The Joint Commission has issued a new sentinel event alert “Preventing Maternal Death”, pointing out that maternal mortality rates may be increasing. Previous studies have shown that hemorrhage, complications of hypertension, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing conditions are the major causes of maternal mortality. Black women, older women, and women who lack prenatal care are at greater risk of dying during pregnancy. The rise in the prevalence of obesity and its complications may be making coexisting medical conditions more important in leading to morbidity and mortality. They also note that significant morbidity is 50 times more common than mortality.
They cite studies putting the percentage of preventable maternal deaths at between 28 and 50%. Prior studies of preventable maternal deaths have identified issues such as inadequate attention to blood pressure management, inadequate management of pre-eclampsia, inadequate attention to vital signs after C-section, hemorrhage after C-section, and pulmonary embolism.
Some hospital systems have begun universal use of pneumatic compression stockings for all women undergoing C-section. Joint Commission makes this one of their recommendations and also suggests that low-molecular weight heparin prophylaxis be considered women at high risk for VTE in the post-partum period.
This sentinel event alert also discusses the importance of recognition of clinical deterioration in patients, an issue we have discussed in detail in our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”. In addition to establishing triggers that should lead to immediate attention to maternal status, they recommend having staff run drills on how to respond to various types of clinical deterioration.
The December 2009 issue of the Pennsylvania Patient Safety Advisory has a great series of articles pertaining to patient safety in obstetrics. They provide a listing of all the maternal complications reported to the PPSRS over a 5-year period plus an excellent review of medication errors in labor and delivery with recommendations for reducing maternal and fetal harm.
The Joint Commission. Sentinel Event Alert. Issue 44, January 26, 2010
Preventing Maternal Death
Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Advisory. December 2009
A new systematic review and meta-analysis (Chan et al 2010) of studies on rapid response teams (RRT’s) again concludes that the evidence fails to support a significant impact of RRT’s on mortality. For adults there was some evidence of a reduction in non-ICU cardiopulmonary arrests (a more modest reduction was seen when only high quality studies were included). However, the meta-analysis showed no overall effect on hospital mortality. In pediatric populations, there was a lower hospital mortality rate seen after implementation of RRT’s. The authors attribute the apparent better outcomes in pediatric populations to the fact that respiratory problems are more frequently the cause of arrest in children and that children overall have far fewer co-morbidities.
The accompanying editorial (Edelson 2010) echoes a point we have made in several of our articles on RRT’s: the weak link is in the recognition of deterioration. Dr. Edelson notes that 2 parameters which have been shown to be predictive of mortality (respiratory rate and mental status) are notoriously poorly monitored. Dr. Edelson also points out that many or our alert systems are based on absolute levels of a vital sign and may miss trends. We actually gave some examples of that in our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.
The need for better systems to identify signs suggestive of deterioration, without creating too many false alarms, is obvious. Along these lines, a new article in Anesthesiology (Taenzer et al 2010) discusses preliminary outcomes for a new system of monitoring post-op orthopedic patients with continuous pulse oximetry at Dartmouth. They developed a system in which data from continuous pulse oximetry was analyzed by computer and tied to a system of notifying the patient’s nurse by pager. Key concepts were setting thresholds that met a balance between high sensitivity and numbers of false alarms. They also incorporated a delay into the notification system to further minimize the number of false alarms that nurses would have to respond to. The ultimate triggers used were an oxygen saturation of less than 80% and a heart rate below 50 or greater than 140. Their preliminary results show a reduction in rescue events and fewer transfers to the ICU. There were also fewer deaths, though the numbers were too small to be considered significant. This is an exciting concept and suggests that noninvasive monitoring tied to computer algorithms might someday operate in the background to help identify patients in need of early intervention.
All this negative evidence does not negate the logic of having a culture of safety that helps recognize early patients that are in need of “rescue”. But it does raise many questions about committing many resources to develop RRT’s without better evidence-based validation of the RRT concept. The idea remains a sound one but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures all need to be validated before hospitals rush willy-nilly into developing RRT’s.
Our other columns on rapid response teams and recognition of clinical deterioration:
Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid Response Teams: A Systematic Review and Meta-analysis. Arch Intern Med. 2010; 170(1): 18-26
Edelson DP. A Weak Link in the Rapid Response System.
