Rapid Response Team (RRT) calls - an additional marker for maternal morbidity
Severe maternal morbidity (SMM) has increased in the United States from 1993 to 20141,2. Common measures of SMM include transfusion of ≥4 units of blood or intensive care unit (ICU) admission per Society of Maternal Fetal Medicine (SMFM) and the American College of Obstetricians and Gynecologists (ACOG) statements3.
Rapid response systems (RRT) are a patient safety strategy associated with reduced cardiac arrest outside of the ICU but contribution of RRTs to SMM assessment is less well known.4
Retrospective analysis of women pregnant or up to 6 weeks postpartum age 18-50 for whom an RRT was called between January 2014 and August 2018 at a university center. Standard indications for RRT include: new blood pressure <90 or >200; heart rate <40 or >150 beats per minute; pulse oximetry <88%; uncontrolled bleeding; acute neurologic change (AMS); seizure; chest pain with ECG changes; or staff concerns of patient’s status. Hemorrhages are managed separately at our institution during pregnancy and were not included.
56 events in 48 women met inclusion criteria. Mean age, gravidity, and parity respectively were 29.2 (SD±6.9, range 18-49), 2.85 (SD±1.7, range1-8),1.69 (SD1.4, range 0-6). The most common indication for RRT was AMS in 29 women (52%), followed by circulatory indication in 17 women (30%), and staff concerns in 8 women (14%). Only 2 women had respiratory compromise (3.6%). Analysis of short-term outcomes revealed that all patients survived until hospital discharge. The majority, 40 women (71%) remained in their room, but 10 (18%) were transferred to the ICU, 4 (7%) were transferred to a stepdown unit, 1 (2%) was transferred to the Emergency Department, and 1 (2%) was transferred to Labor and Delivery.
While 18% of cases would have been reviewed on the basis of ICU admission alone, a majority would not meet criteria for review for SMM under the current ACOG/SMFM consensus statement. A significant proportion of women had an escalation in care. Review of RRTs may capture additional maternal morbidities otherwise missed. Further analysis of risk factors and outcomes provides opportunities for care improvement.
1. Prevention CDC. Rates in Severe Morbidity Indicators per 10,000 Delivery Hospitalizations, 1993–2014. 2017. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/rates-severe-morbidity-indicator.htm (accessed July 17 2018).
2. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. American journal of obstetrics and gynecology 2004; 191(3): 939-44.
3. American College of O, Gynecologists, the Society for Maternal-Fetal M, Kilpatrick SK, Ecker JL. Severe maternal morbidity: screening and review. Am J Obstet Gynecol 2016; 215(3): B17-22.
4. Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Annals of internal medicine 2013; 158(5 Pt 2): 417-25.