Join us as we dive deeper into the rising severe maternal morbidity and maternal mortality rates in the United States through a data-driven, quality improvement lens. Each episode will foster discussion with those committed to improving maternal health outcomes and saving lives.
Christie - 00:00:05:
Welcome to Aim for a Safer Birth. I'm your host, Christy Allen, Senior Director of Quality Improvement Programs at the American College of Obstetricians and Gynecologists, or ACOG. On this podcast, we dive deeper into the rising severe maternal morbidity and maternal mortality rates in the United States through a data-driven quality improvement lens. In this episode, I'm excited to talk with Dr. Carey Eppes and CheyAnne Harris about maternal early warning signs implementation. Say that 10 times fast. Dr. Eppes is a maternal fetal medicine specialist in Houston, Texas. She's the MFM Division Director for Baylor College of Medicine. She also serves as the immediate past chair of Texas Perinatal Quality Collaborative, which is known as Texas Collaborative for Healthy Mothers and Babies, and is a member of the Texas Maternal Morbidity and Mortality Review Committee. So Dr. Eppes is joining us, as well as CheyAnne Harris. And CheyAnne is the Director of Clinical Excellence and Operations for Titus Regional Medical Center in Mount Pleasant, Texas, with years of experience in providing and enhancing maternal care practices. She's a member of the Texas AIMS Hypertension Faculty and has participated in Texas AIMS Hypertension work and a Levels of Maternal Care Surveyor for ACOG. So thank you both for joining me. And we're here to talk today about maternal early warning signs, or we may call it MEWS throughout the course of the day, since that's a little bit of a long. Long way to do it. So thank you so much for taking the time to talk.
Carey - 00:01:29:
Thank you, Christy. We're happy to be here.
Christie - 00:01:31:
Wonderful. So I think we probably need to lead off by having us talk about what is MEWS. We talk a lot about early warnings. We talk about maternal signs. And even those of us that do this a fair amount can conflate patient education with some of these pieces. So maybe, Dr. Eppes, if you could get us started talking about what we mean when we say MEWS or maternal early warning signs.
Carey - 00:01:55:
I agree. I think that's an important piece of this. And I have learned through our work in implementing it across Texas that defining it is critically important. So I look at it as both an alert and a response system. And I think that response piece is the most critical. The alert portion is really focused on what are the key maternal symptoms and vital signs that we know are associated with a high risk of adverse pregnancy outcomes if they're not responded too quickly. And that's where the response piece comes in. So dictating who responds when, how, and what you do if that doesn't occur is a critical part of early warning systems.
Christie - 00:02:34:
So it's not just warning. It's also about sort of how you respond to that warning. And prepare to get ready. By implementing the system. Did I sum that up right?
Carey - 00:02:44:
Totally agree.
Christie - 00:02:45:
Yep. Perfect. So you're here to talk about your experiences and not just have me ask questions. I can tell you that from the AIM side of things here at ACOG, we've been working on the resource kit that we've rolled out and is available on our website. So it's saferbirth.org. And that came out of materials that I think had been developed quite a long time ago now. Time flies at ACOG and through the Council for Patient Safety and Women's Healthcare. And then I know you all sort of took that and ran with it more than almost anyone else in Texas. So I'd love for you guys, and you're welcome to sort of talk it together, but what was that? What did it look like? Because I know that we took some of your work and you've been gracious enough to share it with us. So we'll circle back to talk about that. But in the meantime, how did y'all get into this work?
Carey - 00:03:36:
So I'll start off and then I'm curious to see what CheyAnne has to add. So the first piece is I have to acknowledge, a key partner of mine in this, who is Christina Davidson, who's not part of the podcast today, but we both originally had implemented an early warning system in our safety net hospital and had just such a tremendous effect on our patient outcomes and kind of the culture of safety in our unit, that this was something we wanted to share with other teams and make go statewide. And so when our state started working on AIM bundles around 2018, the first bundle that we did was postpartum hemorrhage. And so our state perinatal quality collaborative, which at the time, Christina Davidson and I were the OB chairs for, we very carefully thought about how to integrate an early system in there, thinking that this would sort of be the foundation for all future bundles that we would do, really along the readiness and recognition realm. But the more we got into it, realized just what a profound effect it has actually on every arm of the AIM bundle. So as our teams were working on hemorrhage, we did kind of an adjunct quality improvement effort working on maternal early warning systems. And the first thing we realize, we're using a usually does for hospitals we had tried, you pick the early warning system that's going to work for you, and got such tremendous feedback from hospitals that they wanted a little bit more guidance. And so spent a lot of time talking to different types of hospital settings to figure out how to make something that would really work for everyone and have enough flexibility, but kind of set the foundational, this is what you need to have. So rural, urban hospitals, that's a huge part of Texas with a lot of rural hospitals. And our state, people that had an in-house provider, people who didn't, and how they can kind of tap into different tools. So then started with, this is what we say are the kind of foundation of vital signs and patient symptoms. And I think that's key. So I'm going to keep emphasizing that. And then worked with them on their different strategies for response. So some of our teams did the most amazing work with leveraging ER physicians or ICU physicians or midwives or other people to respond who aren't just the classic obstetrician that might work with in-house hospitalist kind of model and then gave tools and simulations and videos and things kind of showing what an early warning system is and isn't. And we probably spent more time on what it isn't to get to the point of effectively creating one. But then did that throughout hemorrhage implementation and then kind of strengthen it as we do severe hypertension.
