quality improvements in the recognition and treatment of sepsis … · 2019-04-16 · 8 years on...
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8 years on – Quality improvements in the
recognition and treatment of sepsis in the
Maternity Unit, Our Lady of Lourdes
Hospital, Drogheda
Ms. Mary Rowland Midwifery Clinical Skills Facilitator
Third National Sepsis Summit
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IN CONFIDENCE
REPORT
into circumstances pertaining to the death of
Mrs. Tania McCabe and her infant son Zach
at Our Lady of Lourdes Hospital, Drogheda
on Friday 9th March, 2007.
EXECUTIVE SUMARY
1.11 Key Findings
The Review Team concluded that Tania died from sepsis with haemorrhage as a
complicating fact. Zach has severe congenital abnormalities, consistent with
otocephaly, a rare and potentially fatal condition not always readily diagnosable
antenatally. Zach’s death was an inevitable consequence of his congenital
abnormalities.
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Physiological Observation Track & Trigger System
(2009)
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ALERT™ (Acute Life Threatening Events Recognition
and Treatment) Programme
(2009)
• Multi-professional
• Patient deterioration
• Maternity scenarios
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PROMPT
Practical Obstetric Multi Professional Training
(2009)
• Train the trainer
programme
• Multi professional team
training
• Locally adapted
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Emergency Skills & Drills
(2010)
• Multi-professional
• Simulated emergencies
• Team work
• Communication
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Saving Mothers Lives - CMACE
(2011)
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Sepsis Awareness Programme
(2011)
• Educational campaign
• Incorporated sepsis into
PROMPT
• COMPASS programme
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World Sepsis Day
(2012)
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Further Education
(2013)
• Department of Nursing &
Midwifery
• Certificate in the
assessment of the acutely
ill woman in maternity
services
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ISBAR - Identify, Situation, Background,
Assessment, Recommendations
(2013)
• Development of ISBAR sticker INITIATE
March 2014
• Staff training
• Consultation
• Pilot & feedback
• Final version
PLAN
March/April 2014
• Development of standing operating procedure (SOP)
• Implementation of final draft
IMPLEMENT
April 2014
• Audit and feedback to staff Audit
July 2014
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Local Practice Guideline
(2014)
• Pathways
• Sepsis screening kits on
emergency trolleys
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Today
(2014)
• Pilot site for national
sepsis screening tool
• Ongoing sepsis education
sessions
• Continue to combat sepsis
together
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Thank You
Ms. Mary Rowland Midwifery Clinical Skills Facilitator
Third National Sepsis Summit