Maternal Hypertension Change Package

This is the Change Package for Maternal Hypertension. It includes information relevant to the AIM Severe Hypertension bundle and The Joint Commission requirements.

Resources Comments
Measure Set This document lists the measures for the initiative.
Severe Maternal HTN FAQs and Scenarios This document includes recommendations for data collection and answers to frequently asked questions about inclusion in metrics.
Key Driver Diagram The diagram provides the underlying approach for the initiative.
Measure Tracking Worksheet This document is designed to assist tracking measures.
Project Assessment Scale This scale will be used for assessing progress in the initiative.
Team Aims Worksheet This document provides guidance on overall aims.
WisPQC Data Terms of Use This document is required for sharing data.
Informational Webinar View recorded Webinar.
Download slides. (PDF)

 

SETTING THE FOUNDATION

The Family Voice
Resource(s) Comments
Voices of Impact The Voices of Impact video series is available through the Council on Patient Safety in Women’s Health Care. The goal of the Voices of Impact video series is to elevate the voices of women and families who have experienced severe maternal events. Putting voices to the numbers can bring awareness to this critical issue and empower women and their care providers to make a positive impact.
Voices of Impact: Irving Family’s Story  

 

Getting Started
Resource(s) Comments
Always Events Toolkit Always Events(R) are defined as those aspects of the care experience that should always occur when patients, their family members or other care partners, and service users interact with health care professionals and the health care delivery system. A one page overview is also available.
Illinois Perinatal Quality Collaborative (ILPQC) The section describing the Severe Maternal Hypertension Initiative contains useful information.
Institute for Healthcare Improvement (IHI) The Institute for Healthcare Improvement (IHI), an independent not-for-profit organization based in Boston, Massachusetts, is a leading innovator, convener, partner, and driver of results in health and health care improvement worldwide. At its core, IHI believes everyone should get the best care and health possible. IHI has a commitment to Person- and Family-Centered Care. This page lists resources for getting started.
PDSA Worksheet This worksheet is a component of IHI’s QI Essential Toolkit. The Plan-Do-Study-Act (PDSA) cycle is a useful tool for documenting a test of change. Use this worksheet for each change you test.
QI Project Charter The QI Project Charter provides a rationale and roadmap for team to clarify thinking about what needs to be done and why.
Walk-through Walk-throughs enable providers to understand the experience of care from the patient’s and family’s points of view by going through the experience themselves.
Reducing peripartum disparities
Tools Comments
Improving Health Equity: Assessment Tool for Healthcare Organizations A resource from IHI.
PA AIM Bundle: Improving Severe Hypertension Treatment and Reducing Racial/Ethnic Disparities This document integrates the AIM Improving Severe Hypertension Treatment and Reducing Racial/Ethnic Disparities bundles.
Reduction of Peripartum Racial/Ethnic Disparities (+AIM) This link provides PDFs of the AIM bundle, complete and supplemental resource listings, and other materials.

 

