Implementation and Evaluation of Obstetric Early Warning Systems in tertiary care hospitals in Nigeria

Abstract

Background Obstetric 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 assess the effectiveness of a validated obstetric EWS in improving health outcomes and explore the experience of health workers/managers regarding its use. Methods This mixed-method study included 2400 obstetric admissions to inpatient wards between 1 August 2018 and 31 March 2019 at three tertiary Nigerian hospitals (1 intervention and 2 control). 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 data was collected to explore the views of healthcare workers on EWS’ acceptability and usability.Results EWS correctly used in 51% (n=307) of cases. Of these, 58.6% (180) 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 reduced from 39.9% to 31.5% (chi-square p=0.002). No statistically significant effect was observed in the other outcomes.Health workers reported that the EWS 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, and that scores consistently correlated with the clinical picture of patients.Identified challenges included rotation of clinical staff, low staffing numbers and monitoring equipment.Conclusion The implementation of EWS improved the quality of patient monitoring, but a larger study will be required to explore the effect on 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. Trial registration: ISRCTN, ISRCTN15568048. Registration date; 9/09/2020- Retrospectively registered, http://www.isrctn.com/ISRCTN15568048