic synthesis approach was used to guide the data synthesis. Confidence in the findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation of Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual).

SETTING AND PARTICIPANTS

Included studies reported on maternity care providers involved in caring for pregnant or postpartum women in any birth setting. Studies were mostly qualitative in design, although survey designs with open-ended questions that provided qualitative data were eligible for inclusion if the qualitative data had been subjected to formal analyses.

FINDINGS

Eight eligible studies, reported across nine records, were identified in the search and included in the review. Three themes representative of maternity care providers' views and experiences of MEWS were generated from the synthesis. These were 'Aid to clinical care provision', 'Impact on workload' and 'Factors affecting MEWS implementation'. MEWS was viewed as a useful tool in guiding clinical care, and for identifying deterioration and the need to escalate care. Some maternity care providers viewed MEWS as beneficial in easing workload burden. Others, however, viewed MEWS as adding to workload because of repetition and duplication. Training in MEWS was considered inadequate and concern existed for some care providers that MEWS would lead to deskilling or eroding of professional judgement.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Maternity care providers hold diverse views on the use of MEWS in clinical practice. While almost all consider MEWS a helpful aid for guiding clinical care, barriers to implementation were identified. These included added workload burden, inadequate training, and concern for deskilling. Attending to implementation barriers will help optimise use of MEWS in clinical practice as currently recommended.

Screening for infectious maternal morbidity - knowledge, attitudes and perceptions among healthcare providers and managers in Malawi: a qualitative study

BACKGROUND

Maternal morbidity and mortality related to infection is an international public health concern, but detection and assessment is often difficult as part of routine maternity care in many low- and middle-income countries due to lack of easily accessible diagnostics. Front-line healthcare providers are key for the early identification and management of the unwell woman who may have infection. We sought to investigate the knowledge, attitudes, and perceptions of the use of screening tools to detect infectious maternal morbidity during and after pregnancy as part of routine antenatal and postnatal care. Enabling factors, barriers, and potential management options for the use of early warning scores were explored.

METHODS

Key informant interviews (n = 10) and two focus group discussions (n = 14) were conducted with healthcare providers and managers (total = 24) working in one large tertiary public hospital in Blantyre, Malawi. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes.

RESULTS

Most healthcare providers are aware of the importance of the early detection of infection and would seek to better identify women with infection if resources were available to do so. In current practice, an early warning score was used in the high dependency unit only. Routine screening was not in place in the antenatal or postnatal departments. Barriers to implementing routine screening included lack of trained staff and time, lack of thermometers, and difficulties with the interpretation of the early warning scores. A locally adapted early warning screening tool was considered an enabler to implementing routine screening for infectious morbidity. Local ownership and clinical leadership were considered essential for successful and sustainable implementation for clinical change.

CONCLUSIONS

Although healthcare providers considered infection during and after pregnancy and childbirth a danger sign and significant morbidity, standardised screening for infectious maternal morbidity was not part of routine antenatal or postnatal care. The establishment of such a service requires the availability of free and easy to access rapid diagnostic testing, training in interpretation of results, as well as affordable targeted treatment. The implementation of early warning scores and processes developed in high-income countries need careful consideration and validation when applied to women accessing care in low resource settings.

Incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia

BACKGROUND

Of the 1010 reported maternal deaths in 2018, just over 65% occurred in hospitals in Ethiopia. However, there is a lack of standardised data about the contributing factors. This study aimed to investigate the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.

METHODS

A retrospective cohort design was used; an audit of 1060 maternity care logbooks of adult women post-partum at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted between December 2018 and May 2019 using a systematic random sampling technique. We used the Facility Based Maternal Death Abstraction Form containing sociodemographic characteristics, women's medical history, and partographs. Primary postpartum haemorrhage was defined as the estimated blood loss recorded by the staff greater or equal to 500 ml for vaginal births and 1000 ml for caesarean section births, or the medical doctor diagnosis and recording of the woman as having primary postpartum haemorrhage. The data analysis was undertaken using Stata version 15. Variables with P ≤ 0.10 for significance were selected to run multivariable logistic analyses. Variables that had associations with primary postpartum haemorrhage were identified based on the odds ratio, with 95% confidence interval (CI) and P-value less than 0.05.

