What factors influence midwives to provide obstetric high dependency care on the delivery suite or request care be escalated away from the obstetric unit? Findings of a focus group study

Alison James,Simon Cooper,Elizabeth Stenhouse,Ruth Endacott

doi:10.1186/s12884-019-2487-0

Alison James, Simon Cooper + Show 2 more

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https://doi.org/10.1186/s12884-019-2487-0

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Abstract

BackgroundIn the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman’s care should be escalated to the critical care team. This study aimed to explore the question: What factors influence midwives to provide OHDC or request care be escalated away from the obstetric unit in hospitals remote from tertiary referral centres?MethodsFocus groups were undertaken with midwives (n = 34) across three obstetric units in England, with annual birth rates ranging from 1500 to 5000 per annum, in District General Hospitals. Three scenarios in the form of video vignettes of handover were used as triggers for the focus groups. Scenario 1; severe pre-eclampsia, physiologically unstable 2; major postpartum haemorrhage requiring invasive monitoring 3; recent admission of woman with chest pain receiving facial oxygen and requiring continuous electrocardiogram (ECG) monitoring. Two focus groups were conducted in each of the obstetric units with experienced midwives. Data were analysed using a qualitative framework approach.ResultsFactors influencing midwives’ care escalation decisions included the care environment, a woman’s diagnosis and fetal or neonatal factors. The overall plan of care including the need for ECG and invasive monitoring were also influential factors. Midwives in the smallest obstetric unit did not have access to the facilities for OHDC provision. Midwives in the larger obstetric units provided OHDC but identified varying degrees of skill and sometimes used ‘workarounds’ to facilitate care provision. Midwifery staffing levels, skill mix and workload were also influential. Some differences of opinion were evident between midwives working in the same obstetric units as to whether OHDC could be provided and the support they would enlist to help them provide it. Reliance on clinical guidelines appeared variable.ConclusionsFindings indicate that there may be inequitable OHDC provision at a local level. Organisationally robust systems are required to promote safe, equitable OHDC care including skills development for midwives and precise escalation guidelines to minimise workarounds. Training for midwives must include strategies that prevent skills fade.

Highlights

In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman’s care should be escalated to the critical care team
Women who become acutely ill during pregnancy or the intrapartum / postnatal periods may be transferred to a critical care unit for complex treatments including organ system monitoring and support [1, 2] and some will remain in the Obstetric Unit (OU) and receive Obstetric High Dependency Care (OHDC) [3, 4] on the Delivery Suite
Short video vignettes were used to trigger discussion in focus groups conducted across three OUs in hospitals in England that were geographically remote from tertiary referral centres

Summary

Introduction

In the United Kingdom, midwives will engage in discussions with the multidisciplinary team as to whether they can provide Obstetric High Dependency Care (OHDC) on the Delivery Suite or whether a woman’s care should be escalated to the critical care team. Escalation of care is defined by Posner and Freund (2004: p 438) as “Any significant unplanned increase in the level of care provided to the patient and includes such outcomes as unplanned intensive care unit admission” [13] This focus group study examined the factors that influence midwives working in OUs remote from tertiary referral centres to provide OHDC or request a woman’s care be escalated away from the OU. Tertiary referral centres are those OUs classed as regional or national centres of excellence, providing specialist care for women with for example, complex comorbidities, and this sets them aside from District General hospitals in the UK [14]

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