References Summary
Britton LE, Berry DC, Hussey JM. Comorbid Hypertension and Diabetes among U.S. Women of Reproductive Age: Prevalence and Disparities. J Diabetes Complications. 2018;32(12):1148-1152. Comorbid hypertension and diabetes are more common among non-Hispanic black women and less likely to be diagnosed.
Cabacungan ET, Ngui EM, McGinley EL. Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin. Matern Child Health J. 2012;16(7):1455-1467. Findings show significant racial/ethnic disparities in maternal morbidities, and suggest the need for better screening, management, and timely referral of these conditions, particularly among racial/ethnic women.
Fasanya HO, Hsiao CJ, Armstrong-Sylvester KR, Beal SG. A Critical Review on the Use of Race in Understanding Racial Disparities in Preeclampsia. The Journal of Applied Laboratory Medicine. 2021 Jan 12;6(1):247–56. Existing studies seeking to identify racial differences in analytes have limited research designs and tend to operationalize race as a proxy for biologically inherent (i.e., genetic) differences between races despite a plethora of other possible explanatory mechanisms.
Gonzalez C, Early J, Gordon-Dseagu V, Mata T, Nieto C. Promoting Culturally Tailored mHealth: A Scoping Review of Mobile Health Interventions in Latinx Communities. J Immigr Minor Health. 2021 Oct;23(5):1065–77. Multi-modal applications that combine texting with self-guided interactive content show promise for culturally tailored mHealth.
Gyamfi-Bannerman C, Pandita A, Miller EC, Boehme AK, Wright JD, Siddiq Z, et al. Preeclampsia outcomes at delivery and race. The Journal of Maternal-Fetal & Neonatal Medicine. 2019 Feb 20;0(0):1–8. Black women were at higher risk for severe morbidity and mortality associated with preeclampsia.
MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017. Am J Public Health. 2021 Sep 1;111(9):1673–81. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period.
Mayne SL, Yellayi D, Pool LR, Grobman WA, Kershaw KN. Racial Residential Segregation and Hypertensive Disorder of Pregnancy Among Women in Chicago: Analysis of Electronic Health Record Data. Am J Hypertens. 2018;31(11):1221-1227. Racial residential segregation was associated with greater prevalence of hypertensive disorder of pregnancy among those living in higher poverty neighborhoods.
Miller EC, Zambrano Espinoza MD, Huang Y, et al. Maternal Race/Ethnicity, Hypertension, and Risk of Stroke During Delivery Admission. J Am Heart Assoc. 2020;9(3):e014775. Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non-Hispanic whites.
Minhas AS, Ogunwole SM, Vaught AJ, Wu P, Mamas MA, Gulati M, et al. Racial Disparities in Cardiovascular Complications With Pregnancy-Induced Hypertension in the United States. Hypertension. 2021 Aug;78(2):480–8. After adjustment for socioeconomic factors and comorbidities, preeclampsia/eclampsia was associated with increased risk of cardiovascular events in women of all races/ethnicities. However, risk was highest among Asian/Pacific Islander women and lowest among Black women. In sum, while Black women were the most likely to experience preeclampsia, Asian/Pacific women were the most at risk for acute cardiovascular complications during delivery hospitalization.
Shahul S, Tung A, Minhaj M, et al. Racial Disparities in Comorbidities, Complications, and Maternal and Fetal Outcomes in Women with Preeclampsia/Eclampsia. Hypertens Pregnancy. 2015;34(4):506-515. Results suggest that African-American women are more likely to have risk factors for preeclampsia and more likely to suffer an adverse outcome during peripartum care.
Singh GK, Siahpush M, Liu L, Allender M. Racial/Ethnic, Nativity, and Sociodemographic Disparities in Maternal Hypertension in the United States, 2014-2015. Int J Hypertens. 2018;2018:7897189. Ethnicity, nativity status, older maternal age, and prepregnancy obesity and excess weight gain should be included among the criteria used for screening for gestational hypertension.
Tiako MJN, McCarthy C, Meisel ZF, Elovitz MA, Burris HH, South E. Association between Low Urban Neighborhood Greenness and Hypertensive Disorders of Pregnancy. Am J Perinatol [Internet]. 2021 Aug 27 [cited 2021 Oct 11]; In this study, greenness was associated with lower hypertensive disorders of pregnancy odds.
The Joint Commission
Resource(s) Comments
R3 Report Issue 24: PC Standards for Maternal Safety Effective July 1, 2020, 13 new elements of performance were applicable to Joint Commission-accredited hospitals. Prevention, early recognition, and timely treatment for maternal hemorrhage and severe hypertension/preeclampsia had the highest impact in states working on decreasing maternal complications.

READINESS: Every Unit

Standards for early warning signs, diagnostic criteria, monitoring, and treatment
Tools Comments
Maternal Early Warning Criteria A multidisciplinary working group convened by the National Partnership of Maternal Safety used a consensus-based approach to define the Maternal Early Warning Criteria, a list of abnormal parameters that indicate the need for urgent bedside evaluation by a clinician with the capacity to escalate care.
MEOWSSCALE A sample nursing policy for the Modified Early Obstetric Warning System (MEOWS) from Crawford Memorial Hospital.
MEWS-Protocol A sample protocol for Maternal Early Warning Signs (MEWS)

 

References Summary
Darwin KC, Federspiel JJ, Schuh BL, Baschat AA, Vaught AJ. ACC-AHA Diagnostic Criteria for Hypertension in Pregnancy Identifies Patients at Intermediate Risk of Adverse Outcomes. Am J Perinatol. 2021 Aug;38(S 01):e249–55. Women with first trimester American College of Cardiology-American Heart Association (ACC-AHA) Stage I hypertension were more likely to develop preeclampsia, deliver preterm, and deliver a small-for-gestational age neonate than normotensive women.
DeSisto CL, Robbins CL, Ritchey MD, Ewing AC, Ko JY, Kuklina EV. Hypertension at delivery hospitalization – United States, 2016–2017. Pregnancy Hypertension. 2021 Dec 1;26:65–8. In 2016–2017, the prevalence of chronic hypertension was 216 per 10,000 delivery hospitalizations nationwide, ranging from 125 to 400 per 10,000 delivery hospitalizations in individual states. The prevalence of pregnancy-associated hypertension was 1021 per 10,000 delivery hospitalizations nationwide, ranging from 693 to 1382 per 10,000 delivery hospitalizations in individual states.
Friedman AM, Campbell ML, Kline CR, et al. Implementing Obstetric Early Warning Signs. AJP Rep. 2018;8(2):e79-e84. To reduce maternal risk effectively, early warning systems that capture deterioration from a broad range of conditions may be required in addition to bundles tailored to specific conditions such as hemorrhage, thromboembolism, and hypertension.
Hannola K, Hoppu S, Mennander S, Huhtala H, Laivuori H, Tihtonen K. Obstetric early warning system to predict maternal morbidity of pre-eclampsia, postpartum hemorrhage and infection after birth in high-risk women: a prospective cohort study. Midwifery. 2021 Aug 1;99:103015. The sensitivity of obstetric early warning system at its best was 72% for pre-eclampsia, 52% for infection and 25% for postpartum haemorrhage.
Hoppu S, Hannola K, Mennander S, Huhtala H, Rissanen M, Tulensalo E, et al. Routine Bedside Use of Obstetric Early Warning System in the Postnatal Ward to Identify Maternal Morbidity Among High-Risk Women. Journal of Patient Safety [Internet]. 2021 Oct 13 [cited 2021 Oct 22]; In high-risk women, OEWS revealed one-half of the morbidity. Women with PPH and preeclampsia benefited most from it. Abnormal blood pressure and pulse had the strongest associations with morbidity.
Magee LA, Singer J, Lee T, Rey E, Asztalos E, Hutton E, et al. The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy – analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study). BJOG: An International Journal of Obstetrics & Gynaecology [Internet]. The broad (versus restrictive) definition had significantly higher sensitivities (range 62–79% versus 36–50%), lower specificities (range 53–65% versus 72–82%), and similar or higher diagnostic odds ratios and ‘true-positive’ to ‘false-positive’ ratios.
Ogunwole SM, Mwinnyaa G, Wang X, Hong X, Henderson J, Bennett WL. Preeclampsia Across Pregnancies and Associated Risk Factors: Findings From a High‐Risk US Birth Cohort. Journal of the American Heart Association. 2021 Sep 7;10(17):e019612. In this diverse sample of high-risk US women, we identified modifiable and treatable risk factors, including obesity and hypertension for the prevention of preeclampsia.
Vidaeff AC, Saade GR, Sibai BM. Preeclampsia: The Need for a Biological Definition and Diagnosis. Am J Perinatol. 2021 Jul;38(09):976–82. Focusing research on developing better diagnostic and screening methods for what is clinically important, namely maternal and perinatal morbidity and mortality from hypertensive disorders of pregnancy, a long overdue upgrade from what was possible centuries ago, will ultimately lead to better management approaches to what really matters.

