Introduction of a modified obstetric early warning system ­(­MOEWS­)­ at an Ethiopian referral hospital: a feasibility assessment

Abstract

Early warning scores are points-based or colour-coded systems used to detect changes in physiological parameters and prompt earlier recognition and management of deteriorating patients. Vital signs recorded within a coloured zone corresponding to degree of derangement (‘trigger’) should prompt an action. The report of the UK Confidential Enquiry into Maternal and Child Health recommends the use of modified versions in the obstetric population. Currently, there is limited research into the effects of early warning scores in low-resource settings where maternal mortality remains high, and there is a need for low-cost, simple methods to reduce this. A modified obstetric early warning system (MOEWS) was introduced for parturients who had undergone surgical intervention at Felege Hiwot Referral Hospital, a tertiary centre in Bahir Dar, Ethiopia. A guideline was developed to accompany the MOEWS, together with training of healthcare workers. Prior to introduction, the quality of postoperative monitoring was assessed through retrospective case note review. This was reassessed at 8 months and 11 months postimplementation, with assessment of response to ‘triggers’. A questionnaire and qualitative interviews were undertaken to establish views of healthcare workers on its acceptability and usability. Recording of postoperative vital signs improved with the implementation of the MOEWS and was sustained at both monitoring periods. The number of patients with vital signs within the coloured zones (‘trigger’) was reduced, although documented action to these remained low. Staff were positive towards the MOEWS, its impact on patient care and felt confident using the system. The introduction of a MOEWS in an Ethiopian referral hospital in this study appeared to improve the monitoring of postoperative patients. With modifications to suit the setting and senior clinician involvement, coupled with regular training, the early warning score is a feasible and acceptable tool to cope with the unique demands faced in this low-resource setting.

Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: results of a mixed-methods study at a national referral hospital in Kenya

“…Use of MOEWS in obstetrics in LMICs has highlighted the need of a 'partnership approach' and leadership from local teams. 28 Our findings include the possibilities of resistance to change in keeping with the adoption theory, which proposes that any group consists of a mixture of 'innovators, early adopters, early majority, late majority, laggards' and resistance to change is expected. 29 There are several steps outlined in innovation research that are transferable to this healthcare context; 'relative advantage', 'compatibility', 'complexity', 'trialability', 'observability'.…”

“…27 Although currently there is no evidence that using neonatal EWS improves outcomes in LMICs, research in closely related clinical areas is encouraging: in Ethiopia, the introduction of a Modified Obstetric Early Warning Score (MOEWS) in a referral hospital, improved practice in several domains. 28 The desired improvement in outcomes can only be achieved from EWSs if there is an appropriate escalation of care when required. In this study, infants' vital signs were retrospectively plotted to the red and amber zones on the NEWTT, using data available via clinical records.…”

“…The follow-up of implementation of MOEWS in Ethiopia showed that attitudes to new practice improved over time. 28 CONCLUSION Development of neonatal EWS in LMICs requires testing the acceptability and feasibility of recording vital signs using locally adapted neonatal EWS charts. Further work is required to ensure that such charts facilitate monitoring of vital signs without increasing workload.…”

“… 27 Although currently there is no evidence that using neonatal EWS improves outcomes in LMICs, research in closely related clinical areas is encouraging: in Ethiopia, the introduction of a Modified Obstetric Early Warning Score (MOEWS) in a referral hospital, improved practice in several domains. 28 …”

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

“…We are aware that clinical outcomes would only have been improved if completion of the EWS had led to an escalation of intervention, physician assessment as speci ed by the system, and the institution of appropriate interventions. It could be argued that the period post-implementation (four months) would not have been su cient to allow such changes to manifest, especially considering the designs of similar studies that measured outcomes after longer periods (12-18 months) (18,26,27). It could also be argued that the lack of standardization of morbidity outcomes used in our analysis limits its comparability to ndings of similar studies.…”