EXECUTIVE SUMMARY

Hospitals can establish programs to educate staff on how to recognize and manage maternal compromise as part of a plan to reduce maternal illness and death.

  • Designating roles is a key element of any maternal health program.
  • Hospital case managers and others need to assess pregnant patients’ health concerns.
  • Nurses and case managers must communicate health problems to providers and work with providers at the bedside to develop a plan of care.

The key to setting up a program for recognizing and managing maternal compromise is to create a team and train staff on how to recognize early warning signs.

“We know that when people learn together, they work better together,” says Suzanne McMurtry Baird, DNP, RN, co-owner and nursing director of Clinical Concepts in Obstetrics in Brentwood, TN.

One of the key issues that comes up when hospital staff debrief after an obstetric emergency is role designation, she notes.

“The majority of teams we work with have absolutely no role designation,” Baird says. “When there’s an obstetric emergency, everyone needs to know what their role is and that they’ve been trained for that role.”

Staff should know their roles, what medications to provide, how to communicate, and who the team leader is.

“You should have a designated leader that was predetermined, and so you know there is one provider leading the team during the obstetric emergency,” Baird says. “You want to be able to work as efficiently as possible and have systems and processes in the hospital that are as efficient as possible.”

Hospitals can achieve this efficiency with team training.

“It’s similar to airlines, where pilots and flight attendants and everyone are training for these emergencies and know what to do if a problem occurs,” she says. “We haven’t done that [training] as well in healthcare yet.”

A first step in training might include teaching frontline staff how to recognize warning signs when a pregnant woman is in medical distress. Baird offers these suggestions for how to recognize and react to early maternal compromise:

• Assessment. Follow the nursing process of conducting a full nursing assessment, based on the patient’s complaint and scenario, Baird says.

• Recognition. “Recognize any assessment parameters outside the normal,” she says.

These might include the following:

- A high heart rate;

- Respiratory rate over 24;

- Shortness of breath;

- High blood pressure;

- Low blood pressure.

“One of the things I teach is vital signs are vital,” Baird says. “These work. These assessment parameters are defined ahead of time and it forces not just recognition, but management.”

Nurses and case managers can use recommendations by the Alliance for Innovation in Maternal Health (AIM) in the AIM bundle and provide staff training with the AIM eModules. (More information is available at: http://bit.ly/2YF6LKk.)

For instance, AIM provides free access to 10 patient safety bundles, including prevention of maternal venous thromboembolism. The bundle uses evidence-based recommendations under readiness, recognition and prevention, response, and reporting/systems learned.

One sample response item is to “use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia.” (Available online at: http://bit.ly/30BFv10.)

• Communication. Case managers and nurses must communicate their assessments and observations to providers and convince them to visit the patient at bedside. This part is crucial, she notes.

“That’s a real key piece that has been missing in the care of these patients,” Baird says. “Often times, nurses will recognize abnormal assessments and communicate them, and there might not be a provider that comes to the bedside for further assessment.”

When providers visit the patients’ bedside, there is greater potential for interprofessional critical thinking about the cause of an abnormal assessment, Baird says.

“For example, let’s say the mom has pre-eclampsia and her urine output drops,” Baird says. “The nurse notes that and communicates it to the provider, who then comes to the bedside and does an assessment with the nurse.”

Then, they discuss reasons why the urine output has dropped for this patient: First, the patient could have low intravascular volume status that decreases renal profusion; secondly, she could have problems with blood flow to the kidneys; thirdly, the patient could have increased vascular resistance, which also decreases blood flow to the kidneys, she explains.

“Through your assessment, you critically think about what the cause is,” Baird says. “It’s through key assessment that you’re trying to determine what’s going on.”

But determining the cause and pinpointing the optimal treatment to include in a plan of care depend on interdisciplinary assessment and communication.

“This is a new way of thinking about how we provide care for these moms,” Baird says. “We recognize that these patients are sick, and how we manage their symptoms is really important.”

• Plan of care. Developing a plan of care is part of a continuous nursing process that includes case managers and the entire team, Baird says.

“Part of the plan might be to get the patient to the right level of care,” she says. “In the past, it was provider-ordered: notify the provider if a heart rate was larger than 120; then the nurse would notify, and they say, ‘Thank you,’ and that’s it.”

There has been a normalization of some of the abnormal components of the assessment, she notes.

“For example, I see a lot of normalization of heart rate abnormalities,” Baird says. “The heart rate is too high, and there may be some who think her heart rate is high because she’s in pain or she’s anxious about her labor and those types of things.”

But this is not true critical thinking about what is causing the high heart rate, Baird adds.

“Now, we have a heightened awareness that we need to appreciate these early warning signs of maternal compromise and do critical thinking about why they’re abnormal.”