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Circulatory concerns:a common cause of rapid response calls in the puerperium frequently resulting in care escalation
Abstract Number: T110-484
Abstract Type: Original Research
Severe maternal morbidity (SMM), generally identified by intensive care unit (ICU) admission or ≥4 units blood transfusion, is increasing in the US and is associated with a high rate of preventability similar to maternal mortality1. Cardiovascular disease is a major contributor to mortality2. Rapid response teams (RRT) are a patient safety strategy associated with reduced cardiac arrest outside of the ICU3. The contribution of RRTs in identification of women with SMM is less known.
Retrospective cohort study of all women pregnant or up to 6 weeks postpartum aged 18-50 for whom RRTs were called at a university hospital between January 2014 and August 2018. Indications for calling an RRT included: 1. New systolic blood pressure <90mmHg or >200 mm Hg; 2. New heart rate <40 bpm or >150 bpm; 3: Respiratory rate <10 per minute or >28 per minute; 4. Pulse oxygenation <88%; 5. Acute neurologic change; 6. Seizure >5 minutes; 7. New onset chest pain with ECG change; 8. Staff concerns. RRTs were considered circulatory if called for indications 1-4, or 7. Management of hemorrhages is a separate protocol. Descriptive statistics were calculated comparing circulatory RRTs with other etiologies.
56 RRTs were called for 48 women. Circulatory etiology was found in 17 women (30.9%). Mean age, gravidity, and parity in the cohort with circulatory etiology were 29.5 (S.D. ±8.2, range 18-49); 2.4 (S.D. ±1.3, range 1-6); and 1.6 (S.D. ±0.97, range 1-6) respectively; not significantly different from other RRTs. All patients survived until hospital discharge, but 47% required escalation of care either to an ICU [5 patients (29%)] or stepdown unit [3 patients (18%)]. This is a significant difference in care escalation compared to RRTs for non-circulatory indications (47% vs 18%, P=0.046). Trend for ICU admission was also higher (29% vs 13% N.S). The remaining 9 patients (53%) did not require escalation of care. The most common circulatory concerns were tachycardia [n =11 (65%)] or hypotension [n= 3 (18%)]. The majority, 13 (76%), occurred in the postpartum period, 4 (24%) occurred antepartum.
Circulatory concerns are common causes of RRTs. While there were no maternal mortalities, a large proportion required care escalation with a higher proportion requiring ICU admission than in women with RRTs of other etiology. Further analysis of risk factors for circulatory etiologies may help decrease SMM.
1. Geller SE, Rosenberg D, Cox SM, et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004; 191(3): 939-44.
2. Briller J, Koch AR, Geller SE. Maternal Cardiovascular Mortality in Illinois, 2002-2011. Obstetrics and gynecology 2017; 129(5): 819-26.
3. Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158(5 Pt 2): 417-25.