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ED Accreditation Update
Sentinel Event Alert issued on maternal deaths ED plays important role in prevention
Specific actions spelled out for education, processes
In a new Sentinel Event Alert1, The Joint Commission focused on an issue to which ED managers are no strangers. In fact, in listing three "Suggested Actions," it focused one squarely on the ED: "Educate emergency room personnel about the possibility that a woman, whatever her presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal deaths occur before the woman is hospitalized or after she delivers and is discharged. These deaths may occur in another hospital, away from the woman's usual prenatal or obstetric care givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment."
"We want to make sure the providers that work in EDs have women of child-bearing age on their radar in terms of the potential for this event," says Pat Adamski, RN, MS, MBA, the director of the Standards Interpretation Group and the Office of Quality Monitoring for The Joint Commission. "When we think about pregnancy and having babies, it's usually a pretty positive event and many women sail through, so when problems do occur, it's something for ED staff in particular to be prepared for, as they deal with pregnant women on a regular basis, but they usually cruise through the ED on the way to labor and delivery."
Adamski says one of the goals of the alert is to raise awareness of certain complications and conditions that might cause potential for maternal deaths -- deaths that can potentially be avoided. "If you know the patient is pregnant, there are a lot of conditions EDs probably are used to seeing, but do not always consider that maternal death piece -- particularly post-delivery," she says. "A woman who comes in with certain symptoms and does not reveal she had delivered within 42 days might cause something to be missed."
Helene Connolly, MD, FACEP, chair of the Department of Emergency Medicine at Mercy Hospital and Medical Center in Chicago, says, "Our protocol is that any female of child-bearing age who presents with abdominal pain or vaginal bleeding will get a pregnancy test. As soon as they come to triage, the nurses have the authority to order the test, and they do so liberally."
In fact, one of the ED's quality indicators is that every woman with abdominal pain has to have a pregnancy test, Connolly says. "We cover it at staff meetings, posted communication, and so on, so we do have continuing education," she says.
Also, during the past 20 weeks a new procedure has been instituted. Any complaint referable to pregnancy will go to labor and delivery for a stress test and will be monitored. "In addition, since EDs have gotten more familiar with ultrasound, maternal deaths from ectopic pregnancies have just dropped to the ground," Connolly says.
Lisa Hrutkay, DO, an attending physician in the ED at Ohio Valley Medical Center in Wheeling, WV, says, "If there is abdominal pain or vaginal bleeding, the patient will get an ultrasound to rule out ectopic pregnancies."
Adamski says, "In the ED you have doctors and nurses who are well-versed in diseases and conditions and the education that follows, but if you have a pregnancy discovered late in the term, it requires specialized knowledge. Of course, it's much easier if you have an OB/GYN."
When education is provided, remember that adult students have a variety of learning preferences, she says. "People need to be addressed in a variety of ways," Adamski says. "If you have 10 learners, a third of them may learn by hearing, another percentage by doing, and so on." In other words, she says, some members of the staff might be fine with an inservice or a self-learning module, while others might prefer a "robust clinical discussion" with staff members bouncing ideas off each other. "It's really a question of what works best for the members of your group," says Adamski.
Drills and protocols
Another Joint Commission suggested action with implications for the ED reads as follows: "Identify specific triggers for responding to changes in the mother's vital signs and clinical condition and develop and use protocols and drills for responding to changes, such as hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local protocols, and to identify and fix systems problems that would prevent optimal care."
Connolly, noting that vitals are the first step in triage, says, "We are very vital sign-driven already." If the vitals are normal, they might be checked once again before discharge. If they are abnormal, the frequency of repeats depends on how abnormal they are.
"Vital signs are particularly important in a pregnant woman -- especially blood pressure, which should be lower," says Connolly. "Where a normal 24-year-old would have 120 over 80, what's normal in a woman who is not pregnant might be a hypertensive sign in pregnant women."
Her ED does not run drills for such situations, "but I'm not saying it's a bad idea," she says. "We had a patient just the other night who was pregnant and hemorrhaging and almost died. It's not a bad idea to dissect a case like that." If it became apparent that there were delays occurring in the treatment of pregnant women, "We'd look for ways to improve," she says. "If you did do a mock drill, you could come up with things that bring you down the wrong path."
Hrutkay, however, isn't certain that mock drills are necessary. "Most of the hemorrhages we have are non-emergent," she says. Usually her staff will see spotting or spontaneous miscarriages, Hrutkay says.
ED managers looking to boost their knowledge and improve protocols might look outside their department for help, Adamski suggests. "If you have an OB department or a family birthing area, they'd be able to provide a wealth of information and help your staff better understand symptoms and sets of symptoms to be able to act on quickly," she says. "If the OB department conducts drills, perhaps they would give your staff the opportunity to participate."