 

Unit education on protocols, unit-based drills
Resource(s) Comments
Classification and Diagnosis of Hypertensive Disorders of Pregnancy This document is from the CMQCC Preeclampsia Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
E-Modules From the Alliance for Innovation on Maternal Health.
Improving Health Care Response to Preeclampsia: A California Quality Improvement Toolkit A PowerPoint from the CMQCC Toolkit.
An updated version of the CMQCC toolkit is expected in 2021.
Preeclampsia Informational Webinar From CMQCC.
Sample Nursing Management Policy and Procedure Appendix U from thee CMQCC Preeclampsia Toolkit.
An updated version of the CMQCC toolkit is expected in 2021.
Simulation Scenario: Hypertension in pregnancy, HELLP with seizure From the CMQCC Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
SMFM Hypertension Webcast From Alliance for Innovation on Maternal Health Care
Rapid access to medications
Tools Comments
Sample Preeclampsia/Eclampsia Medication Toolbox List Appendix S of the CMQCC Preeclampsia Toolkit (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
Steps for Preparation, Storage, Ordering, and Administration of Magnesium Sulfate Component of CMQCC Preeclampsia Toolkit (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.

 

System plan for escalation, appropriate consultation, and maternal transport
Tools Comments
Policy for Severe Hypertension in the Obstetrical Patient This is an example of a hospital policy from Beaver Dam Community Hospitals (2019).
WAPC Levels of Care Resources Includes resources related to maternal transport.

RECOGNITION AND PREVENTION: Every patient

Standard protocol for measurement and assessment of BP
Tools Comments
Accurate Blood Pressure Measurement Patient care and treatment recommendation from CMQCC (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
Taking a Blood Pressure A poster from the Oklahoma PQIC

 

References Summary
Bowen L, Pealing L, Tucker K, McManus RJ, Chappell LC. Adherence with blood pressure self-monitoring in women with pregnancy hypertension, and comparisons to clinic readings: A secondary analysis of OPTIMUM-BP. Pregnancy Hypertension. 2021 Aug 1;25:68–74. Median percentage of days with self-monitored blood pressure readings was 77% in the chronic hypertension group and 85% in the gestational hypertension group. Adherence did not vary by different socio-demographic groups.
Herman HG, Barda G, Miremberg H, Gonen N, Torem M, Kleiner I, et al. Management of pregnancies with suspected preeclampsia based on 6-hour vs 24-hour urine protein collection—a randomized double-blind controlled pilot trial. American Journal of Obstetrics & Gynecology MFM. 2021 Sep 1;3(5):100429. Managing pregnancies suspected of preeclampsia with a 6-hour urine protein collection is feasible and associated with similar maternal and neonatal outcomes. In cases where the 6-hour result is in the 168 to 475 mg range, we propose completing a 24-hour collection.
Hoppe KK, Williams M, Thomas N, Zella JB, Drewry A, Kim K, et al. Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study. Pregnancy Hypertens. 2019 Jan;15:171–6. Results indicate telehealth is a promising strategy for postpartum hypertension management to decrease maternal morbidity and hospital readmission.
Hurrell A, Webster L, Chappell LC, Shennan AH. The assessment of blood pressure in pregnant women: pitfalls and novel approaches. American Journal of Obstetrics and Gynecology [Internet]. 2021 Jan 26 [cited 2021 Oct 13]; This review provides an update on methods to assess blood pressure in pregnancy and appropriate technique to optimize accuracy.
Thomas NA, Drewry A, Racine Passmore S, Assad N, Hoppe KK. Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum. BMC Pregnancy Childbirth [Internet]. 2021 Feb 19 [cited 2021 May 14];21. Postpartum women perceived the telehealth remote intervention was a safe, easy to use method that represented an acceptable burden of care and an overall satisfying method for postpartum blood pressure monitoring.
Tran K, Padwal R, Khan N, Wright M-D, Chan WS. Home blood pressure monitoring in the diagnosis and treatment of hypertension in pregnancy: a systematic review and meta-analysis. CMAJ Open. 2021 Jun;9(2):E642–50. Many issues related to home blood pressure monitoring in pregnancy are currently unresolved, including technique, monitoring schedule and target values.

