Obstetric Early Warning System Configuration Ideas to Improve Patient Outcomes Andrea Tennison, RNC-OB Project Implementation Manager, CPN Baptist Health

Obstetric Early Warning SystemConfiguration Ideas to

Improve Patient Outcomes

Andrea Tennison, RNC-OBProject Implementation Manager,

CPNBaptist Health System, San Antonio,

Texas

Conflict of Interest Disclosure

The faculty and planning committee have declared no conflict of interest.

The content of this presentation represents the views of the author and

presenters. GE, the GE Monogram, Centricity and Imagination at Work are trademarks of General Electric

Company.

About Me CPN System Administrator since 2010 Certified in Inpatient Obstetrics Labor & Delivery 16 years MSN in Nursing Informatics in Progress Centricity Perinatal Users Group Board

Member Baptist Health System - 6 Hospital WAN Additionally Supporting 3 Hospitals in

Chicago on 2 Databases

PurposeThe Purpose of this Activity is to

Demonstrate the Basic Principles of the Obstetric Early Warning System and to Enable the CPN System Manager to

Build the Appropriate Automatically Computed Items

and Configurations to Help Improve Patient Outcomes for Patients on the Obstetric Unit

Objectives

Criteria for successful completion include attending the entire session and turning in an evaluation form.

Discuss the Obstetric Early Warning System and How it Can Improve Patient Outcomes

Discuss Principles of the Obstetric Early Warning System and How it is Applied to Current Documentation Practices

Define the Steps Necessary to Incorporate the Obstetric Early Warning System into the Centricity Perinatal Database

What is OB EWS?

911

Many times, obstetric patients exhibit warning signs in the hours before experiencing critical health problems like cardiopulmonary arrest

Subtle changes can go unnoticed, allowing a patient’s condition to deteriorate without interventions, commonly referred to as "failure to rescue“

Between 2004 and 2006, Health Grades reported that "failure to rescue" accounted for 128 deaths out of every 1,000 patients nationally

What is OB EWS? Increased cardiovascular reserves and other

physiological changes in childbearing women can make recognition of impending maternal collapse difficult

A tool that brings attention to these changes can impact the overall outcome of the mother and baby

OB EWS helps the bedside clinician with recognition of critical signs and symptoms that a patient’s condition may be deteriorating, prompting the caregiver to evaluate and intervene

Benefits of OB EWS Assists in Conveying Information

Concisely, Accurately and Efficiently Increases Communication Encourages Initiation of the Chain of

Command Provides Guidance to Nurse Providing

Care Not Designed to Replace the Individual

Patient Assessment Visual notifications on Chalkboards

Provides Quick Reference when Built in Centricity

How Does it Work? Uses Parameters Specific to the Labor and

Delivery Patient to Identify Patients who May be at Risk for a Potential Emergency

Nurse Applies the OB EWS Scoring System Upon Admission Each Assessment Change in Patient Condition

Each Parameter Range is Assigned a Numerical Score

Actions are Implemented on the Total OB EWS Score

Entire Clinical Picture Should be Considered when Making Care Decisions

Parameter Ranges & Numerical Scores

Scoring Parameters Respiratory Rate Heart Rate Blood Pressure Temperature Oxygen Saturation Level of

Consciousness Urine Output Fetal Heart Rate

Tracing Uterine Activity Bleeding

OB EWS

OB EWS Downtime Form

Required Interventions on

Back of Downtime Form

Updated Hourly

Automatically & Can be Manually

Refreshed as Often as

Necessary

Display of All Patient OB EWS Scores

Chalkboard View

OB EWS ~ CPN

Legend to Identify Numeric Value of

the Colors Displayed

Displays Most Recent Data &

Related Numerical Score

Notifications for Outdated or Missing Documentation that

Affect the Total Score

Nurse Can Refresh Calculations on Demand

If Score is Elevated, Nurse Can Easily Review

Parameters & Validate Accuracy

Recommended Interventions are Listed

on Same Screen for Quick Reference

Review ScreenOB EWS ~ CPN

Score Required Interventions

Green (0-1) Continue to monitor and document findings according to AWHONN maternal and fetal monitoring standards

Yellow (2-3)Review patient status with Shift Supervisor/Charge NurseIf intervention is required, primary RN will complete interventions, notify provider of concern & completed interventions, and continue to monitor

Orange (4-5)

Immediately review patient status with Shift Supervisor/Charge Nurse and notify providerIncrease monitoring frequency to every 5 to 15 minutes until score is 3 or lessOnce score is 3 or less, continue to monitor and document findings according to AWHONN maternal and fetal monitoring standards