RESULTS

The incidence of primary postpartum haemorrhage in the hospitals was 8.8% (95% CI: 7.2, 10.6). Of these, there were 7.4% (95% CI: 2.1, 13.3) maternal deaths. Eight predictor variables were found to be independently associated with primary postpartum haemorrhage, including age ≥35 years (AOR: 2.20; 95% CI: 1.08, 4.46; P = 0.03), longer than 24 hours duration of labour (AOR: 7.18; 95% CI: 2.73, 18.90; P = 0.01), vaginal or cervical lacerations (AOR: 4.95; 95% CI: 2.49, 9.86; P = 0.01), instrumental (forceps or vacuum)-assisted birth (AOR: 2.92; 95% CI: 1.25, 6.81; P = 0.01), retained placenta (AOR: 21.83; 95% CI: 6.33, 75.20; P = 0.01), antepartum haemorrhage in recent pregnancy (AOR: 6.90; 95% CI: 3.43, 13. 84; p = 0.01), women in labour referred from primary health centres (AOR: 2.48; 95% CI: 1.39, 4.42; P = 0.02), and births managed by medical interns (AOR: 2.90; 95% CI: 1.55, 5.37; P = 0.01).

CONCLUSION

We found that while the incidence of primary postpartum haemorrhage appeared to be lower than in other studies in Africa the associated maternal mortality was higher. Although most factors associated with primary postpartum haemorrhage were consistent with those identified in the literature, two additional specific factors, were found to be prevalent among women in Ethiopia; the factors were referred women in labour from primary health facilities and births managed by medical interns. Maternal healthcare providers in these hospitals require training on the management of a birthing emergency.

Implementation and evaluation of obstetric early warning systems in tertiary care hospitals in Nigeria

Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers about the implementation of an obstetric EWS and assess its effectiveness as an alternative clinical monitoring method compared to standard practice. This mixed-method study included obstetric admissions (n = 2400) to inpatient wards between 01/08/2018 and 31/03/2019 at three Nigerian tertiary hospitals (1 intervention and two control). Outcomes assessed were the efficiency of monitoring and recording vital signs using the patient monitoring index and speed of post-EWS trigger specialist review. These were evaluated through a review of case notes before and four months after EWS was introduced. Qualitative data was collected to explore healthcare workers' views on EWS' acceptability and usability. EWS was correctly used in 51% (n = 307) of the women in the intervention site. Of these women, 58.6% (n = 180) were predicted to have an increased risk of deterioration, and 38.9% (n = 70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. Health workers reported that the EWS helped them cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use and that scores consistently correlated with the clinical picture of patients. Identified challenges included rotation of clinical staff, low staffing numbers and reduced availability of monitoring equipment. The implementation of EWS improved the frequency of patient monitoring, but a larger study will be required to explore the effect on health outcomes. The EWS is a feasible and acceptable tool in low-resource settings with implementation modifications. Trial registration: ISRCTN, ISRCTN15568048. Registration date; 9/09/2020- Retrospectively registered, http://www.isrctn.com/ISRCTN15568048.

Effect of Intelligent Vital Sign Monitoring System on Postoperative Nursing Care of Severe Patients

In order to study the observation of postoperative vital sign data of critically ill patients, this paper developed a set of vital sign data acquisition system based on intelligence and realized the design of vital sign data acquisition system APP based on Android Studio programming software, which was used to realize the information collection of vital sign data of patients. PDA is connected with a vital sign measuring equipment through Bluetooth. The patient's wristband is scanned with PDA to read the patient's information, and then the measured vital sign data are obtained automatically by measuring APP. The initial alarm value is set to be greater than 1%, and it needs more than 60 and less than or equal to 120 RR interval data to judge apnea. Information collection of intelligent vital sign detection can not only save the time of nursing staff but also improve the nursing quality.

Wavelet Transform Artificial Intelligence Algorithm-Based Data Mining Technology for Norovirus Monitoring and Early Warning

Norovirus monitoring and early warning can be used for diagnosis without etiological testing, and the treatment of this disease does not require the antibiotics. It often occurs in preschool children and affects their growth and development, so the coping measures for this disease are more prevention than treatment. In this study, the clinical data of 2133 children with diarrhea were collected. Based on the artificial intelligence (AI) algorithm of wavelet transform, a related model for data mining and processing of children's intestinal ultrasound images and stool specimens was constructed. Then, the norovirus infection trend was warned based on the wavelet analysis algorithm model. The results showed that the intestinal ultrasound image processed by the wavelet transform algorithm was clearer. The positive detection rate of norovirus in children with clinical diarrhea was as high as 59%, and the children had different degrees of body damage, of which the probability of compensatory metabolic acidosis was the highest. The epidemiological analysis found that children with norovirus infection were mainly concentrated in the age group under 2 years old and over 5 years old and showed a peak of infection in December. In summary, the intelligent algorithm based on wavelet transform can realize the noise reduction of intestinal ultrasound, and it should protect children with susceptible age and susceptible seasons to reduce the clinical infection rate of norovirus.