 

Standard response to maternal early warning signs
Resource(s) Comments
Consultation Triggers in Severe Preeclampsia for All Obstetric Units From CMQCC (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Nursing Assessment Frequency From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Preeclampsia Early Recognition Tool (PERT) From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Proteinuria From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Treatment for Acute-onset Severe Hypertension during Pregnancy and the Postpartum Period AIM FAQ topic (08/30/2016)

 

References Summary
Choi YJ, Shin S. Aspirin Prophylaxis During Pregnancy: A Systematic Review and Meta-Analysis. American Journal of Preventive Medicine. 2021 Jul 1;61(1):e31–45. Initiation of low-dose aspirin administration before 20 weeks of gestation considerably decreases the incidence of pre-eclampsia and related neonatal outcomes without increasing bleeding risk.
US Preventive Services Task Force. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: US Preventive Services Task Force Recommendation Statement. JAMA. 2021 Sep 28;326(12):1186–91. The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication for preeclampsia after 12 weeks of gestation in persons who are at high risk for preeclampsia. (B recommendation)
Standards for educating women on signs/symptoms of hypertension and preeclampsia
Tools Comments
Discharge Information for Patients with Diagnosis of Preeclampsia, HELLP Syndrome or Eclampsia Appendix Q from CMQCC Preeclampsia Toolkit (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
Educating Patients Less than half of well-educated women know the signs and symptoms of preeclampsia. The Preeclampsia Foundation is working to improve the resources available to all women and their caregivers by providing evidence based educational materials in its store.
Maternal Mental Health: Depression and Anxiety From the Council on Patient Safety in Women’s Health Care
POST-BIRTH Warning Signs Success Story: An Interview with a New Mother AWHONN has developed a standardized approach to ensuring that postpartum parents are empowered to recognize and act on signs of potentially life-threatening postpartum complications.
Preeclampsia Patient-oriented graphic on signs and symptoms from the Preeclampsia Foundation. Graphic can be ordered from the Preeclampsia Foundation. This example is Appendix O from the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Preeclampsia and Eclampsia Patient-oriented graphic from Froedtert and the Medical College of Wisconsin (07/19)
Preeclampsia (High Blood Pressure during Pregnancy) Patient information from ACOG District II
Prenatal and Postpartum Patient Counseling or Education From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Sample Discharge Sheet for Hypertensive Disorder Patients Sample from Florida PQC (2/2016)
7 Symptoms Every Pregnant Woman Should Know A brief video by the Preeclampsia Foundation.
Speak Up For New Parents Consumer-oriented resource from The Joint Commission.

 

References Summary
Ahmed S, Brewer A, Tsigas EZ, Rogers C, Chappell L, Hewison J. Women’s attitudes, beliefs and values about tests, and management for hypertensive disorders of pregnancy. BMC Pregnancy Childbirth. 2021 Sep 30;21:665. Women with experience of hypertensive disorders were enthusiastic about improved predictive and diagnostic tests. However, varied views about treatment options and expectant management suggest the need for a shared decision-making tool to enable healthcare professionals to support pregnant women’s decision-making to maximize the utility of these tests and interventions.
Marshall CJ, Huma Z, Deardorff J, Britton LE. Prepregnancy Counseling Among U.S. Women With Diabetes and Hypertension, 2016–2018. American Journal of Preventive Medicine. 2021 Oct 1;61(4):529–36. Women with prepregnancy diabetes, hypertension, or both reported low levels of the recommended prepregnancy counseling, suggesting an evidence−practice gap that should be addressed to optimize maternal and infant health outcomes. There is a need for evidence-based and patient-centered models of prepregnancy counseling for those with diabetes and hypertension.
Tsigas EZ. The Preeclampsia Foundation: the voice and views of the patient and her family. American Journal of Obstetrics & Gynecology [Internet]. 2021 Aug 31 [cited 2021 Sep 14]; This article shares the unique perspective of affected women and their families, the effect preeclampsia has, and what the healthcare system can deliver in the future.
Vinogradov R, Smith VJ, Robson SC, Araujo-Soares V. Informational needs related to aspirin prophylactic therapy amongst pregnant women at risk of preeclampsia – A qualitative study. Pregnancy Hypertension. 2021 Aug 1;25:161–8. New interactive and accessible informational resources are needed to engage pregnant women and their partners in aspirin prophylactic therapy.

