OHIO PREGNANCY ASSOCIATED MORTALITY REVIEW (PAMR) TEAM ASSOCIATED FACTORS FORM Please Circle: OFFICIAL WORKING COPY Case # DEATH REVIEW PROCESS 1. Estimate the degree of relevant information (records) available for this case a. Complete: All records necessary for adequate review of the case were available b. Mostly Complete: Minor gaps (i.e. information that would have been beneficial but was not essential to the review of the case) c. Somewhat Complete: Major gaps (i.e. information that would have been crucial to the review of the case) d. Not complete: Minimal records available for review (e.g. death certificate and no additional records) 2. What additional records (if any) would have been needed for review? Please list: Date of Review a. Complete b. Mostly Complete c. Somewhat Complete d. Not Complete N/A N/A 3. Does team agree with primary cause of death listed on death certificate? YES NO (Go to # 5) (Go to #4) 4. If team DOES NOT agree with primary cause of death, list suggested COD: If unknown, please state: 5. Does team agree with manner of death? YES NO (Go to # 7) (Go to #6) 6. If team DOES NOT agree with manner of death, please indicate manner: NATURAL ACCIDENT SUICIDE HOMICIDE COULD NOT DETERMINE 7. Was death pregnancy related? YES NO CAN T DETERMINE 8. Please indicate the number that reflects the level of consensus among your team when determining if death was pregnancy-related Member Consensus: Consensus decisions reflect a sense of agreement and unity among committee members. (1) Team can give an unqualified yes to the decision. We are all for it. (2) Team can live with the decision; We find it acceptable. (3) Team does not fully agree with the decision. A few members disagree with the determination, but they trust the wisdom of the team. (4) We need to do more work before reaching consensus. No clear unity in the team. 9. Please indicate COD Code from CDC classification list (Put 999 if COD Unknown): LEVEL OF CONSENSUS #.
ASSOCIATED FACTORS: For each individual, clinical, or systems-level factor below, please indicate whether that factor was: (1) and contributed to the maternal death; (2) but did not contribute to the maternal death; OR (3) but unclear if contributed to the maternal death 10. INDIVIDUAL FACTORS DEFINITION a. Delay or failure to seek care b. Noncompliance with medical recommendations c. Lack of knowledge regarding importance of event d. Lack of knowledge of treatment or follow-up e. Cultural, religious, or language factors f. Environmental factors g. Intimate partner violence h. Other history of violence i. Mental health j. (a) Substance use Alcohol, illicit drugs, prescription abuse The woman delayed or failed to seek care, treatment or follow-up care/actions (e.g., missed appointment and did not reschedule) The woman did not accept medical advice (e.g., refused treatment for religious or other reasons or left the hospital against medical advice) The woman lacked knowledge or understanding regarding the significance of a health event (e.g., shortness of breath as a trigger to seek immediate care) The woman lacked knowledge or understanding about the need for treatment/follow up after evaluation for a health event (e.g., needed to keep appointment for psychiatric referral after an ED visit or exacerbation of depression) Demonstration that any of these factors was either a barrier to care due to lack of understanding or led to refusal of therapy due to beliefs (or belief systems) Factors related to weather or terrain (e.g., the advent of a sudden storm leads to a motor vehicle accident) Physical or emotional abuse perpetrated by the woman s current or former intimate partner Physical or emotional abuse other than that perpetrated by intimate partner (eg: family member or stranger) The woman carried a diagnosis of a psychiatric disorder. This includes postpartum depression Woman s substance abuse directly compromised woman s health status (e.g., acute methamphetamine intoxication exacerbated pregnancy-induced hypertension or woman was more vulnerable to infections or medical conditions) Instances of differential treatment by health care professionals or facilities (e.g., clinician bias/judgment affected treatment or how teams responded to woman s substance abuse) should be appropriately noted in one of the clinical factors in Question #16 AND Contributed DID NOT Contribute UNCLEAR if Contributed
(b) Substance use - Tobacco k. Mental retardation/ Cognitive impairment l. Chronic medical condition m. Obesity n. Childhood sexual abuse o. Childhood trauma p. Uninsured/Lack of financial resources q. Unstable housing r. Isolation: Lack of family/friend support system Woman s use of tobacco directly compromised the woman s health status (e.g., long term smoking led to underlying chronic lung disease) The presence of a form of cognitive impairment (e.g., mental disability led to a failure to seek treatment or adhere to therapy Occurrence of one or more significant preexisting medical condition(s) (e.g., cardiovascular disease or diabetes) Body Mass Index (BMI) = height/weight 2 ; Obese BMI > 30.0 and contributed to the cause of death Woman experienced rape, molestation, or other sexual exploitation during childhood plus persuasion, inducement or coercion of a child to engage in sexually explicit conduct Woman experienced physical or emotional abuse or violence other than that related to sexual abuse during childhood Lack or loss of health care insurance or other financial duress that impacted woman s ability to care for herself (e.g., did not seek services because unable to miss work or afford postpartum visits after insurance expired) Woman lived on the street or in a homeless shelter OR living in transitional or temporary circumstances with family or friends Social support from family, partner, or friends was lacking, inadequate and/or dysfunctional (e.g., domestic violence, no one to rely on to ensure appointments were kept) s. Other (Please Specify)
