The “how-to” of severe maternal morbidity review
Two recent expert opinions have called for all US obstetric hospitals to routinely review all cases of SMM in order to identify potential improvements in care that can be generalized to other patients.16,17 The review template was adapted from the model developed by the Centers for Disease Control and Prevention (CDC) for the review of maternal deaths. A review form is available for free download from The Council on Patient Safety in Women’s Health at www.safehealthcareforeverywoman.org.18,19 In the Table and following are the key elements of implementing routine review of all cases with SMM.
Create a multidisciplinary severe maternal morbidity review committee. The review committee should represent obstetric care providers, such as nursing, ob/gyns, anesthesiologists, certified nurse midwives, critical care specialists, and others as needed. Its culture should be one of nonblaming and broad focus. The discussion should be directed at system issues as well as provider and patient issues that might have affected the outcome. To encourage forthrightness, the committee’s proceedings should be confidential and covered under the state-specific requirements for protecting findings and deliberations from discovery.
Identify potential cases of severe maternal morbidity. Two screening criteria easily identify peripartum women with SMM: Admission to an ICU, and/or transfusion of 4 or more units of blood.
These 2 criteria are relatively easy to identify in the medical record, and they have been validated as having high sensitivity and specificity for identifying women with severe morbidity.14,20 Another more cumbersome method to screen for SMM is to use ICD-9 discharge diagnoses. Researchers at the CDC found that the use of selected ICD-9 codes identified approximately 1.5% of deliveries as potentially having SMM.12
Identify the morbidity. Identify morbidities such as hemorrhage, hypertension, sepsis, and cardiomyopathy. Once identified by any method, each case should have a preliminary review to determine if it is really an SMM and, if so, what the type of morbidity is. If the case is an SMM, a further in-depth review by the multidisciplinary review committee should be undertaken.
Abstract key data, timeline, and summary from medical record, focusing on morbidity. A detailed case abstraction, meaning a comprehensive but concise, organized summary of relevant information from the patient’s chart, should be prepared, focusing on the specific morbidity being reviewed. A sample SMM review form is available for downloading.19
Present case to confidential multidisciplinary review committee for discussion. The abstractor presents a summary of the case to the committee for discussion of the case.
Determine sequence of events leading to morbidity, its primary cause, and affected organ systems. The review committee should discuss each case, clarify any questions, and come to agreement on the pathway that led to the severe morbidity and the reasons for it.
Assess provider, system, and patient factors that might have affected outcome. The committee should consider all aspects that affected the outcome, including patient, provider, and system factors.
Decide if there were opportunities to alter outcome. The committee should determine if there were opportunities for improvement in care and, if yes, how likely they were to have had an effect (ie, not likely, somewhat likely, strongly likely).
Make recommendations (system, provider, patient) to improve care in future. Such opportunities should be delineated and recommendations made regarding the system, provider, and patient.
Have system in place to collect information, effect change, and determine if changes improved future outcomes. At minimum, each case would have a summary in which the key morbidity and etiology are noted and opportunities and recommendations for improvement in care are recorded. An example of a form that could be used to capture such information is available.19 Ideally, each hospital committee would retain such key data confidentially.
Recommendations made by the committee for system, process, and provider changes need to be put into place and the results evaluated. If the recommendations were correctly chosen and implemented, the incidence of preventable morbidities would be expected to decrease over time.