Early recognition of the ill patient

1. Early recognition of the ill patient Dr Philip BarclayConsultant AnaesthetistLiverpool Women�s Hospital www.somoa.org � Society of Mersey Obstetric Anaesthetists

2. Early diagnosis of illness

3. Early diagnosis of illness

4. Critical Point 1

5. Critical Point 3

6. Critical Point 2

7. Admissable evidence Gold standard: RCT Breast cancer screening: HIP trial, 1977 60,000 women enrolled Mortality rate reduced from 5 per 10,000 in controls to 2.3 and 3.4 in women over 50 and 60 UKCTOCS has similar aim 200,000 women enrolled, results due over 12 years

8. Inadmissable evidence Clinical judgement Expert opinion

9. Hazards of inappropriate early diagnosis Increased diagnosis of subclinical disease Treatment may do more harm than good Labelling women as patients Increased HDU referral

10. Sepsis

11. Sepsis

12. The retrospectoscope

13. The experienced midwife �Clinical nous� Neural networks, performing a Bayesian analysis using a model honed from years of clinical practice Problem of quantification

14. The power of numbers

15. Traditional nursing/midwifery Florence Nightingale until 1980s Physiological parameters monitored Explicit: �TPR� (with BP) Implicit: conscious level, cyanosis 6 parameters

16. March of the machines Automated P and BP Allows �observations� by unqualified staff Time to put the R back into TPR(Nursing Times, 2001)

17. Early Warning Scores Based on APACHE II ITU system used since 1985 Simple physiological measures Scored according to degree of deviation from normal Calling criteriaTotal score or severe abnormality in any one parameter Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system used for patients admitted to intensive care unit (ICU), which used parameters such as BP, RR, FiO2, pH pO2, HCO3, Na K, Cr, ARF, WCC, Cr, Age, Chronic organ failure, Glasgow Coma Scale.Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system used for patients admitted to intensive care unit (ICU), which used parameters such as BP, RR, FiO2, pH pO2, HCO3, Na K, Cr, ARF, WCC, Cr, Age, Chronic organ failure, Glasgow Coma Scale.

18. Many different schemes EWS: HR Sys BP RR T Neurol MEWS: plus SpO2 PAR: plus Urine Output MET: ABCD approach

19. Many different schemes Schemes developed from intuitive physiological ranges Values chosen were not validated Do they work?

20. Can EWS predict outcome? APACHE II scores predict outcome in ICU Do parameters measured in Early Warning Scores predict outcome?

21. Can EWS predict outcome?Goldhill, 2005 Mortality range: <15%, 15-25%, 25-35%, >35% Temperature Heart rate Systolic Blood pressure Respiratory Rate SpO2 Level of consciousness

22. Can EWS predict outcome?Goldhill, 2005 Mortality range: <15%, 15-25%, 25-35%, >35% Outcome predicted by: Individual parameters scores Number of abnormal parameters0 or 1 = 4% 2=10% 3 = 23%

23. Can EWS predict outcome?Goldhill, 2005 Mortality range: <15%, 15-25%, 25-35%, >35% Outcome predicted by: Early Warning Scores 0 = 4% 2 = 11.6% 5 = 23% ?9 = 53%

24. Can EWS save lives?

25. Can EWS save lives?MERIT study, Lancet 2005 Cluster RCT in Australia 23 hospitals randomised to use MET Over 130,000 admissions in 6 months Outcome measure: Cardiac arrest, unexpected death or ICU admission No significant difference

26. Can EWS save lives in pregnancy? Predictive value seen with mortality 4% to 50% Overall mortality in pregnancy: 0.007% ICU admission rates are also low: 0.07% What size RCT required to show improved outcome? �Impossible�

27. Can EWS save lives in pregnancy?Surviving Sepsis Campaign >40,000 deaths in UK each year due to Sepsis 10,000 deaths in ITU Mortality from Genital tract sepsis: 3 to 6 per year ITU admissions: >200,000 admissions from 1995 to 200333 due to GTS with 2 deaths.

28. Low mortality in pregnancy Young Few comorbidities Protective physiological changes of pregnancy: increased cardiovascular reserve Cardiovascular fitness strongly associated with survival after surgery, trauma and illness

29. What might EWS offer Communication Response to treatment Step up to Level 2 or 3 care Step down care

30. MEWS in action in HDU 30 year old woman with twin pregnancy admitted at 20 weeks with premature rupture of membranes. Despite Ab prophylaxis, developed purulent liquor and required IV antibiotics for septicaemia (SIRS plus infection). Transferred to HDU and initially improved with 6 hour resusciation bundle, although she remained persistently hypotensive. She then developed sudden onset of breathlessness, despite only 1 litre of Hartmans > hypoxaemia and lactic acidemia. Responded to 100% oxygen and furosemide with good diuresis. Made steady recovery and did not require transfer to ITU.30 year old woman with twin pregnancy admitted at 20 weeks with premature rupture of membranes. Despite Ab prophylaxis, developed purulent liquor and required IV antibiotics for septicaemia (SIRS plus infection). Transferred to HDU and initially improved with 6 hour resusciation bundle, although she remained persistently hypotensive. She then developed sudden onset of breathlessness, despite only 1 litre of Hartmans > hypoxaemia and lactic acidemia. Responded to 100% oxygen and furosemide with good diuresis. Made steady recovery and did not require transfer to ITU.

31. Where do we go from here? Early Warning scores validated for pregnancy Cultural change Focus on Obstetric Critical Care

32. Illness cause physiological disturbance Quantification and communication Assess response to treatment Could predict and improve outcome but unlikely to be proven with RCTs Return to good clinical practice What can EWS do for Yous?

33. Tests for early diagnosis of illness Cheap Well established Agreed validity

34. Recognition of the ill patient Significant illness causes physiological disturbance Charting � baseline, trends Pattern recognition Severe disturbance requires escalation of level of care

35. What might EWS offer Simplicity Communication � common �risk� language amongst midwives, obstetricians and anaesthetists Auditable standard of care

36. Admissable evidence for EWS in pregnancy Low incidence of death or ITU admission in pregnancy makes RCT impossible Very hard to raise evidence above case series