The Issue of Failure to Rescue in Maternity

More than 50% of maternal deaths are potentially preventable. (Nair et al., 2019) This assignment is going to look at the issue of Failure to Rescue in Maternity, namely failure to prevent deterioration in women. I will talk about the tragic case of Savita Halappanavar, and the key factors that resulted in her avoidable death. I will then proceed to discuss the investigation of this death, and the strategies put in place to avoid failure to rescue cases in the future, using the Irish Maternity Early Warning Score (IMEWS). I will discuss its development, its use and its success.

I will now discuss the case of Savita Halappanavar, how the signs of her deterioration were missed, and what followed this tragic death. Savita presented to University Hospital Galway at 17 weeks pregnant, she was presenting with an incomplete miscarriage and was denied her request for an abortion on the grounds that her request would be illegal under Irish law at the time. Savita was inadequately monitored and assessed and developed Septicaemia and died as a result of this. The death was proceeded both by investigations by the HSE and by an independent investigation report. The Arulkumaran report found that Savita’s death had three Key factors, inadequate assessment and monitoring; failure to offer all management options to a patient; and non-adherence to clinical guidelines related to the prompt and effective management of sepsis. As a result of Savita’s death, the HSE recommended introduction of an appropriate Early Warning systems chart. (HSE, 2013)

Failure to rescue refers a failure to prevent a clinically important deterioration resulting from a complication of an underlying illness, or a complication of medical care. In 2004 the IHI along with the joint commission, identified FTR as the number 1 contributor to hospital deaths. The 3 top factors in failure to rescue are failure to recognize early signs of deterioration; failure to assess/plan ; and failure to communicate. ( Pateint safety notes)

As a result of Savitas death, it was recommended that an Early Warning System (EWS) be implemented in Maternity hospitals. An EWS tracks the physiological vital signs of a patient and triggers a response or score when the threshold has been reached, and the patient is in danger of deteriorating.(Nair et al., 2019) However IMEWS was developed specifically for pregnant woman and for women up to 42 days after the birth, as during this time the woman’s physiological vital signs differ to a regular patient. So the idea was to create a similar system that aligned with the physiological changes in pregnancy and helped to detect critical illness and improve outcomes with early intervention. (Department of Health, 2019)

IMEWS was developed by a multidisciplinary team lead by Ina Crowley. (Department of Health 2019) Drafts were submitted, and feedback was received nationwide from many different healthcare professionals. A national training programme was then introduced to implement the system. IMEWS was formally introduced nationally in 2013. From the beginning, it was decided to call it a system rather than a score encouraging it as a tool in clinical judgement not to replace it. The system easily identifies a woman’s vital signs and any deteriorations can be easily spotted and monitored or treated. It not only highlights a woman’s vital signs deteriorating, but It will also trigger the user and advise on clinical escalation.(Maguire et al., 2014) IMEWS aims to be a safe, timely, standardised and appropriate hospital monitoring system.(Department of Health, 2019)

IMEWS monitors the vital signs of a pregnant and postpartum woman, including heart rate, respiratory rate, blood pressure, temperature, oxygen saturation, urinalysis, pain and level of alertness and is shown to be beneficial in the early recognition and prompt treatment of ill women. It not only is used in maternity setting, but used whenever a pregnant woman presents to a general hospital. IMEWS is used as a baseline on vital signs on admission. The subsequent observations should all be recorded on the same report. The minimum frequency for observations is 12 hours. IMEWS should not be used in labour, these vital signs are recorded on a partogram. The IMEWS can be hugely beneficial in a postnatal ward, where observations are less often, there is less staff and generally more relaxed than on the delivery ward, where vital signs would be checked frequently, and usually the woman has continuous care. (Maguire et al., 2014)

Clinical staff in both maternity and general hospitals should receive education and training in IMEWS. Audits should be collected and reviewed regularly to review implementation and effectiveness of IMEWS. (Department of Health, 2019)

The studies done on the effectiveness of IMEWS have all been positive. The largest Irish study of the IMEWS, was a retrospective study to see if IMEWS had of been applied in cases of maternal infection, and the outcome was it improved the recording of patient observations in particular respiratory rate.(Maguire et al., 2015)

Another retrospective study in Columbia found that obstetric early warning systems obtained was directly related to the survival prediction percentage, and the use of these scores are highly useful in identifying woman at an increased risk of dying.(Paternina-Caicedo et al., 2017)