Implementation and Evaluation of an Electronic Maternal Early Warning Trigger Tool to Reduce Maternal Morbidity

Abstract

Objective We compare maternal morbidity and clinical care metrics before and after the electronic implementation of a maternal early warning trigger (MEWT) tool. Study Design This is a study of maternal morbidity and clinical care within three linked hospitals comparing 1 year before and after electronic MEWT implementation. We compare severe maternal morbidity overall as well as within the subcategories of hemorrhage, hypertension, cardiopulmonary, and sepsis in addition to relevant process metrics in each category. We describe the MEWT trigger rate in addition to MEWT sensitivity and specificity for morbidity overall and by morbidity type. Results The morbidity rate ratio increased from 1.6 per 100 deliveries in the pre-MEWT period to 2.06 per 100 deliveries in the post-MEWT period (incidence rate ratio = 1.28, p = 0.018); however, in cases of septic morbidity, time to appropriate antibiotics decreased (pre-MEWT: 1.87 hours [1.11–2.63] vs. post-MEWT: 0.75 hours [0.31–1.19], p = 0.036) and in cases of hypertensive morbidity, the proportion of cases treated with appropriate antihypertensive medication within 60 minutes improved (pre-MEWT: 62% vs. post-MEWT: 83%, p = 0.040). The MEWT trigger rate was 2.3%, ranging from 0.8% in the less acute centers to 2.9% in our tertiary center. The MEWT sensitivity for morbidity overall was 50%; detection of hemorrhage morbidity was lowest (30%); however, it ranged between 69% for septic morbidity, 74% for cardiopulmonary morbidity, and 82% for cases of hypertensive morbidity. Conclusion Overall, maternal morbidity did not decrease after implementation of the MEWT system; however, important clinical metrics such as time to antibiotics and antihypertensive care improved. We suspect increased morbidity was related to annual variation and unexpected lower morbidity in the pre-MEWT comparison year. Because MEWT sensitivity for hemorrhage was low, and because hemorrhage dominates administrative metrics of morbidity, process metrics around sepsis, hypertension, and cardiopulmonary morbidity are important to track as markers of MEWT efficacy. Key Points

Comparison of the efficacy for early warning systems in predicting obstetric critical illness

“…This is a retrospective study of obstetric women admitted to ICU, we compared the accuracy of four obstetrical scoring early warning systems (MOEWS, ICNARC OEWS, MEOWS Chart and MEWT) for identi cation of women at risk. It was demonstrated that the most common indications for admission to obstetric ICU in this study were hypertensive disorders, cardiovascular disease, obstetric hemorrhage and suspected infection, which is consistent with previous studies [12,18]. Women with hypertensive and hemorrhage have a higher risk of developing critical illness.…”

“…Hence, they established MEWT in 2016, which removed pain indicators, but increased mean arterial pressure MAP and fetal heart. Relevant studies showed that MEWT had a lower clinical false trigger and better clinical relevance, but the sensitivity is low and it is possible to miss some potentially high-risk patients [10,12]. In 2013, Carle et al collaborated with the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Project established obstetric early warning score (ICNARC OEWS) [13].…”

Analysis of clinical application effects and challenges of early warning system for the high‐risk obstetric women of China: A scoping review

“…At present, the commonly used early warning systems for high‐risk pregnant women include EWS, MEWS, MEWC, MEWT, MEOWS and OEWS (Blumenthal et al, 2021; Edwards et al, 2020; Klumpner et al, 2020; Smith et al, 2021). Some studies have also applied APACHE II (Paternina‐Caicedo et al, 2013) and SOFA (Vincent et al, 1998) to the early warning of severe obstetric patients, but APACHE II has some limitations in the assessment of critically ill pregnant women, and it may overpredict maternal mortality.…”

A new modified obstetric early warning score for prognostication of severe maternal morbidity

“…At present, multiple modified obstetric early warning scores (EWS) are widely used for early identification of critically ill women with obstetric complications. The Modified Early Obstetric Warning Score (MEOWS) [ 5 , 11 , 12 ], Maternal Early Recognition Criteria (MERC) [ 13 , 14 ], Modified Early Warning System (MEWS) [ 2 , 15 ], Maternal Early Warning Trigger (MEWT) [ 16 , 17 ], Maternal Early Obstetric Warning System (MEOWS chart) [ 18 , 19 ], Irish Maternity Early Warning System (IMEWS) [ 20 , 21 ] and ICNARC Obstetric Early Warning Score (OEWS) [ 7 , 22 ] are the most common. In 2020, ICNARC OEWS was first compared with the APACHE II score in India [ 22 ].…”