RESPONSE: Every case of severe hypertension/preeclampsia

Standard protocols for hypertensive disorders
Resource(s) Comments
Acute Treatment Algorithm Appendix E from the updated CMQCC toolkit (2021).
Includes 1) Diagnostic Algorithm, 2) Antihypertensive Treatment Algorithm for Hypertensive Emergencies, and 3) Magnesium Dosing and Treatment for Refractory Seizures.
Daily Assessment for Delivery versus Continuing Pregnancy From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Eclampsia algorithm Appendix E from the CMQCC Preeclampsia Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period ACOG Committee Opinion No. 623. February 2015.
OB Hypertension This is a sample order set provided by Fort Healthcare.
Preeclampsia Early Recognition Tool (PERT) Appendix D from the CMQCC Preeclampsia Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
Sample Order Sets: Labetalol, Hydralazine, Oral Nifedipine These sample order sets were adapted from Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Committee Opinion No. 692. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017. 129:e90-95.

 

References Summary
Deshmukh US, Lundsberg LS, Culhane JF, Partridge C, Reddy UM, Merriam AA, et al. Factors associated with appropriate treatment of acute-onset severe obstetrical hypertension. American Journal of Obstetrics and Gynecology. 2021 Sep 1;225(3):329.e1-329.e10. Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment.
Rosenbloom JI, Nelson DM, Saunders S, Cole FS, Chandarlis J, Macones GA, et al. Addressing medically-underserved populations through maternal-fetal transport: A geographic analysis. The Journal of Maternal-Fetal & Neonatal Medicine. 2018 Dec 26;0(ja):1–111. Despite regionalization of maternal care in the USA, there is little contemporary information on characteristics and utilization of maternal–fetal transport. We used geographic analysis to investigate referral and transportation patterns of the maternal–fetal transport service at our institution.
Schneider P, King PAL, Keenan-Devlin L, Borders AEB. Improving the Timely Delivery of Antihypertensive Medication for Severe Perinatal Hypertension in Pregnancy and Postpartum. Am J Perinatol [Internet]. 2021 May 2 [cited 2021 May 17] Implementation of a quality improvement initiative for perinatal hypertension associated with pregnancy and postpartum improved the delivery of appropriate and timely therapy for severely elevated blood pressures and demonstrated the impact of interdisciplinary communication in the process.
Spencer NM, Gabra M, Bedell SM, Scott DM, Rauk P. Improving compliance with guidelines for hypertensive disorders of pregnancy through an electronic health record alert: A retrospective chart review. Pregnancy Hypertension. 2021 Aug 1;25:1–6. An automated EHR alert improved timely administration of rapid-acting antihypertensive medications for hypertensive emergency and has the potential to improve compliance with national preeclampsia guidelines.
Squire Eppes C, Han SB, Haddock AJ, Buckler AG, Davidson CM, Hollier LM. Enhancing Obstetric Safety Through Best Practices. Journal of Women’s Health [Internet]. 2020 Nov 23 [cited 2020 Nov 30]; The authors review 1) several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention, and 2). the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting.
Thompson X, Sullivan MB, Mathura P, Wong A, Crawford J, Sia W. Implementation of a Clinical Decision Laboratory Ordering Algorithm for Preeclampsia: A Quality Improvement Initiative. J Obstet Gynaecol Can. 2020 Oct;42(10):1223-1229.e3. A quality improvement (QI) approach was used to analyze the ordering process in the obstetrics wards of a tertiary care centre. An
algorithm for ordering preeclampsia investigations was developed by a multidisciplinary team, implemented, and posted

 

Support plan for patients, families, and staff for ICU admissions and serious complications
Tools Comments
Patient, Family, and Staff Support After a Severe Maternal Event From the Council on Patient Safety in Women’s Health Care. This is a recording of a live event on Oct 14, 2014.
Post-discharge Evaluation: Elevated Blood Pressure An algorithm from ACOG District II
Postpartum Discharge Phone Call Script This script provides suggested language for a range of topics.
Save Your Life: Get Care for These POST-BIRTH Warning Signs

This patient-focused document developed by AWHONN is available in:

 

References Summary
Chou C-C, Liaw J-J, Chen C-C, Liou Y-M, Wang C-J. Effects of a Case Management Program for Women With Pregnancy-Induced Hypertension. Journal of Nursing Research. 2021 Oct;29(5):e169. The nurse-led case management program was shown to have short-term positive effects on the psychosocial outcomes of a population of Taiwanese patients with PIH.