Christie - 00:06:15:
So I'm going to pause you for just a second because, wow, that is a huge project. I think of Texas and we all know Texas is big, quite big. And it's, you know, for small states, I love that you're hitting on a lot of the points that I think people might resist some of this work, right? But what it isn't is we know that the MEWS idea is not a bundle. It follows quality methodologies, but it's like as all of the resources that AIM develops are, it's an enhancement to support the implementation of those bundles. I think that's important to share with our listeners. I also appreciate the shout out to Dr. Davidson, who is phenomenal. And I think many of our listeners have met her through different work we ask her, beg her for in AIM. And we so appreciate her commitment to that work and you representing it on her behalf as well. She's a great partner to many of us. I guess one of the questions I have is, did folks feel like this was an add-on in addition to the bundle? You do so much. And I don't know if maybe CheyAnne can speak to that a little. Since you were doing this on the ground, was it like another thing you were doing? How did that work in real life?
CheyAnne - 00:07:21:
So with it kind of corresponding to the work when we started the hemorrhage bundles and AIM and then bleeding into the hypertension bundle. It did seem to the bedside staff that it was an additional thing. Like we were co-implementing things. And I believe at first it was a little bit overwhelming for them. But we had to refocus how we introduced it, that it was supplementary and it was an enhancement to the work that we were doing. I remember presenting it to my staff as guardrails of providing care to our maternal patients. So when you're talking about readiness and response, the guardrail shows you what you should do, but then it also prompts you to react. Looking at maternal early warning signs as an all-encompassing. Implementation with critical values and presentations of patients that prompts our staff to take further action, take guesswork out of common red zones that they need to address and have a standard platform for care collaboration. So even taking it a step further that this is a collaborative effort and it allows, regardless of what type of maternal health crisis that we're facing, it allows a collaborative conversation where we're speaking the same language with the other care team members outside of the direct care of the obstetrician and the maternal nurses, which I think is important and in the past has been an area for breakdown in maternal care.
Christie - 00:08:53:
So from my perspective, you're speaking my language too, talking about guardrails. I ask the question, it's a little bit of a trick question, right? Were people resistant? Nobody ever wants to talk about that. I am reflecting on my own experience at the bedside. And as a quality implementer and feeling like, oh God, it's like another thing. You're already making us do a bundle. You're with those guardrails. I think it kind of writes the bundle work into it if you think of it that way. I do know that the scariest times when I've practiced, I was a night nurse in OB. And the scariest times to me were three o'clock in the morning. And I'm like, I don't like this. And I'm not sure what I'm supposed to do. Like who's on call? Who's got the pager? Or like, are they home? Are they here? And I think that I love the idea of removing the guesswork. It doesn't mean we take out someone's judgment. I'm like, the patient doesn't look right. Right. We can still say that, but it gives you a pathway to follow. Dr. Eppes, I don't know if you have anything to add to that or other thoughts about how it looked across Texas.
Carey - 00:09:51:
Gosh, I agree with so much of what both of you just said. I think it probably felt like a big lift when we were doing it concordant with hemorrhage, but it felt so foundational when we started hypertension and our state's about to do sepsis. And so it will just continue to build. Thinking back through when we started at my hospital, which was in 2014, and just how hard that new change was in getting people to communicate in a different way. And now I have residents come and ask, can you create a MEWS for our GYN patients? Or can you do it in these different areas? Because it's become, they look at it so differently and it is just the framework with which we respond to things and communicate with each other that they now actually ask for it in other areas. So that might take 10 years, but it feels really good when you get there.
