Highlighting the successes and challenges of adapting and implementing Modified Obstetric Early Warning Chart.
Adaption and implementation of the Modified Obstetric Early Warning Chart: the challenges.
In 2012, the maternal mortality ratio at Mpilo Central Hospital, Bulawayo was 557 per 100,000 live births. Whilst this ratio is lower than that Zimbabwe as a whole, staff at Mpilo felt that this rate could be reduced. In the UK, case reviews have identified that failure to recognise, treat and request senior help for unwell women, contribute to their deaths. Modified Obstetric Early Warning Charts (MOEWS) have been introduced to help address this. It is likely that issues around identification and action are not confined to the UK and the team at Mpilo felt that MOEWS could be an effective way to help reduce maternal morbidity or mortality in their own setting.
MOEWS charts form part of the clinical picture of a patient whilst also providing a simple scoring system. A patient’s vital signs (pulse, blood pressure, respiratory rate and temperature) are plotted on a colour coded observation chart. Abnormal observations fall into an amber or red zone and an alert is triggered if this happens once in the red zone or twice in the amber zone. This tool, together with the associated guideline, provide a pathway to be followed in the event of deteriorating observations and this facilitates communication between team members. Midwives are empowered to request a medical review and instigate treatment.
A significant challenge to the project was the appropriate adaption of the charts for the Zimbabwean setting. The same observations are necessary as in the UK however there are fewer resources in Mpilo. Testing for urinary protein, for example, requires access to urinary dipsticks. Measuring a patient’s temperature requires regular access to a thermometer. Lack of availability of these items therefore leads to incomplete charts.
An additional challenge was that of staff re-deployment across areas of the hospital. Plotting observations is an entirely new way of working for the nurses and midwives in Mpilo and as such, continuous impromptu ward based education is required for new staff placed within the maternity unit.
Despite these issues, the Zimbabwean and UK teams have worked together to develop and implement MOEWS in all clinical areas of the maternity unit including antenatal and postnatal wards, the delivery suite and theatre recovery. A meeting of Sisters from each department was called to revise the chart and this was then piloted and introduced into regular clinical practice. The adaption of the MOEWS chart, with all members of staff having the opportunity to suggest developments, has enabled a sense of local ownership key to its success.
This, together with training to enable the use of charts, has had a direct effect on patient care. Seven months after introduction, 77% of patients whose observations ‘trigger’ a MOEWS are now receiving appropriate and timely treatment. This is compared to 4% before. Midwives have also reported that it is easier to get unwell patients reviewed by doctors and this has increased their confidence to provide appropriate care.
“[The charts are] really working out, because we can now diagnose problems in advance. Now we know with the two amber and one red reading we need to call the doctor and the doctors, they are coming, it’s not a problem like it used to happen.” (Midwife, Mpilo Hopsital)
The MOEWS initiative has been a success, mainly because the Zimbabwean team wanted to use the charts and so have localised them for use. The role of the UK team has been purely supportive, allowing the Mpilo team to make key decisions throughout the phases of design and implementation. Despite the lack of access to certain resources, the team decided to keep parameters such as urinary protein and temperature on the chart because it is hoped that such resources will become available in future. Following the pilot, the Zimbabwean team also decided to focus the use of the charts on high-risk patients and so this is what has happened. Some of the more recent changes made to improve the MOEWS charts have even been taken back to the UK for incorporation at Southmead Hospital in Bristol. This is just one example of how a health partnership is mutually beneficial to both parties.
Several key lessons have been learnt during the project.
Flexibility is key: Staffing, political situations and communication difficulties may impact on the smooth running of a project. Working as a team to overcome difficulties and not being too focused on specific deadlines can help with ensuring a good environment and eventual success.
Team motivation must be sustained: it is important to motivate both partners within the team. Much of the motivation for both partners came from the successful implementation and the results of the spot check audits. In order to obtain these figures however, there needed to be sustained support and encouragement from the Southmead team.