Creating a Co-Managed Obstetrical/ Intensive Care Unit

Purpose for the program: The critically ill pregnant woman presents a complex challenge to physicians and nurses in both obstetric and critical care specialties. Statistics suggest the overall estimate of obstetric patients in the United States that require critical care services is 1-3% annually. A multidisciplinary approach was taken to review the literature and create an environment where the complicated obstetric patient can receive co-managed care in a large, university hospital birth center. The Key focus was to recognize complications of pregnancy,in addition to recognizing the effect of pre-existing disease on pregnancy, in order to care for the criticially ill patient who has the potential to develop a life threatening condition.

Proposed change: The literature shows the majority of intensive care admissions for obstetric patients are secondary to obstetrical complications (e.g.hypertensive disorders, hemorrhage) along with complications, related to pre-existing conditions (e.g.respiratory failure, diabetes) warranting a higher level of care. A proposal was developed using a co-managed approach of obstetric and critical care specialties to care for critically ill obstetric patients within a 6 bed, ICU licensed unit located in the birth center.

Implementation, outcomes and evaluation:  A multidisciplinary team consisting of Obstetric and Critical Care Nursing, Maternal Fetal Medicine and Critical Care Physicians,Anesthesia ,Respiratory,Pharmacy, and Infection Control, was established to improve the assessment and management of the complicated obstetric patient. A change in culture and the need for additional education was identified witin the birth center, as well as throughout the facility recognizing this unit as the place where the complicated obstetric patient would receive care.

To implement the proposal, "OB Triggers" were developed, to guide staff  in identifying patients that would be transferred to the OB/ICU beds. A core team of nursing staff was established to take ownership of the unit, receive additional education on pregnancy complications and the effect of preexisting disease.

Since the initiation of this project,an increase in the daily census of complicated patients/day in the 6 bed OB/ICU Unit, has been demonstrated through cumulative statistics based on diagnosis coding. An increase in the amount of co-management opportunities also has been demomstrated  based on admitting physician and consults.

Implications for nursing practice:  The implementaton of this project helped staff to recognize the importance of ongoing assessment of each patient identifying complications of pregnancy that requires an increased level of care. In addition, the project has given all members of the health care team tools for recognizing the need for co-managed care and for implementing timely and well coordinated interventions when faced with increasingly complicated patients at risk for  life-threatening conditions.

Keywords: Maternal Fetal Medicine, Critical Care Medicine, Co-Management