Christie - 00:10:39:
All change takes time, right? I remind myself of that quite a bit because I'd like it to be faster. And when you're doing it in the moment, it feels like forever. It applies to so many things in life. I'm wondering if the two of you maybe can go back and forth and like, what does this look like, right? We've mentioned guardrails, we've mentioned vital signs, we've mentioned response. So like if I had never heard a MEWS, which would be unfortunate, I would love the idea of you all sort of talking through an event. It doesn't have to be super detailed, but like what that looks like for you all when it's going the way it's meant to and implemented. Because the resource kit gives folks the steps to implement this, right? But the actually doing of it, we all know the reality isn't always exactly the same. You've got those guardrails. So if you all want to kind of give me an idea what that looks like. So CheyAnne, you have a nurse taking care of a patient and they check a blood pressure and what do they find? What kicks this off?
CheyAnne - 00:11:38:
Yeah, so I can think of a specific example of patients that I've cared for in the past where you... Have a blood pressure and a pulse come across and your pulse is, let's say, 135. 140s. And you're like, oh, wow, you know, is she moving? Is she bending her arm? Back to nursing 101, right? You know, you want to take care of the patient, not necessarily nurse the machine. That's the great thing about MEWS is that it does tell, you know, validate those triggers when you have them. So, you go in and you validate. It is certain that the patient's having those elevated heart rates. And so, you have a concern for your patient, you know, depending on her presentation, you know, is she hemorrhaging? Is there sepsis going on? Do we have an infection? Coming up, you have that my patient doesn't look right feeling, but maybe you need to communicate it more than that patient doesn't look right. And especially whenever you've got varying levels of experience, and this is definitely in a post-COVID culture where we had a large turnover, especially at the bedside and nursing staff. Where you have a younger set of nurses and there may not be as developed relationships among the care team. And it gives them the capability to say, hey, I have a MEWS trigger. My heart rate is greater than 120. I rechecked it. It is truly greater than 120. My patient's diaphoretic. She's complaining of abdominal pain. This is triggering our MEWS protocol. When can I expect you at the bedside or what further steps can I take to help you with your assessments? It gets that ball rolling so that a patient doesn't potentially get missed.
Christie - 00:13:22:
So what I'm hearing you describe initially, I'm going to repeat it back because I have to because I'm a quality person. So I got to do closed loop communication. I'm obligated even on a podcast. So what I hear you saying is someone goes in the room, gets some vital signs. It's like, oh, that's not ideal. And then kind of takes in the context, right? How's the patient look? What else is going on? Was she just like, you know, crying because the baby was crying and we're trying to breastfeed? Or is there something else happening? Assists that kind of context. Maybe if it's a nurse's aide or a medical assistant who gets that, what is their step in that process?
CheyAnne - 00:13:59:
Right. So their step would, it kind of follows that chain of command. So they would want to report that into the nurse overseeing that patient. So it also gives people who maybe don't have that nursing prepared or provider prepared background, those same guardrails. So again, we're all speaking that same language and standardizing what. What is not okay. Or what needs to be validated.
Christie - 00:14:22:
It does need to be validated. Right. I hear that. I don't know that all of our listeners will necessarily understand the day-to-day at the bedside, right? So it's not often the nurse going in and checking a blood pressure when we're fortunate to be supported by techs or nursing assistants, which is a godsend. And I never want that to sound negative. A lot of times folks do like rounds of vitals. They go patient to patient. And I know traditionally when I worked on the floors, you know, you could maybe not get those vitals for like 40 minutes because you've been told to get all the vitals. So you're getting all the vitals. This builds in like an automatic stop, right? Like a hard stop of like, oh, I'm going to stop and tell the nurse now, right? So they wouldn't continue on and like report out at the end. It would be like an immediate sort of recognition thing.
CheyAnne - 00:15:04:
Right. It kicks off that escalation cascade.
Carey - 00:15:08:
Can I add a piece there? Because I think what you just said is so critical and so much of the behind the scenes work that makes this so effective is the whole goal is from the time the patient actually has the abnormal symptom or vital sign to the response is as short as possible. And so that alert period is really from the first time the patient has it. And I learned and would not have realized before doing this work that in so many of our hospitals or outpatient centers, there's a machine attached to a patient and not humans involved in that process. And then it would push to an electronic medical record. And it's not until someone logs back into the electronic medical record that they even realize that vital sign occurred, which could be hours after it happened for the patient. So I think the most effective way to create an early warning system is having it go from a human being with the vital sign, if you have a tech taking that, to immediately notifying the nurse, to immediately notifying the responding person and having an expectation of what the response is supposed to look like and an escalation process if it doesn't. I.e., if I call and the OB that is in charge of this patient is in a C-section, that doesn't mean you just leave the vital sign and the patient until they're done two hours later. But knowing that you have to have a response in whatever time your team has set. In my hospital, it's 15 minutes. We set at least within 60 for our state, looking at kind of the different structures and in-house, out-of-house hospital folks, that then you have to go to somebody else if you haven't had a response within 15 minutes. And everybody knows who that is and how that communication is supposed to go, which as CheyAnne just explained, usually has to involve, this is a MEWS trigger. I'll see you at bedside in X amount of time. So I think that's the hard work that so many people had to do behind the scenes so that it wasn't just waiting for it to be in an electronic format for people to know it existed.
