Background
Introduction
In the UK, midwives will engage in discussions with the multidisciplinary team as to whether they can provide OHDC on the Delivery Suite or a woman requires her care to be escalated [12]. Escalation of care is defined by Posner and Freund (2004: p 438) as “Any significant unplanned increase in the level of care provided to the patient and includes such outcomes as unplanned intensive care unit admission” [13]. This focus group study examined the factors that influence midwives working in OUs remote from tertiary referral centres to provide OHDC or request a woman’s care be escalated away from the OU. Tertiary referral centres are those OUs classed as regional or national centres of excellence, providing specialist care for women with for example, complex comorbidities, and this sets them aside from District General hospitals in the UK [14].“an interim level of care for women requiring interventions over and above the [specialised] ‘high risk’ obstetric care that will be carried out routinely on a consultant led labour ward … It will be implemented where a woman has deteriorated clinically but her care can be managed appropriately on the labour ward” [10].
Indications for OHDC
Identifying women who require OHDC
Obstetric high dependency care provision
Midwives and OHDC
Summary
What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres?
Methods
Study design and setting
Obstetric Unit | Range of births per annum | Neonatal care facilitiesa | Number of delivery beds | Number of OHDC rooms |
---|---|---|---|---|
H | 1500–1900 | Special Care Unit (SCU) | 5 | 0 |
I | 4000–4500 | Local Neonatal Unit (LNU) | 9 | 0, but OHDC equipment available and taken to the bedside |
J | Approximately 5000 | Neonatal Intensive Care (NICU) | 10 | 1 |
Recruitment and sample selection
Development of video vignettes
Scenario 1 | Scenario 2 | Scenario 3 | |
---|---|---|---|
Clinical Picture | Postnatal mother with severe pre eclampsia at 30/40 gestation. Vaginal birth 90 min previously. Neonate transferred to neonatal unit | Postnatal mother who has recently had a primary PPH. On-going management in progress after the initial emergency treatment. Neonate with mother. | Woman 32/40 pregnant with comorbidities (type 2 diabetes and ventricular septal defect repaired in infancy). Raised BMI. Admitted with mild chest pain and low oxygen saturations (88–90%) in air. |
Intravenous magnesium sulphate / intravenous anti- hypertensives in progress | Blood transfusion in progress. | Continuous ECG in progress | |
Uncontrolled hypertension | CVP line in situ due to poor peripheral access | Requiring 4 L/min oxygen, via face mask to maintain oxygen saturations at 97% | |
Hyperreflexia, 4 beats of clonus | Hourly CVP readings requested to guide fluid replacement | Stable vital signs whilst patient has oxygen therapy in progress, (but at risk of deterioration) | |
Headache | Stable pulse and blood pressure. Lochia within normal limits. | Normal CTG, normal fetal movements. | |
Blood picture shows HELLP syndrome | Reduced urine output | Differential diagnosis of cardiac event or pulmonary embolism | |
Overall, presents with an unstable clinical picture in view of uncontrolled severe hypertension, blood picture and neurological examination findings. | Overall, relatively stable condition, but requiring CVP monitoring. | Currently stable with oxygen therapy in progress but potential for deterioration | |
Workload | Moderate. All women on the Delivery Suite are in labour – mainly low risk. | High. All but one of the Delivery Suite rooms are occupied however, anticipated that three women will be transferred home / to the post natal ward in the next hour. | Low to moderate. There are empty rooms, mainly low risk women in labour. |
Staffing | Correct number and grades of midwives on duty for the maternity unit in question | All band 6 midwives with one band 7 midwife coordinating. One band 6 midwife off sick. | All band 6 midwives (except one newly qualified midwife) on duty with one band 7 midwife coordinating. No staff off sick. |
Data collection
Data analyses
Ethical considerations
Results
The environment
By contrast, Unit J had a fully equipped, designated high dependency care room on the Delivery Suite with the requisite equipment for midwives to undertake continuous ECG and invasive monitoring. Unit I had a number of large rooms on the Delivery Suite where women could receive OHDC because ‘emergency’ and ‘high dependency’ trolleys carrying the relevant equipment were taken direct to the bedside.P1: “If they want all that high-tech stuff, we’re not geared up for it here”.(Unit H / FG / Band 6 / S3)
Unit I was ‘linked’ to the main general hospital by a series of long corridors, but was a significant distance away from the ICU / general HDU and some midwives identified that the physiological instability of a woman might outweigh the need for her care to be escalated;P1: “Yeah location wise geography wise here, we’re in an entirely separate entity from the main hospital so that to me, when I’m making decisions makes a difference because you’ve gotta think about a time scale, if you’re asking for help how long its gonna to take to get them there you know and if you want emergency help.” (FG / Unit H / Band 7 / S1)
