Maternal Critical Care: The Role of Critical Care Outreach Teams in Improving Care

Over a decade ago a multi-collegiate working party produced the document “Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant women” in an attempt to bring together the existing standards and recommendations for the care of women who became critically ill during their pregnancy or shortly after giving birth.¹ This guidance was updated and released in 2018² and yet the Confidential Enquiry into Maternal Deaths and Morbidity (MMBRACE Report) for the triennium 2018 – 2020 showed an increase in maternal deaths compared with 2015 – 2017 and whilst not statistically significant for all deaths, it was so for deaths as a direct result of pathology associated with pregnancy.  The increase persisted even when the deaths of women from Covid-19 infection were excluded.³

The Confidential Enquiry found that 229 women had died during their pregnancy or in the 6 weeks after delivery, giving a maternal mortality rate of 10.9 for 100 000 maternities and whilst this value is relatively low when considered on a global scale, the UK still has a comparatively higher maternal mortality ratio than many other European nations.⁴ Of the cases reviewed in the MMBRACE report of 2022 only 22% of women were felt to have received good care, and in 38% of cases, failures in care were felt to have impacted on the outcome for these women, showing we still have gains to be made in the provision of care for woman who become critically ill during pregnancy and birth.  For every woman that dies in pregnancy, many more experience significant morbidity and may require admission to a critical care setting, so improvements in care stand to benefit a significant number of women.

One aspect that makes caring for this patient group potentially challenging is the variable nature of where their care is located.  Cranfield et al describe the benefits and compromises that are associated with different locations within the acute care setting for the management of pregnant or recently pregnant patients.⁵  The majority of women who become unwell during pregnancy will be assessed or managed within a delivery suite setting staffed by obstetricians, midwives and obstetric anaesthetists but many others – for example women with acute medical or surgical pathologies not directly related to their pregnancy or whom are not at high risk of imminent delivery – will be cared for on general medical and surgical wards.  Clearly there are advantages to being co-located near parent specialties but the teams on these non-obstetric wards may be less comfortable with identifying deteriorations in obstetric patients or with providing care to mothers and babies in the post-partum period.  A consistently worrying trend in maternal mortality and morbidity is the persistence of the erroneous use of National Early Warning scores (NEWS) for obstetric patients being cared for outside of the maternity wards rather than a Maternal Early Warning Score (MEWS) that is designed to detect deranged physiology in the pregnant population.³

Obstetric and midwifery teams working on delivery suites, antenatal and postnatal wards can expertly manage a wide range of complications of pregnancy as well as the care after birth for both the woman and her baby, however, the provision of critical care is often not possible in these settings.   Enhanced Maternal Care (EMC) is defined as an intermediate level of care for pregnant or recently pregnant women where a higher level of observation, monitoring and interventions can be provided than on a ward.^6.  Whilst EMC does not encompass the provision of ventilatory support or vasoactive drugs, women receiving enhanced care are clearly at risk of deteriorating and needing transfer to a critical care setting for these advanced interventions.  The provision of enhanced maternal care by specially trained midwifery staff enables more complex women to receive their medical care within an obstetric setting but the prevalence of delivery suites with the ability to provide this care is highly variable.

The challenges in meeting the needs of this vulnerable patient group across the hospital led to me reflect on the role of the Critical Care Outreach Team in supporting the various teams involved as by the nature of their work they are present at all locations within the secondary care setting.

Critical Care Outreach Teams (CCOTs) were developed in response to the Comprehensive Critical Care Report in 2000⁷ which found that ward teams needed greater input managing acutely unwell patients.  Many hospitals now have well established CCOTs who support wards in identifying and treating deteriorating patients, facilitating timely and safe admissions to Critical Care and supporting patients and staff in the recovery phase from critical illness when patients return to the ward setting.⁸  In 2022 the Critical Care Outreach Practitioner (CCOP) Framework was published to serve as a nationally recognised standard of competence, skills and behaviours for those working in CCOTs and to facilitate structured career progression.⁹  The Enhanced Practice Level competencies cover a broad range of disease states and rehabilitation from critical illness and include a large number of competencies related to maternal critical care.  The vast majority of CCOT practitioners may have limited exposure to an obstetric setting as part of their critical care nursing training and many report a lack of confidence in this area.  

As a senior ICM trainee with experience of obstetric anaesthesia and an interest in maternal critical care (fostered in the year I spent as a trainee midwife before medical school) I was approached by our regional CCOT Network Lead to develop a teaching session covering these competencies for several of our local CCO Teams.  We now provide a half day study day that addresses the maternal competencies in the CCOP Framework which include an awareness of key documents and guidance in this field, the anatomical and physiological changes associated with pregnancy, the importance of using a maternal early warning scores in identifying emerging pathology, the role of obstetric emergency teams and the management of maternal collapse, as well as the importance of psychological care for these women.  One of the consequences of delivering these sessions has been to affirm for me the vital role that CCOT can play in enhancing the provision of maternal critical care wherever in the hospital it is needed.

