Implementation and Evaluation of Obstetric Early Warning Systems in tertiary care hospitals in Nigeria
Authors: Umar Aminu , Ibrahim Saidu , Liman Idris , Chama Calvin , Ijaiya Munirdeen , Mathai Matthews , Ameh Charles 
Published: September 2020

AbstractBackgroundObstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers/managers who implemented a low resource setting-specific statistically derived and validated EWS and to assess its effectiveness in improving health outcomes.MethodsThis mixed-method study included 2400 women admitted to inpatient wards between 1 August 2018 and 31 March 2019 at three tertiary Nigerian hospitals (1 intervention and 2 control) with pregnancy and childbirth-related complications. The quality of patient monitoring and prevalence of outcomes were assessed through retrospective review of case notes before and 4 months after EWS was introduced. Outcomes were maternal death, direct obstetric complications, length of hospital stay, speed of clinical review, caesarean section(CS) and instrumental birth rates. Qualitative interviews and focus group discussions were undertaken to explore the views of healthcare workers on EWS’ acceptability and usability.ResultsEWS was correctly used in 51% (n=307) of cases. Of these, 58.6% (180) were predicted to have increased risk of deterioration, and 38.9% (n=70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. CS rate dropped from 39.9% to 31.5% (chi-square p=0.002). No statistically significant effect was observed in the other outcomes.Health workers reported positive experience using EWS, with the feeling that it helped cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use, evaluate at a glance, and that scores consistently correlated with the clinical picture of patients. Identified challenges to use included rotation of clinical staff, low staffing numbers and monitoring equipment.ConclusionThe implementation of EWS improved the quality of patient monitoring, but a larger study will be required to explore the effect on critical care admission and health outcomes. With modifications to suit the setting, coupled with regular training, the EWS is a feasible and acceptable tool to cope with the unique demands faced in low-resource settings.Summary boxWhat is already known?An obstetric EWS algorithm with seven parameters (RR, temperature, systolic BP, pulse rate, consciousness level, urinary output and mode of birth), was developed and internally validated using data from low resource settings.What are the new findings?There was a significant improvement in the frequency of vital signs recording following implementation of the algorithm in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites.CS rate dropped from 39.9% to 31.5% (chi-square p=0.002) in the intervention arm, though difficult to attribute to reduction in medically unnecessary CS.The obstetric EWS algorithm was easy to use, easy to evaluate at a glance, capable of guiding referral and accurate, with scores always correlating with the clinical picture of patients.What do the new findings imply?EWS is feasible to implement and potentially acceptable tool to cope with the unique demands faced by obstetric practice in low-resource settings