Christie - 00:17:13:
It's speaking a new language to some extent. One of the things that's been hitting for me recently and doing some of the podcasting and just the work in AIM is that, you know, folks already assume a lot of this is happening. On the ground. Like, and I don't think it's out of ignorance, even it's, you know, that is, this is what we aspire to is this tight communication in a timely manner. But as we've just spoken to real life and the realities of patient care and our healthcare system don't always align with that. So this is like, um, I think of it as a safety net, but it's more than a safety net. You'd have to fall for a safety net to work, and we're trying to get it before we're there. Right, is how. At least I'm thinking of it. All right. So to back up, we got an abnormal heart rate. This heart rate was quite high. And the provider has been called now. The nurse was alerted. The provider was called. We said, this is a MEWS trigger. We used those words. We were real clear. And then they've got, it sounds like a time limit. And where do they do it? Does that mean the provider needs to be on the unit? Does it need to be like in the house? What is, how does that look?
Carey - 00:18:17:
We said, at least for Texas, that people had to be at bedside within 60 minutes. And that is probably one of the hardest changes that people had to make and one of the biggest culture change things that existed. And I think we required a lot of justification that it would make a difference in various scenarios. But we said within 60 minutes. And if people wanted to do it in a shorter amount of time, they could, but at a minimum 60.
Christie - 00:18:42:
Okay. So they're there. And then what happens, right? If the heart, it's still, say the heart rate's still high, like the patient is. Tell me about the patient if you want to, CheyAnne. You had a specific instance in mind.
CheyAnne - 00:18:55:
Yes. In this instance, the provider came to bedside. There was initial conversation about whether or not this patient was having an anxiety attack. This patient was known to have anxiety. And however, the nurse who had been caring for her for several hours had kind of seen her be anxious and not be anxious. She wasn't anxious at this time. The patient was palindiaphoretic, so the nurse had that gut feeling along with that MUTES trigger and was able to say, no, I don't believe this is anxiety. I really think there's something going on. The patient had had a vaginal delivery and had a hematoma that was actually bleeding up towards her back instead of bleeding outwards or protruding. So the blood loss that was going on was not visually seen. And also was in a hemorrhage with bundle massage. So kind of a hidden hemorrhage. And so that nurse, the provider got to bedside. Did notice now that this patient, you know, was not having anxiety, was palindiaphoretic, and was able to order stat labs, see that the H&H was having some shifts, did some additional vitals, saw that the blood pressure was starting to trend down, and then was able to do some examination and find that hematoma. That may not have been found for so much later, you know, when we did have severe blood pressure change. So it did get that escalation process in place and wasn't dismissive of something that could have been different.
Carey - 00:20:25:
Can I highlight something CheyAnne just said, which is one of my favorite parts of early warning systems? I think, you know, so much that happens in the middle of the night, we are sleep deprived and probably not at our best selves. And so we're so at risk of all of our normal cognitive biases, like that is anxiety. I'm going to err towards normalcy bias or anchoring bias so much more often. And I think that's the nice thing about early warning systems is they standardize the way you have to respond and make it so that when you have to actually see the patient, you might realize, all right, I can't just normalize this heart rate for anxiety. And you have to kind of tap into, all right, which of my bundles am I going to go into from this tachycardia? Is it sepsis? Is it a pulmonary embolism? Is it hemorrhage and hypovolemia? And I do think that bringing people to bedside helps with that, but it standardizes and makes us less vulnerable to those biases that we all have.
CheyAnne - 00:21:22:
And I'm going to tag off the bias as well. Sometimes people have the perception of healthcare providers, whether it's physicians or nursing staff or support staff, that we're dismissive because we've been seeing it or we've been doing it forever. But honestly, sometimes it's a bias because we want to see our patients in the best light. We want to see them do well and we want to speak that they're doing well. And so sometimes that bias is missed just because we want our patients to not be sick.
