Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

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20 Maternal Intensive Care in Belgium KCE Reports 94 ACOG GUIDELINES In this chapter we point out the American guidelines of perinatal care. These guidelines are written by the American College of Obstetrics and Gynaecology and published in 2002. We would like to remark that the American healthcare organisation, training and management differ considerably from the European. Therefore it is not possible to adopt these guidelines. It are quite general guidelines and lack of specificity. Nevertheless, these are important guidelines and can be interesting a point of reference. As mentioned above the ACOG guidelines of perinatal care (2002) mention three levels of in-hospital perinatal care: basic care (level I), specialty care (level II) and subspecialty care (level III). Subspecialty care is more or less comparable with intermediate (MIC) care. The guidelines for specialty care (level II) apply only for the Neonatal Intensive Care (NIC). The subspecialty guidelines (level III) cover the concept perinatal care and deal with maternal as well as neonatal levels care (more or less comparable to our Belgian P* function). Subspecialty care (level III): • Provision of comprehensive perinatal care services for both admitted and transferred women and neonates of all risk categories including basic and specialty care services as described previously; • Evaluation of new technologies and therapies; • Data collection and retrieval. The services provided by a subspecialty care facility vary markedly from those at a specialty facility. Subspecialty care services include expertise in neonatal and maternalfoetal medicine. Both are usually required for management of pregnancies with threatened maternal complications at less than 32 weeks of gestation. Foetuses that may require immediate complex care should be delivered at a subspecialty care centre. In circumstances where subspecialty level of maternal care is needed, the level of care subsequently needed by the neonate may prove to be at the basic or specialty level. It is difficult to predict accurately all neonatal risk and outcomes before birth. Appropriate assessment and consultation should be used, considering the potential risks of the woman as well. FORUM ON MATERNITY AND THE NEWBORN OF THE ROYAL SOCIETY OF MEDICINE We want to focus an article published in The Midwives Journal of the Royal College of Midwives 7 . This article was the result of the challenges of setting up a designated high dependency/recovery unit (HDU) within a maternity service. Interesting in this article is that the authors (HDU working party consisting of obstetricians, physicians, midwives, anaesthetists and neonatologists) extensively describe their definition of intermediate care, the organisational aspects (staffing & training, …) and admission criteria. This situation is somewhat similar to the Belgian MIC-structure. The authors agreed (as many others did, cf. supra) that the HDU would exist for patients requiring more observation and/or nursing care than on a general ward. It would not normally include patients requiring ventilation or invasive monitoring. The service would exist for patients too sick to be cared for on a general ward to step up in care intermediate to that on a the ICU, and for others where appropriate to step down from ICU to HDU. The aim of their maternity recovery/HDU is to offer women and their families a consistently high level of individual, medical, and psychological care delivered by staff who understands the physiology and pathology unique to obstetric patients. The levels of care are defined as follows: • Care level one (recovery): patients at risk of deterioration in their conditions, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with advice and support from the critical care team;
KCE Reports 94 Maternal Intensive Care in Belgium 21 D. Intensive Care • Care level two (HDU): patients requiring more detailed observation or intervention, including post-operative care or support for a single organ system, and those stepping down from a higher level of care. In contrast with the lack of consensus concerning the definition of intermediate care, there seems to be a broad consensus about the definition of intensive care. Below we cite the most relevant definitions of general and obstetric intensive care: “Intensive care is appropriate for patients requiring or likely to require advanced respiratory support, patients requiring support of two or more organ systems, and patients with chronic impairment of one or more organ systems who also require support for an acute reversible failure of another organ 16 .” Intensive care is advanced and highly specialized care provided to medical or surgical patients whose conditions are life-threatening and require comprehensive care and constant monitoring. It is usually administered in specially equipped units of a health care facility (Medical Subject Headings (MeSH), consulted on 22/03/07, www.pubmed.gov ; online medical dictionary, consulted on 26/03/2007, http://cancerweb.ncl.ac.uk/omd/) INTENSIVE CARE UNIT Intensive Care unit:” A service for patients with potentially recoverable conditions who can benefit from more detailed observation and intensive treatment than can safely be provided in general wards or high-dependency areas. A minimal nurse-patient ratio of one to one is specified, together with 24-hours dedicated cover by resident trainee medical staff (Department of Health/NHS London, 1996). Intensive Care Unit: “A hospital facility for provision of intensive nursing and medical care of critically ill patients, characterised by high quality and quantity of continuous nursing and medical supervision and by use of sophisticated monitoring and resuscitative equipment; may be organised for the care of specific patient groups, e.g., neonatal or newborn ICU, neurological ICU, pulmonary ICU.” (MeSH, consulted on 22/03/07, www.pubmed.gov; online medical dictionary, consulted on 26/03/2007, http://cancerweb.ncl.ac.uk/omd/). OBSTETRIC INTENSIVE CARE DEFINITIONS As mentioned above, there are no specific definitions for obstetrical intensive care. Systems, guidelines and definitions applicable to general critical care population have been extrapolated to obstetric population. This is also what the authors of the following definition did. Mirghani et al 17 audited the obstetric admissions to the ICU in tertiary referral teaching hospital in the United Arab Emirates between 1997 and 2002. The patients were divided into two groups, based on the severity of their illness and need for organ support. “Patients requiring advanced respiratory support, two or more organ system support and those with chronic system insufficiency and requiring support for acute reversible failure of another organ system where considered genuinely to need ICU admission.”
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