884: Comparison of strategies to screen for severe maternal morbidity

In 2016 the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) published a recommendation that hospitals review all cases of SMM. Several approaches to screen for potential cases of SMM have been proposed. We compared strategies to identify SMM. This retrospective study included women delivering at or beyond 23 weeks at a large tertiary center from February to July 2018. We identified women who potentially experienced SMM using 3 approaches: 1) transfusion of 4 units of packed red blood cells or intensive care unit (ICU) admission as proposed by ACOG/SMFM; 2) the ICD-10 based SMM algorithm developed by the Centers for Disease Control (CDC); 3) a hospital-specific screening protocol that included women transfused with any blood product component, admitted to the ICU, delivered with general anesthesia, or admitted to or consulted on by the inpatient MFM service and flagged as experiencing SMM. Patients screening positive by these methods underwent case review by a multidisciplinary committee to determine the presence of SMM using the 2016 ACOG/SMFM guidelines. We calculated test characteristics for the 3 approaches using committee review as the gold standard diagnosis for SMM. We identified 159 of 2828 eligible deliveries as potential cases of SMM. ACOG/SMFM criteria identified 16 cases, CDC algorithm 103 cases, and hospital protocol 100 cases (Figure). Fifty-six cases were adjudicated by committee review as SMM (2.0% of deliveries). The ACOG/SMFM criteria had a high positive predictive value (PPV) but poor sensitivity. The CDC definition had higher sensitivity but low PPV (Table). Our hospital protocol had high sensitivity, but modest PPV. The ACOG/SMFM screening criteria of transfusion of 4 units of packed red blood cells or ICU admission detected only about a quarter of all cases of SMM and the CDC ICD-10 based criteria only about two-thirds. Hospital-specific protocols that include clinician-flagged cases should be used to identify potential cases of SMM warranting review.View Large Image Figure ViewerDownload Hi-res image Download (PPT)