Christie - 00:21:54:
I mean, real talk, it's never, I love bundles and I love the tools we use and I love the quality work we do, but we need to acknowledge as all folks that have been at the bedside, you know, realistically speaking, it's almost never as clear cut as we have when you get a clinical scenario in a simulation or in a quality work or, and that's okay because you're doing specific things in those tools and with those. But the reality is that it's three o'clock in the morning and you haven't had your dinner yet and you work the night before and I want my patients to be healthy. I don't want to overreact. I don't want to, exactly to your point, CheyAnne. And then also, you know, you call a provider and who maybe is having a similar experience or who's just come out of two rooms and is right. So I love the idea of having both a shared language and it's almost like a pause, but a quick pause. It's like getting people there quickly to take that moment to really focus in. And I think worse slash best case scenario, nothing's wrong, right? That's, that's a win. That doesn't mean you triggered a false alarm. That means you triggered an alarm and were able to make sure the patient was safe. Can you, either you speak to that experience too, because I do think that would stop me potentially as someone at the bedside of like, well, I don't want to like, maybe I can make it normal. How do you work against that bias for our teams?
Carey - 00:23:10:
I think that's where the other side and the. Kind of fourth R in the reporting section of what we've done with MEWS is so critical. Looking at in these responses, what happened to our patients and where did we change their trajectory or where was it okay that there wasn't something wrong? And instead of doing 9 million expensive tests, having somebody come to the bedside and see them and say, no, I actually think it's these things. This is my differential. This is what we need to do or not do. It often changes that so that you're not over-testing as well. And then finally, when patients have physical exam symptoms, that's one of the things I love is a key part of this. They see that someone is responding to them and taking them seriously for like a severe headache or other symptoms. And that has made a huge difference in our patients feeling like they've been listened to and then often changes kind of that relationship down the way.
Christie - 00:24:08:
Right. So I'm going to say, and maybe this is a question for you, CheyAnne, I think that the framework of the bundles and of these resource kits is around those five R's, right? And Dr. Eppes, you just mentioned the fourth R. The fifth R is respectful care. And I do think respectful care is listening to people. That can be hard. I think as a patient, you don't always know what to call out. I once, just personal experience, had an infusion going and I had back pain and I figured out my back hurts. I've been sitting in this chair. I didn't know I was supposed to tell them if I had back pain. Because that was the first sign of a reaction. And by the time I did, they're like, why didn't you say something sooner? I'm like, here I am. I'm a nurse. I'm experienced. I'm a patient advocate. I felt so silly. But like, you've just had a baby and everything's changing and everyone's told you all along, well, that's normal for pregnancy or that's, you know, and maybe you've been feeling kind of crummy. So like, how do we make sure that we are hearing patient voice? I hear the recognizing the vitals. And if a patient's reporting like a severe headache, that also triggers amnesia. Is this correct? It's not just numbers.
Carey - 00:25:11:
Correct, which I think is really key. And at least our team has learned to explain to the patients what's going on in that process. We actually had an instance where the bedside nurse, there was a patient with a symptom, and they picked up the phone and said, I'm triggering MEWS. I need you at bedside in 15 minutes. And the patient actually thought that... There was kind of a conflict going on on the other side of that. And so we learned we had to say, you know, these are the things that we use in our maternal early warning system. You have triggered it. Things might be okay, but they might not. And this is where we get together as a team. So I'm going to call and ask the doctor to come to bedside because you're having a severe headache. And this is what we would expect. And that made a big difference in how patients felt like we are working together as a team. You know, one of those core things we're asking them about in surveys all the time to respond to symptoms that they're having. But we had to kind of build in the this is what you might see our team doing. This is why we're having this phone call. And this is what you should expect on the other side of it. But this is part of us listening to you and responding to your symptoms to make sure you're okay.
Christie - 00:26:14:
Because coming to the bedside makes the patient part of that team too, as they should be, right? They're the ones who you're going to ask questions. Is this normal for you? Do you normally get headaches, right? Not to even have that bias, but like the patient's going to be the best reporter. I think that's one thing we did choose to highlight in the resource kit. Patient is still the reporter and the best trigger. Trigger's kind of a scary word if you don't understand what's happening. And I can see why it could sound like a conflict. I find it incredibly reassuring that if someone calls for help, people come, but you don't always know what's happening. And again, it's back to that respectful care and communication, right? Meeting folks where they're at. So I appreciate that focus. Anything you want to add to that, CheyAnne, about experience you all have had working with patients who've experienced a MEWS trigger or any tips or tricks you'd have for folks on the ground?
