FAST-M complex: New intervention to improve recognition and management of suspected maternal sepsis
Maternal sepsis is defined as 'organ dysfunction resulting from infection during pregnancy, child birth, post-abortion, or the post-partum period'. Globally it is the third most common direct cause of maternal mortality, accounting for 11% of deaths and disproportionately impacting low-resource settings within low- and middle-income countries (LMICs).
Early recognition and timely initiation of sepsis treatment have both been shown to improve outcomes. Use of sepsis screening tools and treatment bundles can reduce time to treatment initiation and have been widely adopted in high-resource settings.
Using a modified Delphi process to engage a wide range of healthcare practitioners from a range of LMICs, as well as an expert panel, a clinically relevant maternal sepsis care bundle was developed through international consensus. The resultant maternal sepsis care bundle, which was called 'FAST-M' to aid with practitioner recall, consisted of the following components: Fluids, Antibiotics, Source identification and control, Transfer to an appropriate level of care, and ongoing Monitoring of mother and neonate.
The aim of this feasibility study carried by J Cheshire et al was to evaluate whether the implementation of the FAST-M complex intervention for the recognition and management of maternal sepsis was feasible and resulted in an improvement in clinical care within a low-resource setting.
The authors conducted a before-and-after study at 15 government healthcare facilities in Malawi between June 2017 and March 2018. The eligible participants were all women who were pregnant or within 6 weeks of miscarriage, termination of pregnancy or child birth (irrespective of outcome) and who were receiving either inpatient or outpatient healthcare.
The intervention consisted of the following components: (i) a modified early obstetric warning system (MEOWS) chart and the FAST-M decision tool, (ii) the FAST-M maternal sepsis care bundle and (iii) the FAST-M implementation programme.
Component 1 – MEOWS chart and FAST-M decision tool
The MEOWS chart supported healthcare practitioners to ensure vital signs were recorded regularly in all women, and thus to identify women at risk of clinical deterioration. The presence of abnormal vital signs prompted healthcare practitioners to screen for maternal sepsis using the FAST-M decision tool. The FAST-M decision tool guided healthcare practitioners to differentiate between those with features of suspected maternal sepsis, those with a maternal infection which had not yet developed into sepsis, and those with abnormal vital signs due to another cause. The distinction between those with maternal sepsis and a maternal infection was based on the degree of derangement in the vital signs.
Component 2 – FAST-M maternal sepsis care bundle
Women deemed to have suspected maternal sepsis were commenced on the FAST-M care bundle, with the aim to initiate all components of the bundle within an hour of sepsis recognition.
Component 3 – The FAST-M implementation programme
The implementation programme consisted of the following: FAST-M training programme and refresher training, sepsis champions, task shifting, performance dashboards and data feedback.
Primary process outcomes included: the proportion of inpatients receiving a full set of vital signs on admission to the ward and the proportion of women with suspected maternal sepsis receiving the full FAST-M bundle (and each of the individual bundle components) within 1 hour of recognition of sepsis.
Secondary outcomes included: the proportion of women with suspected maternal sepsis escalated to senior healthcare practitioners on the basis of abnormal vital signs and the proportion of women with suspected maternal sepsis who received a clinical review by a senior clinical decision maker following their diagnosis.
During the evaluation of the FAST-M intervention, 12,753 inpatients were admitted to the maternity wards. Of those, 415 inpatients (163 women during the baseline and 252 women during the intervention) had their records examined to assess whether their vital signs had been taken on admission to the wards.
- Following the implementation of the FAST-M intervention, women were more likely to have a complete set of vital signs taken on admission to the maternity wards compared with the baseline phase (P < 0.001).
- Improvements were seen across the measurement of all vital sign variables; respiratory rate, temperature, heart rate, blood pressure, urine output and neurological assessment.
- Fetal heart rate was comparatively well recorded before the intervention, so the improvement in recording of this variable was small.
- A total 119 women with suspected maternal sepsis were identified during the study, 12 during the baseline phase and 107 during the intervention phase.
- Following the implementation of the FAST-M intervention, the identification of cases of suspected maternal sepsis increased as a proportion of the total number of maternal infection cases during the study (12/106 [11.3%] versus 107/166 [64.5%], P < 0.001).
- Following the implementation of the FAST-M intervention, women being treated for suspected maternal sepsis were more likely to receive all components of the FAST-M treatment bundle within 1 hour of recognition of suspected sepsis.
- Improvements in sepsis management were seen across all components of the FAST-M treatment bundle, with women more likely to receive intravenous fluid therapy (P = 0.004), source identification, consideration for transfer (P = 0.003) and ongoing monitoring within 1 hour of sepsis recognition.
- Following the implementation of the FAST-M intervention, women with suspected maternal sepsis were more likely to be escalated to senior healthcare practitioners on the basis of their abnormal vital signs ( P = 0.02). Similarly, women were more likely to receive a clinical review by a senior clinical decision maker following their diagnosis of suspected maternal sepsis (P < 0.001).
Early recognition of patients with sepsis is critical to ensuring timely management and improved maternal outcomes. Use of MEOWS charts has been shown to predict severe maternal morbidity and mortality and to be associated with improved health outcomes.
The authors found that the use of paper-based MEOWS charts combined with staff training and task shifting meant vital signs were more frequently measured and recorded. In addition, escalation of abnormal vital signs to senior healthcare practitioners increased, meaning women at risk of deterioration were more likely to be identified earlier and screened for sepsis.
In low-resource settings, poor sepsis recognition and lack of screening protocols can act as barriers to prompt identification and treatment. Use of sepsis screening tools has been shown to reduce time to treatment initiation. In combination with the FAST-M implementation approach, use of the FAST-M decision tool helped streamline maternal sepsis identification and guide healthcare practitioners to make correct diagnoses.
The evaluation of the feasibility of the FAST-M intervention is an attempt to answer the WHO and Jhpiego calls to develop and test strategies to improve the recognition and management of maternal sepsis.
Implementation of the FAST-M intervention, which sought to improve the recognition and management of maternal sepsis in a low-resource setting, was not only feasible but also resulted in improved clinical care. Future work will scale up the intervention for a multi-country intervention trial to determine intervention effectiveness.
SOURCE: Cheshire J, Jones L, Munthali L et al; BJOG 2021;128:1324–1333.