Maternal ICU opens at Texas Children’s Hospital
Earlier this year, Jacqueline Elizondo was diagnosed with the flu. She was 35 weeks pregnant. By the fourth day of her illness, she could barely move and her breathing had grown labored and painful. She called her doctor, who sent her to Texas Children’s Pavilion for Women to get a lung X-ray. As Elizondo watched the worried technicians conferring with nurses, she could tell something was terribly wrong. Almost immediately, she was admitted to the hospital. Technicians could barely find a vein for her IV because she was so dehydrated. Soon, a nurse took her hand and told her she would be going to a brand-new unit, one created especially for pregnant women in need of critical care.
In her room with shiny, state-of- the-art equipment, Elizondo found herself surrounded by “an army of doctors.” They tried breathing treatments, to no avail. Finally, they explained that she would be undergoing an emergency C-section—that in order for her to get better, she needed to first have her baby.
That army soon delivered a healthy little boy. A week later, after recovering from bacterial pneumonia and sepsis in that very same room, Elizondo finally took him home.
Her life was saved in an intensive care unit (ICU) unlike any other in Texas.
Located in the labor and delivery unit of Texas Children’s Pavilion for Women, the new four-bed maternal intensive care unit opened in January. Dedicated to obstetric (OB) intensive care, the unit offers a specialized, private space for high-risk expectant and postpartum mothers. Staffed 24/7 by a pulmonary critical care team, a maternal-fetal specialist team and nurses certified in intensive care and advanced cardiovascular life support, the space has all the capabilities of a typical ICU as well as the most advanced obstetric equipment and fetal monitoring systems.
The new unit accommodates women who have been diagnosed with certain high-risk pregnancies or severe postpartum complications, including placenta accreta, sepsis, cancer, congenital heart defects or hypertensive disorders. Although Texas Children’s Hospital has been offering these services since opening the Pavilion in 2012, this is the first time dedicated space has been set aside for these clinical cases.
“Even in most advanced academic centers, pregnant patients are usually placed with a general adult ICU population, and then they call in the OB doctors to help them manage, but there are very few standalone OB critical care units that are dedicated just to taking care of mom and baby,” explained David Muigai, MBChB, an intensivist trained in both pulmonary and critical care medicine who serves as the medical director for the maternal ICU.
Placing a pregnant or postpartum woman in a traditional ICU can be problematic if the care team is not familiar with the nuances and complications associated with obstetrics.
“Women during pregnancy have varied, unique changes to their physiology related to how the heart works, how it pumps, the amount of blood volume they have in their body, when that volume will shift—you need to know obstetrics and you need to know intensive care,” said Lynda Tyer-Viola, Ph.D., vice president of Women’s Services and Professional Development and Research at Texas Children’s Pavilion for Women.
“We see the sickest of the sick, and I think having that comprehensive team of experts right here makes a huge difference in timing and in implementing life-sustaining therapies,” added Liz Bolds, one of the nurse specialists staffing the new unit.
Although the focus is on highly specialized clinical care, the hospital also wants the maternal ICU to be a place for families.
“We expect and encourage families to stay with the patients,” Tyer-Viola said.
Already, the team has observed benefits to carving out this dedicated space for their sickest patients.
“We had a patient who came in with very severe cardiogenic shock, who ordinarily … we would not have managed to harness all the monitoring or the degree of monitoring that we wanted to do easily. But because of this unit, we were easily able to hook her up to all the hemodynamic monitoring that was needed,” Muigai said.
Cardiologists also seem to feel more comfortable in the room because it looks and feels like an ICU.
“Before, people would walk into the labor and delivery unit and they were bumping into moms and dads who just had a baby, so they were very happy and walking up and down the hallway,” Muigai said. “In the middle of all that there is this really sick woman in this room, and sometimes it didn’t have the same gravitas. I think having this location and having these services here, you can tell they are feeling the depth, the gravity of the issue, as they come in through the doors.”
Maternal mortality rates
The United States is under intense scrutiny for alarmingly high maternal mortality rates, with Texas ranking especially poorly when it comes to mothers dying from causes related to pregnancy or childbirth. More than 60 percent of maternal deaths are preventable, according to some estimates.
“Too many moms are dying unnecessarily from avoidable, critical conditions,” Muigai said. “When moms first present to health care workers with acute or critical maternal conditions, a lot of times health care workers are not equipped, either with the knowledge or familiarity or the infrastructure, to deal with those conditions.”
Part of the problem is that there has been a shift away from investing in maternal care.
“Community hospitals are actually moving away from caring for pregnant moms and obstetric care in general, so that now obstetric care tends to be centered in large cities or academic hospitals,” Muigai said. “You can’t really impact maternal mortality if you don’t provide the regional centers with somewhere that they can send their very sick moms. And that’s where we come in.”
The need for specialized services is so critical that in 2013, the Texas Legislature passed the maternal levels of care designation law, requiring designation for all maternal care facilities in the state by their ability to provide certain levels of care. Under the new rule, effective March 2018, designation will become an eligibility requirement for Medicaid reimbursement beginning Sept. 1, 2020.
Facilities will be ranked Level I through IV, with Level I being basic care and Level IV being fully comprehensive care. Texas Children’s Pavilion for Women has already completed their survey for Level IV designation and is awaiting the results. The facility participated in the pilot for maternal levels of care in August, Tyer-Viola said.
“The standard for ICU maternal care is that the nursing and medical staff must be trained in high-risk OB care. Level IV designation asks for evidence that you have training on perinatal high-risk conditions for your ICU staff. … It also states that you have to have the ability to do fetal monitoring in the ICU setting,” Tyer-Viola said, adding that while most hospitals seeking the highest designation will partner with their adult medicine ICU settings, the Texas Children’s maternal ICU took a unique approach in ensuring their ICU nurses are all perinatal nurses, as well.
For fetal monitoring, most adult ICUs will bring a stand-alone fetal monitor to the bedside that the perinatal team will read, Tyer-Viola said. But the Pavilion for Women’s new maternal ICU rooms are linked to a central fetal monitoring system and analytics system, to ensure those patients receive the same oversight and surveillance as any laboring patient.
The Pavilion for Women is also part of the TexasAIM initiative, a collaboration between the Texas Department of State Health Services, the Alliance for Innovation on Maternal Health (AIM) and the Texas Hospital Association to help hospitals and clinics carry out maternal safety projects through implementing best-practices. The Pavilion for Women is sharing all of its data as well as its processes and procedures.
“We have a maternal early warning system—triggers—so it doesn’t matter who the patient is, once they reach a certain point in their blood pressure, or their pulse, their pain management, warning signs around sepsis—we activate a system that a provider goes immediately to the bedside with two specialized nurses,” Tyer-Viola said.
A host of protocols help treat patients quickly and effectively.
“We’ve been perfecting it, and we’ve been able to drive down our OB adverse events, and, we believe by sharing that through TexasAIM and the talent and tenacity that we have here, that we’re going to influence the maternal mortality rate,” Tyer-Viola said.
Today, Elizondo stays home with her weeks-old boy, an easy baby who “eats like a champ.” Her lungs have yet to completely heal, but she and her son are both healthy.
“You can’t claim to be taking care of children holistically if you’re not also taking care of their moms,” Muigai said. “I think that is really something that is precious and is unique.”