11. CLINICAL FACTORS DEFINITION Clinicians delayed or failed to make diagnosis, treatment or follow-up decisions. AND Contributed DID NOT Contribute UNCLEAR if Contributed a. Delay in or lack of diagnosis, treatment, or follow-up b. Use of ineffective treatment Response or management to triggers can be by one or more providers, such as response by OB, ER, anesthesiologist, or other providers. Please specify provider type: Clinicians used ineffective treatment, or continued to use treatment without improvement rather than moving to an alternative course of action. Treatment can include procedures, such as BLS/ACLS, inductions, augmentations, or cesareans, in addition to pharmaceuticals c. Misdiagnosis Clinicians made an incorrect diagnosis d. Failure to refer or seek consultation e. Lack of continuity of care f. Inadequate patient education g. Lack of communication between providers h. Inadequate preconception Counseling i. Failure to screen/inadequate assessment for risk j. Other (Please Specify) Specialists were not consulted or did not provide care; Referrals to specialists were not made Care providers did not have access to woman s complete records or did not communicate woman s status sufficiently. Lack of continuity can be between prenatal, labor and delivery, and postpartum providers The woman was not given formal instruction regarding a health event (e.g., a newly diagnosed woman with diabetes not receiving nutritional counseling) Care was fragmented (i.e., uncoordinated or not comprehensive) among or between health care providers This may be between providers of the same specialty (e.g., partners in a practice) or it may between/among different disciplines all caring for the same woman The woman was seen prior to or between pregnancies but risk factors for poor outcome were not identified and/nor addressed Factors placing the woman at risk for a poor clinical outcome were not recognized and the woman was not transferred to a provider able to give a higher level of care
12. SYSTEM FACTORS DEFINITION a. Inadequately trained/unavailable personnel or services b. Inadequate or unavailable equipment/technology c. Lack of standardized policies/procedures d. Unavailable facilities e. Poor communication/ Lack of case coordination or management/ Lack of continuity of care (system perspective) Personnel were not appropriately skilled for the situation or did not exercise clinical judgment consistent with current standards of care, (e.g., error in the preparation or administration of medication or unavailability of translation services) Equipment was missing, unavailable or not functional, (e.g., absence of blood tubing connector) The facility lacked basic policies or infrastructure germane to the woman s needs, (e.g., response to high blood pressure or a lack of or outdated policy or protocol) Facilities with an appropriate risk level of care were not present in the geographic nor otherwise accessible area to woman Care was fragmented (i.e., uncoordinated or not comprehensive) among or between health care facilities or units, (e.g., records not available between inpatient to outpatient or among units within the hospital, such as Emergency Department and Labor and Delivery) AND Contributed DID NOT Contribute UNCLEAR if Contributed f. Unavailable or inadequate response by EMS EMS personnel were not appropriately skilled for the situation or did not arrive in a timely manner g. Barriers to accessing care: Insurance, provider shortage, transportation h. Inadequate community outreach/resources i. Inadequate law enforcement response System issues as opposed to woman noncompliance led to lack of care Examples include lack of insurance despite Medicaid expansion non-eligibility, a provider shortage in woman s geographical area, or lack of public transportation Lack of coordination between healthcare system and other outside agencies/organizations in the geographic/cultural area that work with maternal child health issues Law enforcement response was not in a timely manner or was not appropriate or thorough in scope j. Other (Please Specify)
13. Opportunity to Alter Outcome? a. Strong: Factor(s) identified that definitely contributed to death; If an alternative action had been taken, death would not have occurred. b. Good: Factor(s) identified that probably or definitely contributed to death; If an alternative action had been taken, death may not have occurred. c. Some: Multitude of fewer or weaker factors that could have been reversed, but it would have required specific actions beyond what could feasibly be accomplished. d. None: No clear point of prevention or intervention; No instances where alternative actions might have changed the outcome. e. Insufficient Information: Death lacked enough supplemental information to determine if there was any opportunity to alter outcome 14. Would this case be a good example to use as a teaching case? a. Strong b. Good c. Some d. None e. Insufficient Information YES NO (Go to # 15) (Go to #16) 15. If YES, What is the key teaching point? Medical (Please Specify): Death - Cause Social Determinants (Please Specify): Other (Please Specify): 16. Would maternal transport to a higher level of care have been of benefit to this woman? YES NO MAYBE N/A 17. CASE RECOMMENDATIONS a. Issue (What could be done better?): b. Intervention (What could be done?): c. Evaluation (How do we know if working?): COMMITTEE REVIEW COMMENTS: