Only ‘limited assurance’ over hospital’s early warning system of illness in pregnant women

An HSE audit has raised questions over the effectiveness of a system designed to provide early detection of life-threatening illnesses in pregnant women and new mothers.

The audit on implementation of the Irish Maternal Early Warning System (IMEWS) found there was no record of how many staff at the Coombe Women and Infants University Hospital in Dublin had read and understood the system.

The audit has found only “limited” assurance can be provided about the adequacy and effectiveness of how one of the country’s largest maternity hospitals is implementing the system.

The audit said the failure to keep a timely record of medical staff’s familiarity with IMEWS could affect compliance with the guideline and, by extension, patient safety.

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A similar audit on the maternity unit at Mayo University Hospital in Castlebar said the adequacy and effectiveness of how it used IMEWS was “unsatisfactory.”

It revealed an induction programme for non-consultant hospital doctors at MUH did not include IMEWS, while there was no evidence that any doctor or consultant working in the hospital had received training in the system.

The early warning system, which was first published in 2013, is an agreed system developed for the early detection of life-threatening illness in pregnancy and postnatal period in maternity hospitals and units across the Republic.

An IMEWS chart is completed at a patient’s bedside and involves the recording of vital signs including breathing rate, oxygen saturation, temperature, pulse and blood pressure.

Staff should escalate care to a patient if values assigned to vital sign readings exceed a predefined threshold for abnormalities.

The audit showed 60 per cent of staff at the Coombe hospital had received training on the early warning system but that further training had been curtailed due to the Covid-19 pandemic.

Computer records on training were not available to HSE auditors due to the cyberattack on its IT system in December 2021.

A random sample of 19 midwives at the Coombe by auditors found 14 were trained in IMEWS but three records were blank and two were missing, while the hospital did not have a training policy in place.

Internal audits, which are conducted quarterly, on the implementation of the early warning system within the Coombe had also not been carried out for two recent periods.

An analysis of 10 randomly selected maternal healthcare records at the Coombe found there was evidence of an increase in the frequency and monitoring of vital signs as a result of IMEWS triggers in only 50 per cent of cases.

Only 40 per cent of records showed a medical review had been received.

A patient’s body mass index was only recorded in 30 per cent of cases, while date of admission, blood pressure and gestation were only documented in 50 per cent of cases.

A full set of observations were completed within the required time frame with only 20 per cent of patients.

The audit said there was a risk to patient safety due to “omissions in recording the details of clinical escalation and medical response.”

However, it noted that trigger scores – when care of a patient needed to be escalated – were recorded correctly in 90 per cent of cases.

The Coombe agreed with a set of recommendations made by HSE auditors including the need to ensure midwives and medical staff had up-to-date training in the system and regular internal audits of implementing it were carried out with proper records kept of all aspects of IMEWS.

A similar audit carried out on another of the country’s largest maternity hospitals – the Rotunda Hospital in Dublin – classified the adequacy and effectiveness of its implementation of IMEWS as “moderate.”