Red (> 5) Call provider IMMEDIATELY and prepare for imminent delivery or maternal rescueBlack (> 99) Documentation missing or outdated…. Correct deficiencies and update score

InterventionsBased on Total Score from Tool

CONFIGURATIONS

Steps to Create OB EWS in CPN 1. Evaluate Documentation

Components2. Create Computed Items

… Lots & Lots of Them3. Develop Documentation

Reminders4. Create Review Summary Screens5. Create notification Alerts on

Chalkboards6. Validate Data & Ensuring

Accuracy7. Provide Education to Staff

Evaluate Documentation

Components

CONFIGURATIONS

AutoRecord Vital Signs

HR Resp Temperature NBPSYS NBPDIA SPO2

EGA Cesareans Urine Output

BHS Urine Output Total Q4

BHS Urine Output ml OR Urine Output

LOC Assessment Fetal Assessment

NICHD Decelerations Fetus A FHR Category Fetus A

Contraction Pattern Cesareans Bleeding

OB Hemorrhage Protocol

Induction Agents Cervical Ripening Agents Induction Agents Oxytocin

Infant Delivery Date Baby A

Documentation Components

CONFIGURATIONS

Cervical Ripening Agents0 Not Applicable1 Cervidil2 Foley Balloon3 Prepidil4 Cytotec5 Other

Oxytocin1 N/A2 Induction3 Augmentation

Induction Agents1 Pitocin Increased milliunits/min @2 Pitocin Decreased milliunits/min @ 3 Pitocin Restarted milliunits/min @ 4 Pitocin Started milliunits/min @5 Pitocin Discontinued


LOC Assessment0 Alert1 Agitation or Confusion2 New Onset of Agitation or Confusion

3 Drowsy4 Drifts Off During Conversation- Responds to

Verbal Commands5 Somnolent- Responds to Painful Stimuli6 Non- Responsive to Painful Stimuli

NICHD Decelerations Fetus A1 None2 Early3 Late4 Variable5 Prolonged

FHR Category Fetus A1 Category I2 Category II3 Category III

CONFIGURATIONS

Documentation Components Contraction Pattern

1 Normal: < 5 Ctxs in 10 Minutes (Averaged over 30 mins)2 Tachysystole: > 5 Ctxs in 10 Minutes (Averaged over 30 mins)3 Irritability4 Preterm/Ante: < 5 Ctxs in an Hour5 Preterm/Ante: > 5 Ctxs in an Hour

Bleeding OBH Activate Checklist (Date Time Item)

Vaginal Delivery with EBL >500 Cesarean Section with EBL >1000

OBH Activate Stage II (Date Time Item) Delivery with EBL <1500 Continued Bleeding or Vital Sign Instability

OBH Activate Stage III (Date Time Item) Delivery with EBL >1500 > 2PRBCs Given, Vital Signs Unstable, Suspicion of DIC

CONFIGURATIONS

Added Options to Existing CPN Item. More Information to

Follow

Added Options to Existing CPN Item Will Discuss This Later On

Urine Output Urine Output ml (Ours is Named BHS Urine Output ml)

Numeric Item

OR Urine Output Numeric Item

BHS Urine Output Total Q4? %EXISTS ( Infant Birthdate and Time @ 0. ) \ %FAIL \\ ? %EXISTS ( AutoRecord ) & ( ~ %EXISTS ( BHS Urine Output ml @ 3.98 ) & ~ %EXISTS ( OR Urine Output @ 3.98 ) ) \ 0. \\ ? %EXISTS ( AutoRecord ) & ( ~ %EXISTS ( BHS Urine Output ml @ 3.98 ) & %EXISTS ( OR Urine Output @ 3.98 ) ) \ %SUM ( OR Urine Output @ 3.98 ) \\ ? %EXISTS ( AutoRecord ) & ( %EXISTS ( BHS Urine Output ml @ 3.98 ) & ~ %EXISTS ( OR Urine Output @ 3.98 ) ) \ %SUM ( BHS Urine Output ml @ 3.98 ) \\ %SUM ( BHS Urine Output ml @ 3.98 ) + %SUM ( OR Urine Output @ 3.98 )

We have this fail on all our maternal computes… will

exclude for rest of presentation for ease of viewing


CONFIGURATIONS

Triggers & Computes

CONFIGURATIONS

AutoRecord Create a Numeric Item Called

AutoRecordOn the Server that Runs PtDs: Open Notepad

Document ||AutoRecord|||||1

Save File as AutoRecord.txt in d:\qs

Usually AutoRecord is created without write permissions. Write permissions are needed to refresh OB EWS on demand.