REPORTING/SYSTEMS LEARNING: Every unit

Establishing a culture of huddles and post-event debriefs
Resource(s) Comments
ACOG Simulation Eclampsia Formative Eval From ACOG
Briefs and Debriefs From AHRQ TeamSTEPPS Pocket Guide
Debriefing Tool From the CMQCC Preeclampsia Toolkit (approved 12/20/2013). This specific tool is for an obstetrical hemorrhage drill.
An updated version of the CMQCC toolkit is expected in 2021.
Obstetric Team Debriefing Form From ACOG District II
PHEW: The Abbreviated Debrief This is a four-step debrief tool.
Role of Medical Simulation From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Severe Hypertension Data and Debrief Form From the Alaska PQC (3/5/2020)
Severe Maternal Hypertension Debrief From the Illinois PQC
Teamwork and Communication From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Multidisciplinary review for systems issues
Tools Comments
Patient, Family and Staff Support Following a Severe Maternal Event From the Council on Patient Safety in Women’s Health Care Safety Action Series (October 14, 2014)
Sustainability Compliance Data Form From the Illinois PQC (2/15/2018)
Sustainability Plan: Maternal Hypertension Initiative From the Illinois PQC
Monitoring outcomes and process metrics
Tools Comments
Severe Maternal Morbidity (long form) Process for reviewing a severe maternal morbidity event from the Council on Patient Safety in Women’s Health Care (6/28/2016)
Severe Maternal Morbidity (short form) Process for reviewing a severe maternal morbidity event from the Council on Patient Safety in Women’s Health Care (6/28/2016)

 

References Summary
Ananth CV, Brandt JS, Hill J, Graham HL, Grover S, Schuster M, et al. Historical and Recent Changes in Maternal Mortality Due to Hypertensive Disorders in the United States, 1979 to 2018. Hypertension. 0(0):HYPERTENSIONAHA.121.17661. The temporal burden of hypertension-related MMR in the United States has increased substantially for chronic hypertension–associated MMR and decreased for preeclampsia/eclampsia-associated MMR. Nevertheless, deaths from hypertension continue to contribute substantially to maternal deaths.
Jenabi E, Afshari M, Khazaei S. The association between preeclampsia and the risk of metabolic syndrome after delivery: a meta-analysis. The Journal of Maternal-Fetal & Neonatal Medicine. 2021 Oct 2;34(19):3253–8. The results of this meta-analysis provide evidence for relation between preeclampsia and increase in risk of metabolic syndrome. However, more epidemiological and clinical studies are needed to explore the mechanism of preeclampsia on increased risk of metabolic syndrome.
Kountouris E, Clark K, Kay P, Roberts N, Bramham K, Kametas NA. Postnatal assessment for renal dysfunction in women with hypertensive disorders of pregnancy. J Nephrol. 2021 Oct 1;34(5):1641–9. Renal dysfunction was present in one in three women with hypertensive disorders of pregnancy at 6–8 weeks postpartum. This includes women with gestational hypertension and chronic hypertension without superimposed pre-eclampsia, and thus these women should also be offered postnatal review.
Malek AM, Wilson DA, Turan TN, Mateus J, Lackland DT, Hunt KJ. Incident Heart Failure Within the First and Fifth Year after Delivery Among Women With Hypertensive Disorders of Pregnancy and Prepregnancy Hypertension in a Diverse Population. Journal of the American Heart Association. 2021 Sep 7;10(17):e021616. Women with hypertensive disorders of pregnancy and pre-pregnancy hypertension were at higher heart failure risk (highest for superimposed preeclampsia) within 5 years of delivery. Non-Hispanic Black women with hypertensive disorders of pregnancy had higher heart failure risk than non-Hispanic White women, regardless of pre-pregnancy hypertension.
Oshunbade AA, Lirette ST, Windham BG, Shafi T, Hamid A, Gbadamosi SO, et al. Hypertensive Diseases in Pregnancy and Kidney Function Later in Life: The Genetic Epidemiology Network of Arteriopathy (GENOA) Study. Mayo Clinic Proceedings [Internet]. 2021 Sep 24 [cited 2021 Oct 8] A history of hypertension in pregnancy is an important prognostic risk factor for kidney disease.
Plummer MD, Andraweera PH, Garrett A, Leemaqz S, Wittwer M, Aldridge E, et al. Hypertensive disorders of pregnancy and later cardiovascular disease risk in mothers and children. Journal of Developmental Origins of Health and Disease. 2021 Aug;12(4):555–60. Our data suggest that gestational hypertension is associated with increased cardiovascular risk in women 8–10 years after first pregnancy and preeclampsia is associated with increased offspring risk at 8–10 years of age, highlighting differences between these two hypertensive disorders of pregnancy.
Wen T, Krenitsky NM, Clapp MA, D’Alton ME, Wright JD, Attenello F, et al. Fragmentation of postpartum readmissions in the United States. Am J Obstet Gynecol. 2020 Jan 18; This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.

INFORMATION FOR EMERGENCY DEPARTMENT PROVIDERS

Readiness
Tools Comments
Are you pregnant…? A sign to support awareness

 