P2: ‘I’d keep her on Delivery Suite, yeah … ..P1: Yeah, it would be … . she's too poorly to be transferred … .P3: “She is, and you wouldn't want to transfer her that ill”.(FG/ Unit I / Band 7/ S1)
Maternal factors
By contrast, Scenario 3 prompted the midwives from all of the OUs to consider the differential diagnoses for the woman, with many of midwives identifying they required a definitive diagnosis in order to determine whether escalation was required or whether care could continue on the Delivery Suite.Scenario one: What would you do in terms of care escalation? Keep on HDU - 1 midwife. Continue monitoring. As IV [intravenous] MgSO4 [magnesium sulphate] and labetalol, obs [ervations] graduating to at least hourly. 1 hourly reflexes. 6 hourly bloods. Reg [istrar] reviews / consultant as needed.Why? Obstetric care that we deal with regularly. (Unit J / ID / P4 / S1)
The midwives identified they were less familiar caring for women with cardiac conditions and there was general agreement during the focus groups that when a woman with a comorbidity had an otherwise uncomplicated pregnancy she should be transferred away from the OU to an appropriate specialist area.P1: “I mean they usually do a VQ [ventilation perfusion] scan don’t they, that would be fine as far as we are concerned, they go from (name of ward) for a VQ scan and things like that but it’s just that, get a diagnosis first and then decide”. (Unit J / FG / Band 6 /S3)
In conjunction with the objective parameters used to predict a woman’s potential for physiological deterioration some midwives made ‘intuitive’ assessments about a woman’s risk of deteriorating, often using colloquialisms.“Concerns EBL [estimated blood loss] 3000mls, difficult peripheral cannulation, urine output 20mls/ hour. Unstable blood picture. Very high risk, plus high risk of further PPH. DIC. HDU / ICU” (Unit I / ID / Band 6 / S2 / P2)
P1 : "Yeah – she could have cardiomyopathy.P2 : She’s a hot potato. She could explode at any time. P3: Because we haven't got a diagnosis, have we?P1: No … ..P2 : And therein lies the problem … .P3 : “Yeah, she could do anything”.(Unit I / FG/ Band 7/ S3)
What would you do in terms of care escalation? ..... High risk care not for us. Over 1.5 litres MOHP [Major Obstetric Haemorrhage protocol] Why? Very high risk. (Unit H / ID / Band 6 / S2 / P3)
Fetal / neonatal considerations
However, the midwives of Units I and J also discussed how women with comorbidities sometimes remained on the Delivery Suite ‘by default’ because other specialist areas were reluctant to provide care for pregnant women. They described how pregnancy effectively became a barrier to care escalation.P7: “Despite being pregnant she’s not an obstetric case, we’re not concerned about her from an obstetric point of view”. (Unit J /FG /Band 7/ S3)
P3: “ … .She’s got this differential diagnosis of PE or … (pause), but she would have come to us because this happens a lot … as soon as they’ve got that pregnancy they want us to have them”. (FG /Unit J / Band 6 / S3)
The midwives appeared to have a lower threshold for escalating a woman’s care away from the Delivery Suite if the neonate had already been separated from her.What would you do in terms of care escalation? Call critical care team for advice re care of CVP line. Ensure venflon access with team. To stay on HDU Labour Ward. Why? To enable her to be supported to stay with baby, but ensure adequate staff to provide care. (Unit J / ID / Band 7 / S2 / P6)
P1 : “I think if she’s not got a baby with her, that would be one of the reasons why I would be less inclined to keep her on labour ward because I think to myself well, go let her get well, and then come back and worry about the baby side of things.”P4 : “Because if you’ve got a term baby or a baby with her you tend to be trying to keep them together don’t you”. (Unit H / FG Band 7 / S1)
Plan of care
The midwives of Unit H, the smallest OU, were united in their decisions to swiftly escalate the care of the woman in Scenario 2. These midwives proactively involved the bed manager, CCOT and ICU staff early on in the scenario and stressed they did not provide care for women with CVP lines. They did not possess the requisite skills (or equipment), and acted in accordance with a local clinical guideline.P6: “She is quite stable, I would probably keep her on HDU on labour ward, but there are a few things I would need to consider … It would have to be a midwife that could do CVP lines, not all our midwives do, umm, however we do work closely with the theatre team and there may be an ODP [Operating Department Practitioner] that can assist us with that.” (Unit J / FG / Band 7 / S2)
