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The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future.

Acute ischemic stroke affects over 800,000 US adults annually, with hundreds of thousands more experiencing a transient ischemic attack. Emergent evaluation, prompt acute treatment, and identification of stroke or TIA (transient ischemic attack) etiology for specific secondary prevention are critical for decreasing further morbidity and mortality of cerebrovascular disease. The Biomarkers of Acute Stroke Etiology (BASE) study is a multicenter observational study to identify serum markers defining the etiology of acute ischemic stroke. Observational trial of patients presenting to the hospital within 24 h of stroke onset. Blood samples are collected at arrival, 24, and 48 h later, and RNA gene expression is utilized to identify stroke etiology marker candidates. The BASE study began January 2014. At the time of writing, there are 22 recruiting sites. Enrollment is ongoing, expected to hit 1000 patients by March 2017. The BASE study could potentially aid in focusing the initial diagnostic evaluation to determine stroke etiology, with more rapidly initiated targeted evaluations and secondary prevention strategies.Clinical Trial Registration Clinicaltrials.gov NCT02014896 https://clinicaltrials.gov/ct2/show/NCT02014896?term=biomarkers+of+acute+stroke+etiology&rank=1

Methods: An electronic screening system for severe sepsis was created in our EHR and implemented in our ED. A best practice advisory (BPA) notifies physicians and nurses of possible severe sepsis and prompts utilization of an order set when three criteria are met. These include: 2 or more modified SIRS criteria positive (Temp>38 C, HR>90, RR>20, SBP<90 or MAP<65, and WBC>12), evidence of end-organ dysfunction (hypotension or organ dysfunction lab values consistent with CMS measure definition) and suspected infection (either temperature > 38 C, antibiotics ordered for the indication of suspected infection, or documented physician suspicion of infection). We performed a retrospective manual chart review of all adult patient encounters with a triggered severe sepsis BPA over a 3-month period to determine whether the patient had potential or suspected severe sepsis at the time the BPA fired. A second reviewer reviewed the cases to determine agreement with a third used as a tiebreaker if disagreement. In addition, we reviewed patients over a 7-week period who received ICD-10 codes for severe sepsis or septic shock to determine if any cases were missed in the ED by our screening criteria.Results: 301 ED patient encounters (2.01% of all adult ED patient encounters) triggered the severe sepsis BPA alert in the 3-month study period. 295 of the 301 encounters were determined via chart review to have suspected severe sepsis or septic shock at the time that the alert fired. The remaining 6 encounters were determined not to have suspected severe sepsis or septic shock at the time of BPA alert and included: alcohol withdrawal, salicylate toxicity, transfusion reaction, GI bleed, and prophylactic antibiotics ordered without appropriately indicating intent. The observed kappa for interrater reliability was 0.854. The positive predictive value of our BPA alert for suspected severe sepsis is 98% (295/301). Over a 7-week period, 86 patients ultimately received ICD-10 codes for severe sepsis or septic shock. 71 met criteria for severe sepsis during their ED evaluation with 70 caught by our automated screening criteria, resulting in a sensitivity of 98.59% (CI 92.4-99.96%). The single case not caught by our BPA logic was due to antibiotics not administered in the ED.Conclusions: The development of an automated severe sepsis screen in the ED at our institution was found to have very high positive predictive value as well as high sensitivity for patients ultimately diagnosed with severe sepsis or septic shock.

Objective Approximately one-third of maternal deaths occur postpartum. Little is known about the intersection between the postpartum period, emergency department (ED) use, and opportunities to reduce maternal mortality. The primary objectives of this systematic review are to explore the incidence of postpartum ED use, identify postpartum disease states that are evaluated in the ED, and summarize postpartum ED use by race/ethnicity and payor source. Study Design We searched PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, Cochrane CENTRAL, Social Services Abstracts, and Scopus from inception to September 19, 2019. Each identified abstract was screened by two authors; the full-text manuscripts of all studies deemed to be potential candidates were then reviewed by the same two authors and included if they were full-text, peer-reviewed articles in the English language with primary patient data reporting care of a female in the ED in the postpartum period, defined as up to 1 year after the end of pregnancy. Results A total of 620 were screened, 354 records were excluded and 266 full-text articles were reviewed. Of the 266 full-text articles, 178 were included in the systematic review; of these, 108 were case reports. Incidence of ED use by postpartum females varied from 4.8 to 12.2% in the general population. Infection was the most common reason for postpartum ED evaluation. Young females of minority race and those with public insurance were more likely than whites and those with private insurance to use the ED. Conclusion As many as 12% of postpartum women seek care in the ED. Young minority women of lower socioeconomic status are more likely to use the ED. Since approximately one-third of maternal deaths occur in the postpartum period, successful efforts to reduce maternal mortality must include ED stakeholders. Systematic Review Registration CRD42020151126. Key Points

Cardiac conditions are the leading cause of pregnancyrelated deaths and disproportionately affect non-Hispanic Black people. Multidisciplinary maternal mortality review committees have found that most people who died from cardiac conditions during pregnancy or postpartum were not diagnosed with a cardiovascular disease before death and that more than 80% of all pregnancy-related deaths, regardless of cause, were preventable. In addition, other obstetric complications, such as preeclampsia and gestational diabetes, are associated with future cardiovascular disease risk. Those with cardiac risk factors and those with congenital and acquired heart disease require specialized care during pregnancy and postpartum to minimize risk of preventable morbidity and mortality. This bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people with cardiac conditions and to respond to cardio-obstetric emergencies. This bundle is one of several core patient safety bundles developed by the Alliance for Innovation on Maternal Health that provide condition-or event-specific clinical practices for implementation in appropriate care settings. The Cardiac Conditions in Obstetric Care bundle is organized into five domains: 1) Readiness, 2) Recognition and Prevention, 3) Response, 4) Reporting and Systems Learning, and 5) Respectful Care. This bundle is the first by the Alliance to be developed with the fifth domain of Respectful Care. The Respectful Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into elements in each domain.

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