Early warning systems in maternity care: protocol for a qualitative evidence synthesis of maternity care providers' views and experiences

Background: Early warning systems (EWS) have been widely adopted for use in maternity settings internationally. The idea in using these systems is early recognition of potential or actual clinical deterioration in pregnant or postpartum women, and escalation of care. Barriers to successful implementation and use of EWS, however, have been identified. If EWS are to be applied consistently, a greater understanding of the views and experiences of EWS from the perspectives of those using and applying EWS in maternity practice is needed. This protocol describes a qualitative evidence synthesis of maternity care providers' (midwives, obstetricians, and allied maternity care professionals) views and experiences of EWS use and application in practice. Methods: Studies will be included in the review if they report on maternity care providers use and application of EWS in any birth setting. Qualitative studies and studies of mixed methods design, where qualitative data can be extracted separately, will be included. To source relevant literature the electronic databases of MEDLINE, CINHAL, Web of Science Core Collection (incorporating Social Science Citation Index) and Maternity and Infant Care (MIDIRS), from date of inception, will be searched. The methodological quality of the included studies will be appraised using the 12-criteria of the assessment tool developed by the Evidence for Policy and Practice Information and Co-ordinating Centre. Thematic synthesis will be used for synthesising the qualitative data from included studies. The confidence in the findings will be assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research. Conclusions: The findings of this qualitative evidence synthesis may provide valuable information on the barriers, challenges, and facilitators for EWS use based on the experiences of those directly involved in EWS application in maternity care provision. PROSPERO registration: CRD42021235137 (08/04/2021).

Why are women still dying from obstetric hemorrhage? A narrative review of perspectives from high and low resource settings

The possibility of hemorrhage will always co-exist with pregnancy, whether anticipated or not. It remains the unwelcome guest in the corner of every delivery room, stealing the lives of young women every day across the globe. In 2014, the World Health Organization reported that hemorrhage was the leading contributor to maternal mortality worldwide, with nearly 75% of maternal deaths due to postpartum hemorrhage. In low resource settings, while maternal mortality is decreasing, hemorrhage remains the single most important contributor to maternal death. Hospital-based deliveries with skilled birth attendants have been encouraged to improve outcomes and, as a result, hospital births have dramatically increased. However, access to higher levels of emergency obstetric care as well as blood products and therapeutic resources remain limiting factors. Meanwhile, in high resource settings, maternal mortality from hemorrhage is increasing, particularly among women of color. While very rare, mortality from hemorrhage generally follows medical interventions such as surgical management of placenta accreta or emergency cesarean section. Primary prevention therefore requires careful selection and conduct of medical interventions, as well as the provision of high quality, supportive, and safe maternity care. It is clear that there is not one single solution in preventing obstetric hemorrhage on a global scale. The international community must employ creative solutions to reduce this ever-present problem.

Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: results of a mixed-methods study at a national referral hospital in Kenya

INTRODUCTION

Fifteen million babies are born prematurely, before 37 weeks gestational age, globally. More than 80% of these are in sub-Saharan Africa and Asia. 35% of all deaths in the first month of life are due to prematurity and the neonatal mortality rate is eight times higher in low-income and middle-income countries (LMICs) than in Europe. Early Warning Scores (EWS) are a way of recording vital signs using standardised charts to easily identify adverse clinical signs and escalate care appropriately. A range of EWS have been developed for neonates, though none in LMICs. This paper reports the findings of early work to examine if the use of EWS is feasible in LMICs.

METHODS

We conducted an observational study to understand current practices for monitoring of preterm infants at a large national referral hospital in Nairobi, Kenya. Using hospital records, data were collected over an 8-week period in 2019 on all live born infants born at <37 weeks and/or <2500 g (n=294, 255 mothers) in the first week of life. Using a chart adopted from the EWS developed by the British Association of Perinatal Medicine, we plotted infants' vital signs. In addition, we held group discussions with stakeholders in Kenya to examine opinions on use of EWS.

RESULTS

Recording of vital signs was variable; only 63% of infants had at least one temperature recorded and 53% had at least one heart rate and respiratory rate recorded. Stakeholders liked the traffic-light system and simplicity of the chart, though recognised challenges, such as staffing levels and ability to print in colour, to its adoption.

CONCLUSION

EWS may standardise documentation and identify infants who are at higher risk of an adverse outcome. However, human and non-human resource issues would need to be explored further before development of an EWS for LMICs.