The Band 7 midwives from Unit I spoke about ensuring a midwife ‘experienced’ in managing a CVP line was allocated to care for the woman. They did not elaborate on how they classed a midwife as being ‘experienced’ but acknowledged that they did not encounter women with CVP lines regularly. Enlisting support from the anaesthetist was seen as a strategy for ensuring the midwife allocated to care for the woman was ‘comfortable’ with the CVP line. Moreover, some midwives stated they would provide OHDC if another professional took responsibility for managing the CVP line aspect of care. Midwives stressed that despite once being competent to care for women needing invasive monitoring, they could not keep up to date, as they did not encounter women requiring invasive monitoring on a regular basis.P1: "The minute you said CVP (CVP said in unison by all midwives with some laughter), the lady needs to go!P6: Yeah, we don’t keep her on labour ward.Participants: Yeah." (All agreeing together with some laughter)(Unit H / FG / Band 7 / S2)
The decision as to whether the woman in Scenario 3 stayed on the labour ward or her care be escalated varied, with some midwives electing to provide OHDC, whilst others identified that transfer to a medical ward or Coronary Care Unit (CCU) was more appropriate. Some of the Band 6 midwives looked to the Critical Care Outreach Team for support.P4: " … they also want a continuous ECG, which none of us interpret, we don’t do ECGs …P1: We don’t, we can’t tell when it’s abnormal … ..P2: But we would often have somebody particularly on the [name of ward] ward, we've had people who've had ECGs … ..P1: Yeah, but not continuously … ..P5: If it went beep or something, we'd know it was doing something (laughter) … .. P5: Again outreach would need to be contacted and come and assess."(Unit H / FG/ Band 7 / S3)
P8: " … .but it’s not our speciality to read an ECG … ..P5: But the registrar and the anaesthetist would be coming in to view it. As long as you know what normal is then as soon as you get something strange you get someone to come and review it don’t you." (Unit J / FG/ Band 7 / S3)
The midwives from Units J and I made recommendations for the investigations the women in the three scenarios required. Midwives requested specific investigations to enable them to assess (in conjunction with the MEOWS scoring) whether a woman’s condition was improving or deteriorating. These investigations informed their decisions as to whether they could provide OHDC or needed to escalate care.P2: "But I agree the scenario is pointing to a PE because she's at a higher risk and I would be happy to keep her as long as they're not relying on me to read that ECG.P3: I don’t think they would … .P2: No … … .P3: I'd expect someone to be in there reviewing it frequently." (Unit I / FG / Band 6 / S3)
The midwives assessed the interventions the women in the three scenarios had received, were receiving and those they might require prospectively, in order to promote physiological stability and avoid escalation of care. During Scenario 1, the midwives discussed the need to increase the woman’s intravenous antihypertensive dose, whilst some considered the need for the addition of a second antihypertensive. They discussed the importance of continuing the magnesium sulphate infusion and ensuring strict fluid restrictions were in place. These measures focused on preventing further physiological deterioration and morbidity / mortality associated with uncontrolled hypertension and fluid overload, thereby negating the need to escalate care away from the Delivery Suite.P2: "And do those bloods again to see if that trend is still … ..P1: Yeah we know that those platelets could be plummeting or coming back up … …P3: Get the next lot of bloods really and review, cause if the platelets go lower we’re in trouble". (Unit J / FG / Band 6 / S1)
Scenario 2 prompted less discussion about prospective treatments from the Band 6 midwives of Unit J and the Band 6 and 7 midwives of Unit H, where the emphasis centred on the issue of the woman having a CVP line in situ and the need for escalation away from the Delivery Suite. In contrast, the midwives of Unit I and the Band 7 midwives of Unit J discussed the need for administration of additional blood products and uterotonics, including tranexamic acid and misoprostol to promote stability and negate escalation. The insertion of a Bakri Balloon to treat / prevent further uterine atony was also suggested.P2: “I'm gonna make sure that lady has one to one care, so her midwife is not needed elsewhere and she hasn’t responded as yet to the Labetalol, her blood pressure is still the same so we could look at what other antihypertensive she could have but you've got to be cautious in case it [BP] crashes.”P3: But equally we know that that there is an increased risk of intracranial haemorrhage if you don’t get their blood pressure down particularly if she’s complaining about a frontal headache. (FG / Unit H /Band 7 /S1)
P3: “The intensivists, that’s in the escalation policy now. If they’ve had an abnormal blood picture they would be speaking with them just to give them the heads up so that they know the blood picture is abnormal. So if she does then require to go over [to ICU], one of our criteria is severe HELLP or she needs a CVP line or art line monitoring, we can’t keep her on the labour ward with those kind of things”. (Unit J / FG /Band 6 /S1)