CheyAnne - 00:27:03:
Said, but tips and tricks is that we do a great job of our response. And, you know, we've done a lot of simulation work. A lot of facilities have done simulation work, making sure that when you are practicing that through simulation, that you are including that patient conversation piece, because sometimes that's not natural for all staff. To look back and have that conversation or even know what is comfortable and what is okay to say and not to say to patients and families. So practicing that. And then when you do have those events live, having debrief after the event is stabilized and asking that question, almost having that fifth R as a part of your debrief. How did we do with respectful and equitable care? Did we ask the patient? And making sure that everybody has feedback in that. And then also going back and asking the patient if the situation permits, asking the patient, did you feel informed through this process? This is what happened to you. What questions did we not address moving throughout? And then communicating that back to your teams as an improvement, process improvement for the next event.
Christie - 00:28:14:
We love a cyclical process. Probably the three of us more than their average person, but we do love that process. So you said something in there that I realized we haven't really touched on, which is how do you build this into other processes for quality improvement? I heard you say simulation. So do you use MEWS in simulation?
Carey - 00:28:33:
Oh, absolutely.
Christie - 00:28:36:
Oh, good. Okay. Tell me more about that though. How would you envision doing that?
Carey - 00:28:40:
Shan, do you want to go first and then I'll jump in?
CheyAnne - 00:28:42:
Sure. But just cut me off when you need to cut me off because I can talk for some simulation for hours. So I took the approach with our team to start building some type of MEWS into any type of simulation that we had. Because really, again, MEWS is supplementary and complementary to every bundle. So whether we're doing a sepsis simulation, a hemorrhage, hypertension, maternal health, whatever it is, we're including some type of MEWS where the staff is getting to practice that communication among the care providers and also practice that communication to the patient so that it's hit through every piece and it becomes a part of our resting nature. Because if we're not practicing using that MEWS terminology and... And even what the triggers are, because, you know, we're very key into the pulse and the blood pressure. But sometimes we can forget about that temperature, that respiratory rate. Or some of the physical presentation, then symptoms that, you know, we see in patients. So building that into simulation just kind of helps that keep fresh on your staff's mind.
Christie - 00:29:46:
So you get to practice before it's happening. Absolutely. Love that.
Carey - 00:29:50:
We also used it a lot to create the MEWS process, both in our initial implementation in the state and in hospitals that we were starting it out in. We're trying to figure out everything that can go wrong. So using simulation to test the system and what the phone calls look like and where we needed to script communication or coach people in what to say. There's a lot of conversation in healthcare, and I see it a lot as an MFM, where people think they have conveyed something to you and then are really upset when they're not getting the response they think they've conveyed. And then the person on the other end of the phone didn't hear that at all. For example, I was asking you to come see the patient. I was asking you to treat her hypertension. And that didn't. And so listening to those conversations in simulations where they might feel a little bit more comfortable or be able to show you what's happening that you don't realize is happening really helped define some of the guardrails that need to go around. And so we were a big proponent on scripting and that that first line needs to be, I'm calling with a MEWS trigger. So it set the stage. And actually, people could probably not pay attention to the rest because they knew it was some abnormal vital sign or symptom that meant they needed to be at bedside. But then really giving the rest of the time to the patient. So for example, having somebody in the mindset, I am triggering MEWS for severe hypertension or for hypotension. And here are the things you want to know. And I'll see you at bedside in whatever time it was. But that script became key. And I would not have realized that until I watched other people simulating it and saw all of the. Errors and that communication that can happen without it.
Christie - 00:31:26:
So as you're talking, I'm thinking about the fact that as a nurse, I was taught to call the physician and make them aware. I don't think I ever knew I could ask someone to come to bedside until I had been practicing for maybe 10, 15 years. I just assumed that if they knew they should come, they should come. No one teaches you, or I think we under-teach folks the critical components of communication. And there's that line, I think, that gets attributed to different people when I hear it said, but the biggest error in communication is the assumption that it actually happened. And never more than when you're stressed out. So I think I've been called even by team members in office jobs of like, but why are you telling me this? What do you need from me? So this is really concrete. I'm calling you with a MEWS trigger. This is the trigger. Here's maybe the context. And then you end it with, here's our plan. So everyone's on the same page. Does that sound right?
Carey - 00:32:20:
Absolutely. And I think that's probably one of the most critical parts of an early warning system.
Christie - 00:32:26:
How do people know what the MEWS triggers are? Like, do you have signage up? Is it part of orientation? Because we're saying these like everybody just knows what they are. And I realized I never asked that.