Include Write Permissions for Staff

Score Calculation Trigger CONFIGURATIONS

AutoRecord Create a Separate PtD Job for Every

Hour

Select the Units for OB EWS to Run

Select Active Patients

Remember to Cycle PtD

Enter File Named:\qs\AutoRecord.txt

-OR-

\\Servername\qs\AutoRecord.txt

Score Calculation Trigger CONFIGURATIONS

Score Calculation Computes

CONFIGURATIONS Complex Computes

OB EWS FHR OB EWS OBH OB EWS EGA Preterm Trigger OB EWS CS Trigger OB EWS UA Aug Trigger OB EWS UA Preterm OB EWS UA Preterm CS

OB EWS UA Term OB EWS UA Term CS OB EWS Total

Simple Range Computes OB EWS HR OB EWS LOC OB EWS NBPDIA OB EWS NBPSYS

OB EWS Resp OB EWS SPO2 OB EWS Temperature OB EWS Urine Output

OB EWS HR

? %EXISTS ( AutoRecord ) & ~ %EXISTS ( HR @ 4. ) \ 99. \\

? ( HR >= 130. ) \ 3. \\ ? ( HR >= 111. ) & ( HR <= 129. ) \ 2. \\ ? ( HR >= 101. ) & ( HR <= 110. ) \ 1. \\ ? ( HR >= 60. ) & ( HR <= 100. ) \ 0. \\ ? ( HR >= 41. ) & ( HR <= 59. ) \ 2. \\ ? ( HR <= 40. ) \ 3. \\ 0.

* Value of 99 is for Documentation Reminder Computes

Values Assigned to Ranges According to the OB EWS Tool

Simple Range Computes

CONFIGURATIONS

OB EWS FHR? %EXISTS ( AutoRecord ) & %EXISTS ( Infant Delivery Date Baby A @ 0. ) \ 0. \\

? %EXISTS ( AutoRecord ) & ~ %EXISTS ( FHR Category Fetus A @ 4. ) \ 99. \\

? ( FHR Category Fetus A = 1. ) \ 0. \\ ? ( FHR Category Fetus A = 2. ) & ( NICHD Decelerations Fetus A > 2. ) \ 2. \\ ? ( FHR Category Fetus A = 2. ) \ 1. \\ ? ( FHR Category Fetus A = 3. ) \ 3. \\ 0.

* Value of 99 is for Documentation Reminder Computes

* Value of “0” after Delivery to Continue Tool Postpartum

Why 2 Items if OB EWS is Calculated on Category? Category I = 0 Category II without Decelerations = 1 Category II with Decelerations = 2 Category III = 3

* Category II has two separate values depending on whether

there are decelerations present

Multiple Item ComputesCONFIGURATIONS

Here is Where it Gets Tricky…

Primarily Focuses on these Contraction Patterns Normal Uterine Activity Irritability Tachysystole < 5 Contractions in an hour > 5 Contractions in an hour

Multiple Item ComputesCONFIGURATIONS Next Parameter Addresses Varying Degrees of Uterine

Activity

Multiple Item ComputesCONFIGURATIONS

Term, Preterm, Laboring, Antepartum, Previous Cesarean, Augmentation

What About All the Other Variables?

Break it Down Into Small Computes First

…..Then Add Them All Together

Multiple Item ComputesCONFIGURATIONSTerm, Preterm, Laboring, Antepartum, Previous Cesarean, Augmentation

“Laboring or Antepartum” Difficult to Create into a Compute Tried to Avoid Adding Item to Current Nursing

Documentation Discussed Options with Nursing Staff Decision Made to Add Options to Existing Item

Contraction Pattern1 Normal: < 5 Ctxs in 10 Minutes (Averaged over 30 mins)2 Tachysystole: > 5 Ctxs in 10 Minutes (Averaged over 30 mins)3 Irritability4 Preterm/Ante: < 5 Ctxs in an Hour5 Preterm/Ante: > 5 Ctxs in an Hour


OB EWS EGA Preterm Trigger? %EXISTS ( Infant Delivery Date Baby A @ 0. ) \ 0. \\ ? ( %EXISTS ( EGA based on EGA in 7th EWS ) ) & ( ( EGA based on EGA in 7th EWS ) < 37. ) \ 1. \\ 0.