References Summary
Balki M, Hoppe D, Monks D, Sharples L, Cooke ME, Tsen L, et al. The PETRA (Perinatal Emergency Team Response Assessment) Scale: A High-Fidelity Simulation Validation Study. J Obstet Gynaecol Can. 2017 Jul;39(7):523-533.e12. The objective of this study was to establish the validity and reliability of a new interdisciplinary teamwork assessment scale, the Perinatal Emergency Team Response Assessment (PETRA), to assess team dynamics during a simulated obstetric crisis.
Bernstein PS, Martin JN, Barton JR, Shields LE, Druzin ML, Scavone BM, et al. National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2017 Jul 7; The patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.
Cunningham SD, Magriples U, Thomas JL, Kozhimannil KB, Herrera C, Barrette E, et al. Association Between Maternal Comorbidities and Emergency Department Use Among a National Sample of Commercially Insured Pregnant Women. Academic Emergency Medicine [Internet]. 2017 Aug [cited 2021 Oct 25];24(8). Among pregnant women, comorbidity burden was associated with more ED utilization. Efforts to reduce acute unscheduled care and improve care coordination during pregnancy should target interventions to patient comorbidity.
Murray Horwitz ME, Rodriguez MI, Dissanayake M, Carmichael SL, Snowden JM. Postpartum health risks among women with hypertensive disorders of pregnancy, California 2008–2012. Journal of Hypertension. 2021 May;39(5):1009–17. Women with hypertensive disorders of pregnancy are at an increased risk for virtually all postpartum complications, including those not related to hypertension, and may benefit from enhanced and comprehensive postpartum care.
Musits A, Wing R, Simoes M, Style M, Petrone G, Musisca N, et al. Interdepartmental Collaboration for Simulation-based Education: Obstetric Emergencies for Emergency Medicine. R I Med J (2013). 2020 May 1;103(4):42–5. An interdepartmental and collaborative approach can optimize the success of a simulation educational program.
Patel S, Rodriguez AN, Macias DA, Morgan J, Kraus A, Spong CY. A Gap in Care? Postpartum Women Presenting to the Emergency Room and Getting Readmitted. Am J Perinatol. 2020 Dec;37(14):1385–92. In this study, the average proportion of women presenting for an emergent hospital encounter in the immediate 42-day postpartum period is 5.7%. Nearly 40% of emergent hospital encounters resulted in admission and the rate increased from to 2.0 to 3.4% over the study period. The most common reasons for presentation were fever, abdominal pain, headache, vaginal bleeding, wound concerns, and hypertension.
Robinson DW, Anana M, Edens MA, Kanter M, Khandelwal S, Shah K, et al. Training in Emergency Obstetrics: A Needs Assessment of U.S. Emergency Medicine Program Directors. West J Emerg Med. 2018 Jan;19(1):87–92. The authors sent a web-based survey covering the four most common obstetrical emergencies (pre-eclampsia/eclampsia, postpartum hemorrhage (PPH), shoulder dystocia, and breech presentation) through email invitations to all program directors (PD) of U.S. Emergency Medicine residency programs. The survey found that PDs are less comfortable in their graduates’ ability to perform non-routine emergency obstetrical procedures.
Wolf LA, Delao AM, Evanovich Zavotsky K, Baker KM. Triage Decisions Involving Pregnancy-Capable Patients: Educational Deficits and Emergency Nurses’ Perceptions of Risk. J Contin Educ Nurs. 2021 Jan 1;52(1):21–9. In areas where obstetric services are not available, emergency departments often become the default for unplanned obstetric care, yet emergency nurses are not universally trained in the identification and treatment of obstetric emergencies. There are significant knowledge deficits in the care of patients presenting with high-risk conditions associated with pregnancy.

 

Recognition
Tools Comments
Emergency Department Recognition and Treatment: Focus on Delayed Postpartum Preeclampsia and Eclampsia From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.

 

References Summary
Bernstein PS, Martin JN, Barton JR, Shields LE, Druzin ML, Scavone BM, et al. National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2017 Jul 7; The patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.
Kantorowska A, Heiselman CJ, Halpern TA, Akerman MB, Elsayad A, Muscat JC, et al. Identification of factors associated with delayed treatment of obstetric hypertensive emergencies. American Journal of Obstetrics & Gynecology [Internet]. 2020 Feb 14 [cited 2020 May 7];0(0). Initial blood pressure in the nonsevere range, absence of preeclampsia symptoms, presentation overnight, white race, having complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to a delay in the treatment of obstetric hypertensive emergency. Quality improvement initiatives that target these barriers should be instituted to improve timely treatment.
Richardson KJ. Postpartum Headache. Adv Emerg Nurs J. 2017 Dec;39(4):258–65. Emergency department providers must possess a strong knowledge base and skill set to recognize subtle presentations and direct care accordingly to ensure positive patient outcomes.
Squire Eppes C, Han SB, Haddock AJ, Buckler AG, Davidson CM, Hollier LM. Enhancing Obstetric Safety Through Best Practices. Journal of Women’s Health [Internet]. 2020 Nov 23 [cited 2020 Nov 30]; The authors review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting.
Vgontzas A, Robbins MS. A Hospital Based Retrospective Study of Acute Postpartum Headache. Headache: The Journal of Head and Face Pain. 2018;58(6):845–51. Nearly three-quarters of postpartum women who present with acute onset headache and receiving neurological consultation are found to have a secondary headache – with nearly half of the secondary headaches attributed to preeclampsia or cerebrovascular headache disorders. The absence of a headache history and a clear post-dural puncture headache description should prompt strong consideration for neuroimaging to rule out cerebrovascular etiologies of headache as well as close monitoring for signs and symptoms of preeclampsia in women presenting with acute severe postpartum headache.
Response
Tools Comments
Evaluation and Treatment of Antepartum and Postpartum Preeclampsia and Eclampsia in the Emergency Department An algorithm from CMQCC.
An updated version of the CMQCC toolkit is expected in 2021.
Need to Treat The Ghostbuster-themed poster from the Illinois PQC