Carey - 00:32:37:
So we... Admittedly, as the state started out thinking we could just let people pick what they are and pretty quickly realized, no, we need to tell them. So we use the original Council for Patient Safety and now what we use for ACOG and well in the toolkit criteria and for Texas, just a single trigger. We made badge buddies. We made adaptable materials for hospitals and have an algorithm that people can share to try to make tools that people can disseminate and ways that they can train folks, which I think became even more critical as CheyAnne referenced earlier after the pandemic when we have so much turnover. But honestly, the tool I see used most often is that badge buddy where people anywhere from the. Resident to the nurse to the patient care technician will look, verify it was a MEWS trigger and call. CheyAnne, what kind of tools do you guys use?
CheyAnne - 00:33:31:
I agree. The badge buddy is a big one. And another thing I feel like when we were implementing MEWS at first, I feel like our labor and delivery staff, and we're in a rural setting, so our makeup looks a little bit different. Our labor and delivery staff, once they got it down, we started focusing on, is this happening on mother-baby? And speaking, Cece, do I... Speaking to what you said earlier. About a nurse's assistant or a tech rolling vital signs across rooms. That was what was happening on our mother-baby unit. And they weren't necessarily looking at their badge buddies because they were looking at their dynamap. And so we also made kind of a badge buddy tag that we. Attached to the dynamap. And that was very helpful. For our mother baby staff.
Christie - 00:34:24:
So when folks are taking the blood pressure, the numbers are right there on a, you say dynamap, but you mean the blood pressure machine. I'm going to get real specific just in case someone uses a different one. I'm old school though. And I'm like, yeah, dynamap. I remember dynamaps. But yeah, so it's the visual cues that folks can reference, but also the reminder that we're not just collecting numbers that there's like, we do stuff with the numbers, right?
Carey - 00:34:48:
Yes. And I want to highlight that neither of us have said that we waited for the EMR to flag something to tell them that was an abnormal vital sign. And I think that is critical. I can't tell you how many times I had to say, don't wait for your electronic medical record for somebody to tell you, for it to tell you somebody's sick. We need to be determining it at the point the vital signs are taken. I think when we started implementing, so many people said or thought they had an early warning system because they had some program built into our EMR that would turn certain colors when they put in certain vital signs. I think the key thing was those vital signs could have been a long time ago. If all of the vital signs were in, it wasn't changing color and people didn't necessarily respond to it. And that is not a maternal early warning system if you don't have an immediate alert and an immediate response. And so many of the things built in are not getting at that. They can. But I think those bedside tools are so important so that there is an immediate alert.
Christie - 00:35:49:
Kind of laughing while you say that because I'm thinking about places I've actually worked where I was like, well, we have a system, but not even in obstetrics and pediatrics, because pediatrics uses some similar tools to this. We have it. Like I filled it out every like four hours or two hours, like I was supposed to. Was I ever fully aware of a process around that? It's just like, it's the same if you're collecting lab data, vital signs, we better be ready to do something about it. And I love the concreteness of what to do and that it uses the whole team. How do you train people coming in? You spoke about turnover, CheyAnne, and I know you've got Dr. Eppes, maybe residents coming through, you've got fellows coming through. So one of the things I hear about a lot in multiple hats that I wear in different work that I do is sustainability not being a thing. You know, you lose that one champion at a smaller hospital, or you like turnover, you've got a whole new batch of residents coming in and they're fantastic, but they don't get the same information because we weren't rolling it out. What do we bake in? I think for CheyAnne at like a smaller facility, I'd love to hear, you mentioned rural, I'd love to hear how you do that, like maybe with travelers or contract folks or with that. And then Dr. Eppes, if you can speak a little bit about the medical education side of it, that would be so helpful to me.
CheyAnne - 00:37:03:
So for our new hires, or if we have travel staff, we set up, depending on their level of experience, we set up a OB residency in all of the components from MEWS to any of the maternal health emergencies that a patient could experience, where they not only learn about it, they get some clinical, some didactic and some simulation work with each piece. So they're getting basically a residency program catered to maternal care because a lot of times, especially. When we do, again, being rural, when we have to bring in new hires that are actually new nurses, they did not get a large portion of obstetric care and maternal care in nursing school. And so really focusing on that and beefing up that education.
Christie - 00:37:57:
So baking it in.
CheyAnne - 00:37:58:
Yes, absolutely. We also keep a flip sheet kind of booklet at every patient bedside with algorithms that reference what steps the staff need to take if they have certain events, certain triggers that happen. And that way, if they find themselves at the bedside. Maybe their preceptor is not with them, they at least have a guide to get things started before they can call for help.
Christie - 00:38:23:
Love it. And then Dr. Eppes, the sort of like turnover and fluctuations that happen in academic settings.
