title: Use of Maternal Early Warning Trigger tool reduces maternal morbidity.
abstract: BACKGROUND
  Maternal mortality in the United States has increased unabated for the past 20 years. Maternal morbidity is also affecting an increasingly large number of women in the United States. A number of national and state organizations have recommend the use of maternal early warning tools as a method to combat this problem. There are limited data suggesting that the use of these types of clinical assessment tools can reduce maternal morbidity.
  
  
  OBJECTIVE
  We sought to determine if maternal morbidity could be reduced with the implementation of a clinical pathway-specific Maternal Early Warning Trigger (MEWT) tool.
  
  
  METHODS
  The tool was developed internally and prospectively implemented as a pilot project in 6 of 29 hospitals within a large hospital system. The primary goal was early assessment and treatment of patients suspected of clinical deterioration. The tool addressed the 4 most common areas of maternal morbidity: sepsis, cardiopulmonary dysfunction, preeclampsia-hypertension, and hemorrhage. To be considered positive, triggers needed to be sustained for >20 minutes and were defined as severe (single abnormal value): maternal heart rate (HR) >130 beats/min (bpm), respiratory rate >30/min, mean arterial pressure <55 mm Hg, oxygen saturation <90%, or nurse concern; or nonsevere (required 2 abnormal values): temperature >38 or <36°C, blood pressure >160/110 or <85/45 mm Hg, HR >110 or <50 bpm, respiratory rate >24 or <10/min, oxygen saturation <93%, fetal HR >160 bpm, altered mental status, or disproportionate pain. Within each group, recommended management or assessment was also provided. Outcome measures were Centers for Disease Control and Prevention (CDC)-defined severe maternal morbidity, composite maternal morbidity, and intensive care unit (ICU) admissions. Two time intervals were used to analyze the effect of the MEWT tool: a 24-month baseline control period and a 13-month MEWT study period. To determine that the findings noted were not simply changes that would have occurred without the utilization of the early warning tool, we also compared a control population from nonpilot sites during the same baseline and 13-month time periods.
  
  
  RESULTS
  There were 36,832 deliveries at the pilot sites (24,221 pre- and 12,611 post-MEWT testing) and 146,359 at the nonpilot sites (95,718 pre- and 50,641 post-MEWT testing) during the 2 study time periods. Use of the MEWT tool resulted in significant reductions in CDC severe maternal morbidity (P < 0.01) and composite morbidity (P < 0.01). ICU admissions were unchanged. At nonpilot sites CDC severe maternal morbidity, composite morbidity, and ICU admissions were unchanged between baseline and the post-MEWT testing time period.
  
  
  CONCLUSIONS
  The use of the MEWT tool in this study, designed to address 4 of the most common causes of maternal morbidity, as well as provide assessment and management recommendations, resulted in significant improvement in maternal morbidity. The variation in hospital delivery services at the pilot sites suggests that this maternal early warning tool would be suitable for use in the majority of maternity centers in the United States.
authors.affiliation: Maternal Fetal Medicine, Marian Regional Medical Center, Santa Maria, CA; Department of Patient Safety, Dignity Health, San Francisco, CA. Electronic address: Laurence.shields@dignityhealth.org.
authors.forename: Laurence E
authors.initials: LE
authors.lastname: Shields
authors.affiliation: Department of Patient Safety, Dignity Health, San Francisco, CA.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Wiesner
authors.affiliation: Department of Patient Safety, Dignity Health, San Francisco, CA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Klein
authors.affiliation: Department of Patient Safety, Dignity Health, San Francisco, CA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Pelletreau
authors.affiliation: Sacramento Maternal Fetal Medicine Medical Group Inc, Sacramento, CA.
authors.forename: Herman L
authors.initials: HL
authors.lastname: Hedriana
mesh_terms: D001794:Blood Pressure; D001831:Body Temperature; D002140:California / Q000453:epidemiology; D003221:Confusion / Q000209:etiology; D019091:Critical Pathways; D042241:Early Diagnosis; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis / Q000517:prevention & control; D006339:Heart Rate; D006340:Heart Rate, Fetal; D006470:Hemorrhage / Q000175:diagnosis / Q000517:prevention & control; D006801:Humans; D007362:Intensive Care Units; D008171:Lung Diseases / Q000175:diagnosis / Q000517:prevention & control; D008428:Maternal Mortality; D010100:Oxygen / Q000097:blood; D010146:Pain / Q000209:etiology; D010343:Patient Admission / Q000706:statistics & numerical data; D010865:Pilot Projects; D011225:Pre-Eclampsia / Q000175:diagnosis / Q000517:prevention & control; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis* / Q000517:prevention & control*; D011446:Prospective Studies; D056152:Respiratory Rate; D018805:Sepsis / Q000175:diagnosis / Q000517:prevention & control
chemical_list: D010100:Oxygen
keywords: critical vital signs; maternal decompensation; maternal mortality