“Term or Preterm” Is the Patient Preterm? … Yes or

No

“Term or Preterm” Is the Patient Preterm? … Yes or

No

“Previous Cesarean” Is the Patient a Previous Cesarean Section? …

Yes or No


OB EWS EGA Preterm Trigger

OB EWS CS Trigger

? %EXISTS ( Infant Delivery Date Baby A @ 0. ) \ 0. \\ ? ( %EXISTS ( EGA based on EGA in 7th EWS ) ) & ( ( EGA based on EGA in 7th EWS ) < 37. ) \ 1. \\ 0.

? ( Cesareans @ 0. ) > 0. \ 1. \\ 0.

“Augmentation” Is the Patient Being Induced or Augmented? …

Yes or No Several Medication Items in CPN


OB EWS Aug Trigger? ~ %EXISTS ( AutoRecord ) \ %FAIL \\ ? ( Cervical Ripening Agents @ 0. ) = 1. \ 1. \\ ? ( Cervical Ripening Agents @ 0. ) = 3. \ 1. \\ ? ( Cervical Ripening Agents @ 0. ) = 4. \ 1. \\ ? ( Oxytocin @ 0. ) > 0. \ 1. \\ ? ( Induction Agents @ 0. ) = 1. \ 1. \\ ? ( Induction Agents @ 0. ) = 2. \ 1. \\ ? ( Induction Agents @ 0. ) = 3. \ 1. \\ ? ( Induction Agents @ 0. ) = 4. \ 1. \\ 0.

CONFIGURATIONS Multiple Item Computes

Too Many Variables to Capture All Variations in One Compute

Create 4 Separate Patient Type Computes

Only One of These Will Yield Answer Remaining Three will Fail with Zero

All Computes Need to Have Numeric Answers for CPN to %SUM Final Score

Instead of %FAIL Use a Zero in these Formulas All 4 Will be Included in Final Total Compute Calculation

No History of CS Previous CS

Term OB EWS UA Term OB EWS UA Term CS

Preterm

OB EWS UA Preterm

OB EWS UA Preterm CS

Term, Preterm, Laboring, Antepartum, Previous Cesarean, Augmentation

…Let’s Take a Look at OB EWS UA Term

OB EWS UA Term One of Four Patient Types

? %EXISTS (AutoRecord) & %EXISTS (Infant Delivery Date Baby A @ 0.)\ 0.\\ ? (%EXISTS (OB EWS EGA Preterm Trigger @ 0.) & (OB EWS EGA Preterm Trigger @ 0.) = 1.)\ 0.\\? (%EXISTS (OB EWS CS Trigger @ 0.) & (OB EWS CS Trigger @ 0.) = 1.)\ 0.\\ ? %EXISTS (AutoRecord) & ~ %EXISTS (Contraction Pattern @ 4.)\ 99.\\ ? (Contraction Pattern) = 2.\ 3.\\ ? (%EXISTS (OB EWS UA Aug Trigger @ 0.) = 1.) & (%EXISTS (Contraction Pattern))\ 1.\\ ? (Contraction Pattern @ 0.) = 3.\ 1.\\ ? (Contraction Pattern @ 0.) = 1.\ 0.\\ ? (Contraction Pattern @ 0.) = 5.\ 0.\\ ? (Contraction Pattern @ 0.) = 4.\ 0.\\ 99.


…Don’t Panic, Let’s Break It Down

OB EWS UA Term



Did the Patient Already Deliver? Yes… It Stops and Provides a Result of 0 No… It Looks at the Next Variable

OB EWS UA Term



Is the Patient Preterm? Yes… It Stops and Provides a Result of 0 No… It Looks at the Next Variable

…Remember, This Formula is Looking for a TERM Patient Only

We Have a Separate Compute for Preterm Patients

OB EWS UA Term



Is the Patient a Previous Cesarean? Yes… It Stops and Provides a Result of 0 No… It Looks at the Next Variable

…Remember, This Formula is Looking for a Patient that has not had a CSWe Have a Separate Compute for Previous CS Patients

OB EWS UA Term



Did the Nurse Document on Contractions in the Last 4 Hours? No… It Stops and Provides a Result of 99 Yes… It Looks at the Next Variable

OB EWS is Calculated on Current Documentation OnlyThe Result of 99 will Trigger a Documentation Reminder on the Review Screen

OB EWS UA Term



Does the Patient Have Tachysystole? Yes… It Stops and Provides Score of 3 No… It Looks at the Next Variable

