Maternal sepsis is recognised by The World Health Organization (WHO) as a major cause of maternal mortality, accounting for over 10% of maternal deaths worldwide.
Dr David Lissauer leads a research group at the University of Birmingham, tackling the problem. “Maternal sepsis can be difficult to recognise in pregnant mothers. But it is vital to be aware of the signs, as patients can deteriorate rapidly. Management of maternal sepsis has been improved in the UK through raising awareness amongst patients and health care workers and introducing a sepsis care bundle but the aim of our work now is to find a similar solution for countries with limited resources.”
“We don’t have a timer or wall clocks that are working for respiratory rate so we have to use our phones. But our phones don’t have a timer so we have to wait for the beginning of the minute to start. There is only one wall clock in all departments that is working so we complained that but then Laura came and gave us timers so we can now check respirations without any problem.”
The Surviving Sepsis Campaign is the gold standard for sepsis management in high income countries. At its core are a bundle that simplifies the complex processes of the care of patients with sepsis - a selected set of initial elements of care that, must be done rapidly and when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone.
While sepsis bundles have been a real success story with robust evidence supporting their implementation, they are not yet fit for purpose across the globe in resource poor settings. That is the aim of this research.
The bundle is born
“We had already been working on the AIMS trial in Malawi, Tanzania, Uganda and Pakistan investigating the benefit of using antibiotics immediately prior to miscarriage surgery with a view to reducing the risk of infection. But what about when we aren’t successful at preventing the infection? It was clear we also needed better approaches for when serious infections did occur,” says Dr Lissauer.
“We needed to develop a care bundle that could be effective in locations with significant challenges; be it a lack of training or infrastructure. There are many community hospitals in low income countries with no access to running water, so we knew that we had to adapt the UK model to something that could be both effective and achievable in this environment.”
Much of the study centres on the introduction of clear and consistent processes. As such, the outcome was the development of a treatment bundle known as “FAST-M”, an acronym that outlines the consideration of the key treatment components: Fluids, Antibiotics, Source Control, Transport, Monitoring (of mother and newborn).
The team is now conducting a pilot feasibility study of the introduction of the bundle at fifteen sites in Malawi.
Healthcare workers now routinely take patient’s observations and chart them on a specially adapted Modified Early Obstetric Warning Score (MEOWS) chart. Abnormal observations on this chart prompt the healthcare workers to use the FAST-M decision tool, which then guides the healthcare worker as to whether the patient has maternal sepsis.
A year of ups and downs
Around a year into the pilot study, the team are pleased to see the bundle having a positive impact on the ground.
Laura Munthali, an in-country study coordinator and former senior midwife (or nursing officer) in Malawi, explained how FAST-M has been received.
“Most health care providers have verbalised the importance of the tools introduced. At Kamuzu Central Hospital, outside of our network, we even have doctors asking why FAST-M has not been introduced there yet.”
The MEOWS chart for early observation that compliments the bundle has been a great aid to hospitals and patient attendants.
“It is now much easier to track progress once a mother has been admitted until discharge. Most facilities have agreed to have patient attendants record vital signs at 6am and 2pm, and where there are shortages, some attendants from quieter wards are able to help the maternity department. It is telling how committed the teams are to the process.”
“By selecting FAST-M champions in each of the participating sites we have helped to build relationships with the facilities and improved our ability to communicate important information from the study. The champions have been an essential part of helping their facility to adopt the tools that are essential for monitoring, diagnosing and treating patients.”
Despite having been welcomed by local healthcare workers, the research team has found a number of obstacles to the implementation of the bundle. Some are perhaps predictable; poor filing systems, staff shortages, an absence of basic infrastructure, inconsistent workforce, equipment shortages, and the congestion of maternity departments.
The solution to these problems are far from simple. But there have been notable successes. One key aspect has been empowering local health care workers to share tasks more effectively. With lower cadre health workers, after the right training and support, helping take on some of the tasks from the midwives. This has ensured key basic actions such as routinely measuring patient vital signs is not disrupted by the staff shortages.
But in order to implement such an intervention more widely, there are further challenges to address. In particular understanding how to fully embed the new tools and ensure improvements in care are sustained in the long-term. There also remain key problems in infection prevention, with running water not provided reliably across the sites, and in our last survey only two in ten workers on maternal wards were able to wash their hands regularly.
Expanding the horizons
Although there are challenges, Dr Lissauer remains optimistic about the FAST-M project. “We know that there is plenty of work to do. What we have seen already is that it is feasible to implement the FAST-M bundle, even in very challenging health environments, and this really has the potential to save lives. The next step is for us to build on those foundations. The qualitative data we are collecting allow us to understand the nuances of each hospital, and the barriers and facilitators to implementation from many perspectives. This will help shape the development of a bundle that is optimised for Malawi as a whole, and for resource poor settings across the world.”
We are working with the World Health Organisation and our partners in Malawi, Kenya, India, South Africa and South America, with the goal of testing the bundle at scale and developing robust evidence of its clinical and cost effectiveness.
The team have also now expanded the programme to better address the critical aspects of infection prevention. Including hand-washing and infection prevention strategies on the wards and in the operating theatre.