Carey - 00:38:29:
Yeah, I think the physician side of education has so much to learn from the nursing side. I used to be the chief of obstetrics at our safety net hospital. And a couple of years into trying to do different safety bundles, I realized we just needed to parallel the physician and the nursing education. You know, nursing teams have an educator and physicians have nothing like that. And so, so much of it is just what's been passed down or what the person teaching you does. So we at least, the new interns as they come in would spend an entire day doing simulation with them as their first thing. And they did simulation in MEWS, hemorrhage, hypertension, and shoulder dystocia. So they knew the process that that hospital followed and all had to participate in it. And then we'd maintain that simulation. They're all required to do all of those simulations annually. It's a requirement for physicians. And credentialing, one of the things we have in Texas is mandatory levels of care. And so you can attach things like participation in education and simulation into credentialing. And so we did, it's part of an onboarding toolkit. And then we do an orientation in our quality and safety meeting every year that reminds people of all of these important things. But then I think that's the introduction. I think the validation and the sustainability piece is we continue to track data on missed MEWS triggers and give one-to-one feedback every time it happens. And for a while we had a safety nurse role. It is highly dependent on staffing to be transparent, but they would watch in real time and tell the people involved when they weren't following something. And that was by far the most effective is catching it in the moment and redirecting people. And that person did it for both our physician and our nursing teams because they needed it together. So really it's mostly. Modeling what the nursing teams are doing very effectively.
Christie - 00:40:15:
I was going to say that's a whole new rapid cycle, whole new definition of rapid cycle process improvement. Real time, love that. Because you don't want to hear you did it wrong in six weeks, right? That's, you can't correct it and you can't do better. All right. With all of that in mind, in this season, we ask people about a one thing. And I'd love to ask each of you sort of your one thing about MEWS or about the process as you went through it that could help any listeners who are considering this for their facility or for their PQC. And I think maybe we start with CheyAnne.
CheyAnne - 00:40:48:
So my one thing with MEWS is educate everyone involved. You can't roll out a collaborative change process without collaboration. And when I say that, we've spoke a lot on today about the OB physician. We've spoke about the nurse aide, the OB nurse, the mother of OB nurse. But also consider when you're doing your education that you're including other key players that may be responding to this. So anesthesia, rapid response teams, your emergency department and your ICU as well. They're a critical piece. And we know from the data that patients that are coming back and having severe morbidity and mortality, a large portion of them are after they leave that immediate birth encounter. It's in the postpartum period. So making sure the same education we're providing to the OB care team is education that the other teams are getting as well. And remember that when you're using MEWS, that you use it as a platform for respectful escalation and communication in your care. And the buy-in will go a lot quicker when you roll it out collaboratively and respectfully among the team.
Christie - 00:42:01:
A really good one thing. Dr. F's hard act to follow. What have you got for us?
Carey - 00:42:08:
I agree. Mine's going to be so much more simple than that. And I was just going to say for people that are starting to implement, it's patience. It's such a huge culture change and in a way that your teams interact. And it's such a teamwork thing that it probably takes a year or two for people to really feel like this has made a difference. This is part of what we do and to not hear everything wrong with it. And so you do have to just ride that out, keep listening to them, keep adapting, but realize it's just going to take a bit. And then when you get on the other side of it, it seems so profound that you don't realize, you know, how did we even function in this way before? But that learning to communicate differently takes a while to feel like it's going well.
Christie - 00:42:49:
I think that really highlights probably the most important thing we're talking about. It's a patient care methodology. It's a safety. It has the R's. But it's communication, both with the patient, but with every member of the team. And it's getting everyone on the same page, which is always the goal for any emergency. So, well, I really appreciate both of you taking the time to talk to me today. I learned, and I'm hoping that folks can tap into some of those wisdom that you shared. For folks that are interested in the resource kit that we have for helping folks implement, which we were so very honored to have the Texas folks really give input on this from the Texas PQC and the work that they did. So it's been vetted from real people who've done this in real life. And it is on the AIM website. And we'll make sure it's linked to with this podcast episode as well. But again, thank you both so much for your time and for joining me from Texas today.
Carey - 00:43:39:
Thanks for having us.
CheyAnne - 00:43:40:
Thank you.
Christie - 00:43:46:
Thanks for tuning in to Aim for Safer Birth. If you like this show, be sure to follow wherever you get your podcasts so you won't miss an episode. To get involved in work related to addressing maternal mortality, be sure to check out the Alliance for Innovation on maternal health at saferbirth.org. Together, we can work towards safer birth and healthier outcomes for all families. I'm Christie Allen, and I'll talk with you next time on Aim for Safer Birth.