Staffing levels, skill mix and workload
Skill mix in the context of midwives providing OHDC appeared to be synonymous with those classed as experienced, senior or competent. Midwives who had undertaken registered nurse training were viewed positively with regards OHDC provision, although it was acknowledged that a nurse qualification did not take the place of ongoing OHDC education and training.P6: “Staffing, because I notice the staffing and the ward is very busy, so I would need to risk assess because obviously, she needs one to one care. It would have to be a midwife that could do CVP lines, not all our midwives do … .I would also be looking at do I need to get more staff to help cover labour ward because I have to look at the risks on the labour ward with such a sick patient around … .” (Unit J / FG / Band 7 / S2)
The Band 7 midwives of Unit J suggested that skill mix was at times, more important than adequate staffing levels, when women required OHDC.P4: “A good thing to have is a nurse who’s then become a midwife, and that’s a good background for caring for somebody who is this ill, but only in as much as you want HDU training for your midwives because that’s what we’ve not got, because I don’t have that. It takes all my efforts to become a bit nursey again and work out the nursing side of it, I could do the midwifery side of it until it gets very very abnormal”. (Unit I / FG/ Band 6 / S1)
The lack of (and need for) adequate training to enable midwives to provide OHDC was raised by some of the focus group participants who expressed concerns that the differing abilities of the midwives to provide care for sick women, had the potential to lead to inequalities in care provision.P3: “I know we always talk about staffing and things but I do feel it’s more skills than numbers, we have lots of conversations about this don’t we? You could have ten midwives on duty but no one able to look after this sick lady. Whereas you could have five midwives on duty and any one of them could look after this kind of patient, so I think it is definitely about skills and abilities as well as numbers.” (Unit J / FG /Band 7 /S2)
Workload also had an impact on the midwives’ EoC decisions. High activity levels and reduced staffing on the Delivery Suite were considered as triggers for escalation. Some midwives stated they would instigate the staffing escalation guideline so that OHDC could be provided.P3: “It’s not fair on the women to have inequality of care because somebody might have HDU and critical care skills and be quite happy to do it but the next person isn’t, so you’ve got to have some kind of policy to escalate the women’s care so that they’ve got equality of care in the appropriate place”.(FG/ Unit I / Band 6 / S1)
Multidisciplinary team working and support
P3: So any woman who is critically ill (long pause) then somebody like this needs to be physically reviewed by the coordinator. It's no good having the story at the board. You need to go in and see them.P1: Yeah, definitely.P2: Because your experience and instinct will tell you just how well or how unwell she is. (Unit I /FG/ Band 7 /S3)
The Band 7 midwives from Unit I recognised the contribution made by the nurses who were sometimes allocated to provide OHDC. The Band 6 midwives seemed less positive about the nurses’ involvement.P7: “Recently I got theatre, because we were busy on labour ward and the midwife didn’t know how to use the CVP line and the theatre staff came across and ran thorough it with her, and next time they watched her do it and she was absolutely fine”. (Unit J /FG/ Band 7 /S3)
The Band 6 midwives were also concerned they might become deskilled in OHDC provision because increasingly the nurses were allocated to provide this care.P2: “It’s not appropriate that they should be caring for them [Women needing OHDC] because they’ve got no midwifery training, they don’t know the significance, ‘because I’ll just walk in the room and know because with experience, well they haven’t got that, have they?” (FG/Unit I/ Band 6 S1)
The midwives from Unit I appeared to liaise with the consultant anaesthetist as the first line of support more frequently than the CCOT, whilst in Unit H, the midwives looked to the CCOT to provide clinical support, liaise with other professionals and organise transfers from the OU to the ICU or general HDU. The midwives from Unit H were very clear as to who they contacted for OHDC support and when. They worked to a clinical guideline and did not deviate. The focus groups held with the midwives of Units I and J suggested that local variations between midwives working on the same Delivery Suite were sometimes apparent, with different midwives seeking different support mechanisms.P2: If she started to deteriorate any more, if she needed more oxygen and her respiratory rate was going up and you had all the other signs … ..P9: That’s were your outreach comes in … ..P5: and we have called outreach before and they can get them a bed really quickly on ICU. (FG / Unit J / Band 7 / S3)