 

References Summary
Bernstein PS, Martin JN, Barton JR, Shields LE, Druzin ML, Scavone BM, et al. National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2017 Jul 7; The patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.
Froehlich RJ, Maggio L, Has P, Vrees R, Hughes BL. Improving Obstetric Hypertensive Emergency Treatment in a Tertiary Care Women’s Emergency Department. Obstetrics & Gynecology. 2018 Oct;132(4):850. A quality improvement initiative was not associated with more women achieving BP control within an hour of obstetric hypertensive emergency treatment, but was associated with decreased time to achieve control. This suggests improved clinical practice after the intervention.
Squire Eppes C, Han SB, Haddock AJ, Buckler AG, Davidson CM, Hollier LM. Enhancing Obstetric Safety Through Best Practices. Journal of Women’s Health [Internet]. 2020 Nov 23 [cited 2020 Nov 30]; The authors review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting.
Waldman I, Wagner S, Posadas K, Deimling TA. The impact of pregnancy on headache evaluation in the emergency department, a retrospective cohort study. Emerg Radiol. 2017 Oct;24(5):505–8. CT should not be considered contraindicated in the pregnant population and the amount of ionizing radiation to the fetus is well within the maximum safe dose, particularly with appropriate shielding. The time difference, cost, fetal exposure risk, and availability of CT compared to MRI should be taken into account when establishing a criterion for diagnostic evaluation.

 

Reporting and systems learning
References Summary
Hutchcraft ML, Ola O, McLaughlin EM, Hade EM, Murphy AJ, Frey HA, et al. A one-year cross sectional analysis of emergency medical services utilization and its association with hypertension in pregnancy. Prehospital Emergency Care. 2021 Oct 4;0(ja):1–12. Prehospital management of hypertensive disorders of pregnancy may focus on identification and treatment of severe pre-eclampsia or eclampsia. Prehospital treatment of hypertensive disorders of pregnancy could be optimized.
Monti D, Wang CY, Yee LM, Feinglass J. Antepartum hospital use and delivery outcomes in California. American Journal of Obstetrics & Gynecology MFM. 2021 Nov 1;3(6):100461. Antepartum hospital use is frequent and is associated with patient clinical and demographic factors. Addressing the high prevalence of antepartum hospital use should be a part of future quality improvement and health equity efforts focused on improving care for patients with the greatest medical and social needs.

 

AFTER HOSPITAL DISCHARGE

Follow-up for hypertension
References Summary
Bick D, Silverio SA, Bye A, Chang Y-S. Postnatal care following hypertensive disorders of pregnancy: a qualitative study of views and experiences of primary and secondary care clinicians. BMJ Open. 2020 Jan 19;10(1):e034382. Evidence of longer term consequences for women’s health following hypertensive disorders of pregnancy is accumulating. Clinicians responsible for postnatal care following hypertensive disorders of pregnancy should ensure they are familiar with relevant guidance, able to implement recommendations and involve women in decisions about ongoing care and why this is important.
Bruce KH, Anderson M, Stark JD. Factors associated with postpartum readmission for hypertensive disorders of pregnancy. American Journal of Obstetrics & Gynecology MFM. 2021 Sep 1;3(5):100397. Hospital readmission for postpartum hypertension was associated with persistent postpartum hypertension (blood pressure of ≥140/90 mm Hg), increasing maternal age, and more severe antepartum hypertension.
Celi AC, Seely EW, Wang P, Thomas AM, Wilkins-Haug LE. Caring for Women After Hypertensive Pregnancies and Beyond: Implementation and Integration of a Postpartum Transition Clinic. Matern Child Health J. 2019 Nov 1;23(11):1459–66. The authors report a postpartum transition clinic after hypertensive pregnancy. In the diverse population, patients attended 2–3 visits, incorporated home blood pressure monitoring, adjusted antihypertensive medications and initiated prevention measures such as nutrition referrals and PCP follow-up.
McLaren RA, Magenta M, Gilroy L, Duarte MG, Narayanamoorthy S, Weedon J, et al. Predictors of readmission for postpartum preeclampsia. Hypertension in Pregnancy. 2021 Sep 11;0(0):1–7. A predictive model using age, race, discharge blood pressures, and preeclampsia was able to predict re-admission for postpartum preeclampsia with a high level of sensitivity.
Palmrich P, Binder C, Zeisler H, Kroyer B, Pateisky P, Binder J. Awareness of obstetricians for long-term risks in women with a history of preeclampsia or HELLP syndrome. Arch Gynecol Obstet [Internet]. 2021 Aug 18 [cited 2021 Oct 13] The authors demonstrated that counselling concerning the risk of long-term cardiovascular disease and risk of recurrence after a pregnancy complicated by preeclampsia or HELLP syndrome has been established in obstetric departments in public hospitals.
Well-woman care
Resource(s) Comments
Wellness Visit WAPC resource based on recommendations for Well-Woman Care — A Well-Woman Chart. Women’s Preventive Services Initiative.

 

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