OB EWS UA Term



Is the Patient Being Induced or Augmented for Labor ? Yes… It Stops and Provides Score of 1 No… It Looks at the Next Variable

OB EWS UA Term



Is the Patient Experiencing Uterine Irritability? Yes… It Stops and Provides Score of 1 No… It Looks at the Next Variable

OB EWS UA Term



Remaining Values for Contraction Pattern Have No Score Value for Term Patients and Result in 0

OB EWS UA Term



…Same Process for all 4 Patient Types

OB EWS Total

? %EXISTS ( AutoRecord ) \ ( OB EWS LOC @ 12.) + ( OB EWS HR @ 12.) +( OB EWS NBPSYS @ 12.)+ ( OB EWS NBPDIA @ 12.) + ( OB EWS Resp @ 12.) +( OB EWS FHR @ 12.) + ( OB EWS Temperature @ 12.) + ( OB EWS SPO2 @ 12.) + ( OB EWS OBH @ 12.) + ( OB EWS Urine Output @ 12.) + ( OB EWS UA Term @ 12.) + ( OB EWS UA Term CS @ 12.) + ( OB EWS UA Preterm @ 12.) + ( OB EWS UA Preterm CS @ 12.) \\ 1000.

…And Now You Have an OB EWS Score

CONFIGURATIONSScore Calculation Computes

Documentation Reminders

& Review Screens

CONFIGURATIONS


OB EWS CS Document OB EWS FHR Document OB EWS HR Document OB EWS LOC Document OB EWS NBPDIA Document OB EWS NBPSYS Document OB EWS Resp Document OB EWS Temp Document OB EWS UA Document OB EWS Urine Output Document

CONFIGURATIONS

CONFIGURATIONS OB EWS FHR

Document


Formula is Item Name as OB EWS Items Already Contains Compute to Capture Missing

Documentation (*99)

Create Computed Text Item Reminders Range & Text:

0-10 Documented 99-100 FHR Category Documentation Missing or Outdated

Create For Each Required Item for Score Calculation

Create Documentation Review Summary Form Normal Form - Not Date/Time Form Read Only, No Write Permissions on Items

OB EWS Review

Place Form on Quick Keys for Easy Access

CONFIGURATIONS Summary Screens

Add Documentation Components as “Read Only” … HR Create Info Boxes Next to Each Item for Documentation

Reminder Compute … OB EWS HR Document

Use Info Boxes to Display Reminders in Color Add Items Individual Scores for Staff Reference… OB EWS

HR


Item from Charting

Documentation Reminder Compute

Score Assigned to Value of Item


Documentation Complete and Within Previous Four Hours

Score Within Normal Limits

What the Nurse Sees…


Documentation Needs Updating

Score Outside Range

What the Nurse Sees…


Missing or Outdated Documentation Individual Item Scores will Display “99” Documentation Missing will Display in Red in the Info Box Staff Returns and Corrects Deficiencies in Chart

Since OB EWS Score Only Automatically Updates Hourly, Will Need to Create Ability to Manually Trigger the Score to Update Once Deficiencies are Corrected

Add Push Button to OB EWS Review Form Set to Prompt for New Form Each Time

Opened


Create an Additional Form to Trigger OB EWS Score

Create a Date/Time Form OB EWS Update AutoRecord Item

Created Earlier

Include “New Button” & “Ok Button” on Form Properties

Add AutoRecord Item on Form Add Text Box with Instructions to Staff

Chalkboard Notifications

CONFIGURATIONS

CONFIGURATIONS Create Visual Alerts by Adding to Unit

ChalkboardsProvides Centralized View of All Patients on the Unit

Add Item OB EWS Total to {{DS PatientData}}

Cycle PDSS Add to Beds on Chalkboard

Insert as “LED” for Color Alert Display

Patient Name OB EWS

CONFIGURATIONS Assign LED Colors for Ranges

Note Colors Used in Color Assignment for Legend

Select Style then Color Assignment

Note: Ranges are “Inclusive” on Chalkboards

Create Legend at Bottom of Chalkboard

Cycle CDSS and PDATS on All Workstations

Select Style then Color Assignment

To Update Colors, Delete

Color Assignment

OB EWS Chalkboard

Staff Education Flyers

QUESTIONS?

Thank You

Documents

Obstetric Early Warning System Configuration Ideas to Improve Patient Outcomes Andrea Tennison, RNC-OB Project Implementation Manager, CPN Baptist Health