Identifying the deteriorating obstetric patient on the general ward

As mentioned earlier, not all unwell pregnant or recently pregnant women will be cared for in an obstetric setting but may instead be located on general medical or surgical wards.  CCOT practitioners are routinely used to helping identify and manage deteriorating patients on this type of ward and with the enhanced level of maternal knowledge afforded by the CCOP Framework competencies they may be better placed to identify those women who need additional input from critical care or obstetric teams.  CCOPs also play a role in supporting and educating ward teams and so can help embed the routine use of MEWS rather than NEWS and raise awareness of the modifications in care for women with acute medical problems in pregnancy such as tighter limits for blood sugar control, atypical presentations of diabetic ketoacidosis, elevated risks for venous thromboembolism and the dangers of an elevated blood pressure in the pregnant population that would not routinely prompt concern in a non-pregnant patient.

Supporting the provision of Enhanced Maternal Care in obstetric settings

Enhanced maternal care describes the provision of a higher level of monitoring and intervention (usually by midwives but some nursing staff may participate in larger centres) and may include the use of invasive arterial blood pressure monitoring.⁶ The provision of EMC is still far from ubiquitous and some women may be receiving this enhanced level of care from midwives supported by the resident obstetric anaesthetist.  This arrangement can be imperfect due to the competing clinical needs on busy delivery suites and the CCOT can be of immense support to the obstetric and midwifery teams caring for these acutely unwell women.  Should women receiving EMC deteriorate despite the care provided on the delivery suite, CCOT members can support staff in identifying the deterioration and expedite timely review by senior Critical Care medical staff for consideration of admission to a higher level of care.

Facilitating safe transfer of critically ill women in pregnancy or after childbirth

The multi-collegiate guidance document Care of the Critically Ill Woman in Childbirth states that CCO Teams should work collaboratively with critical care units and maternity units to ensure seamless transition of care between units.² CCOT practitioners are skilled and experienced in facilitating the transfer of patients across all hospital sites and so are well equipped to support the clinicians undertaking these transfers.

Provision of holistic care to the woman recovering from critical illness

A significant aspect of the CCOT role is the delivery of care to patients who are stepped down to the ward setting from critical care and whilst this encompasses a medical assessment to ensure that recovery is sustained there is a significant amount of psychological support in the form of helping patients to make sense of their experiences in intensive care.  Women who become mothers – or sadly experience the death of a baby – during an episode of critical illness report the trauma surrounding these devastating events¹⁰ and whilst the majority will receive an obstetric led de-brief in the coming weeks or months many women may benefit from an ICU specific follow up.  Automatic criteria for prompting a referral to an ICU follow up clinic vary between trusts but often depends upon a certain duration of admission or prolonged mechanical ventilation.  ICU admissions in obstetric patients are not always particularly long and so may not necessarily prompt a follow-up referral but CCOT practitioners are well placed to explore women’s understanding of their time in Critical Care and pick up on signs that women may benefit from a more in-depth review of their admission in an outpatient setting.

Conclusions

The pregnant population represents a vulnerable patient group with increasingly complex comorbidities.  Despite advances in medical care the rate of maternal mortality appears to have plateaued and the provision of care to critically ill women in pregnancy can still be improved.  The challenges of meeting the needs of these women across multiple different locations within secondary care requires a truly multi-disciplinary approach and Critical Care Outreach practitioners have a vital role in supporting both women who become critically ill during pregnancy or after birth and the teams looking after them.

References

1. Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman. The Royal College of Anaesthetists. July 2011. https://warwick.ac.uk/fac/sci/med/about/global/etatmba/training/malawi/module7/t6_prov_eq_matandcritcare.pdf (accessed October 2023)
2. Care of the critically ill woman in childbirth; enhanced maternal care. The Royal College of Anaesthetists. August 2018 https://www.rcoa.ac.uk/sites/default/files/documents/2020-06/EMC-Guidelines2018.pdf (accessed October 2023)
3. Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018 – 2020.  MMBRACE-UK. November 2022. https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2022/MBRRACE-UK_Maternal_MAIN_Report_2022_UPDATE.pdf (accessed October 2023)
4. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. WHO. February 2023. https://www.who.int/publications/i/item/9789240068759 (accessed October 2023)
5. Current perspectives on maternity critical care. K. Cranfield, D.Horner, M. Vasco, G. Victory, D.N. Lucas. Anaesthesia 78(6) 758 – 769. June 2023. https://doi.org/10.1111/anae.15948
6. Enhanced Maternal Care Units: Guidance on Development and Implementation.  The Intensive Care Society. September 2023. https://ics.ac.uk/resource/enhanced-maternal-care-units.html (accessed October 2023)
7. Comprehensive Critical Care: A review of adult critical care services.  Department of Health.  May 2000.  http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4082872.pdf (Accessed October 2023)
8. NICE Guideline 94 Emergency and acute medical care in over 16s, Chapter 27: Critical Care Outreach Teams. March 2018. https://www.nice.org.uk/guidance/ng94/evidence/27.critical-care-outreach-teams-pdf-172397464640 (accessed October 2023)
9. Critical Care Outreach Practitioner Framework. National Outreach Forum, Intensive Care Society and Critical Care Networks – National Nurse Leads. December 2022. https://www.cc3n.org.uk/uploads/9/8/4/2/98425184/critical_care_outreach_practitioner_framework.pdf (accessed October 2023)
10. Maternal critical care: what can we learn from patient experience? A qualitative study.  L. Hinton, L. Locock, M. Knight. BMJ Open.  April 2015.https://bmjopen.bmj.com/content/5/4/e006676 (accessed October 2023)