Arch Intern Med. 2010; 170(1): 12-13
Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of Pulse Oximetry Surveillance on Rescue Events and Intensive Care Unit Transfers: A Before-and-After Concurrence Study. Anesthesiology 2010; 112(2): 282-287
The January 7, 2010 issue of the New England Journal of Medicine had two extremely important articles on infection prevention. The first was a randomized controlled trial of chlorhexidine-alcohol vs. povidone-iodine for surgical site antisepsis (Darouich et al 2010). This study showed that the chlorhexidine-alcohol group had significantly lower incidences of superficial incisional infections and deep incisional infections. But there was no difference in the rate of organ-space infections.
The lack of a good head-to-head study of these two antiseptics has been problematic in the past. In our efforts to reduce the risk of surgical fires, the debate about which antiseptic to use has been an unsolved one. Clearly the risk of fire is significantly higher with alcohol-based products. And since it had previously appeared that there was no substantial difference between the two products in antisepsis efficacy, there had been a trend toward using more povidone-iodine. However, the new study clearly shows superiority for the chlorhexidine-alcohol solution. So the real caveat now will be to ensure adequate drying time when using chlorhexidine-alcohol to reduce the risk for surgical fires.
The second paper (Bode et al 2010) looked at a strategy of rapid identification of nasal carriers of Staph aureus (using a PCR assay) followed by nasal decontamination with mupirocin nasal ointment and chlorhexidine soap in an effort to reduce surgical site infections. This was a randomized controlled multicenter trial. The nasal decontamination group had significantly fewer surgical site Staph aureus infections and the effect was most pronounced for deep surgical site infections.
Darouich RO, Wall MJ, Itani MF et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis. NEJM 2010; 362:18-26
Bode LGM, Kluytmans JAJW, Wertheim HFL et al. Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus. NEJM 2010; 362:9-17
What do you think about “medical clearance”? You know, that’s where a surgeon sends you a patient before surgery so you can give your blessing that the surgery is safe for that patient and the patient can likely tolerate the surgery. To be honest, most primary care physicians know very little about the mechanics and stresses involved in surgery and anesthesia. So the pre-op “medical clearance” evaluation often consists of reflexly ordering a bunch of tests that clearly add to the cost of medical care but often add little to patient safety or quality outcomes. The American College of Cardiology and American Heart Association have issued Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery but these are often not followed.
Two recent papers help put those guidelines in context and suggest we need more restraint in pre-op cardiac testing. Writing in the Annals of Internal Medicine in November 2009, Chopra et al suggest it is time to throttle back on testing. The suggest that perioperative tests and treatments improve cardiac outcomes only when targeted to clearly defined patient subsets and that clinical trials have shown no additional benefit of cardiac testing in patients at low to moderate risk for perioperative cardiovascular events.
Furthermore, perioperative coronary revascularization can cause harm and does not improve clinical outcomes, even in high-risk patients. Though the role of perioperative beta blockers is still evolving, perioperative β-blockers at doses titrated to heart rate and blood pressure can reduce risk in high-risk patients. They suggest that implementing the American College of Cardiology/American Heart Association perioperative guidelines can improve clinical outcomes and reduce perioperative costs.
The second paper (Wijeysundera et al 2010) was a retrospective cohort study done in Canada. They found that noninvasive stress testing before major non-cardiac surgery was associated with improved one-year survival and shorter mean hospital length of stay. However, when patients were stratified by cardiac risk, the mortality benefit was primarily in those with high risk (Revised Cardiac Risk Index 3-6 points) and to a much lesser degree in those at intermediate risk (RCRI 1-2 points). Furthermore, such testing in those at low risk actually caused harm.
Basically, both papers support the current ACA/AHA guidelines. Not everyone needs pre-op cardiac testing and you can actually harm some patients by doing it. Keep in mind that there are other things you could be doing as part of that “medical clearance”. You could be doing simple tests to identify patients at risk for post-op delirium and suggesting strategies to minimize that possibility.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al; ACC/AHA Task Force Members. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007; 116: e418-e500 http://circ.ahajournals.org/cgi/content/full/116/17/e418
Chopra V, Flanders SA, Froelich JB, Lau WC, Eagle KA. Perioperative Practice: Time to Throttle Back. Annals of Internal Medicine 2009. Published online before print November 30, 2009
Duminda N Wijeysundera, W Scott Beattie, Peter C Austin, Janet E Hux, Andreas Laupacis
Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study
BMJ 2010;340:b5526 (Published )