AIM Severe Hypertension Change Package

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.

SETTING THE FOUNDATION

General Resources

Resource(s)	Comments
Expected Outcomes and Measures	This document lists the expected outcomes for and the measures associated with the initiative.
Definitions	This document gives key definitions used to guide data collection.
Data Collection Form	This document was developed to facilitate data collection.
Driver Diagram	The diagram provides the underlying approach for the initiative.
Kick-off Webinar	View recorded Webinar.

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

Resource(s)	Comments
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.
Improving Health Equity: Assessment Tool for Healthcare Organizations
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.
PA AIM Bundle: Improving Severe Hypertension Treatment and Reducing Racial/Ethnic Disparities
Reduction of Peripartum Racial/Ethnic Disparities (+AIM)	This link provides PDFs of the AIM bundle, complete and supplemental resource listings, and other materials.
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.

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

Resource(s)	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
MEWS-Protocol
Sample hospital policy
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.

Unit education on protocols, unit-based drills

Resource(s)	Comments
Classification and Diagnosis of Hypertensive Disorders of Pregnancy
E-Modules	From the Alliance for Innovation on Maternal Health.
Improving Health Care Response to Preeclampsia: A California Quality Improvement Toolkit
Preeclampsia Informational Webinar	From CMQCC.
Sample Nursing Management Policy and Procedure
Simulation Scenario: Hypertension in pregnancy, HELLP with seizure
SMFM Hypertension Webcast	From Alliance for Innovation on Maternal Health Care

Rapid access to medications

Resource(s)	Comments
Sample Preeclampsia/Eclampsia Medication Toolbox List	Appendix S of the CMQCC Preeclampsia Toolkit (approved 12/20/2013)
Steps for Preparation, Storage, Ordering, and Administration of Magnesium Sulfate	Component of CMQCC Preeclampsia Toolkit (approved 12/20/2013)

System plan for escalation, appropriate consultation, and maternal transport

Resource(s)	Comments
Policy for Severe Hypertension in the Obstetrical Patient	This is an example of a hospital policy.

RECOGNITION AND PREVENTION: Every patient

Standard protocol for measurement and assessment of BP

Resource(s)	Comments
Accurate Blood Pressure Measurement	Patient care and treatment recommendation from CMQCC (approved 12/20/2013)
Taking a Blood Pressure	A poster from the Oklahoma PQIC

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)
Nursing Assessment Frequency	From CMQCC Preeclampsia Toolkit (approved 12/20/2013)
Preeclampsia Early Recognition Tool (PERT)	From CMQCC Preeclampsia Toolkit (approved 12/20/2013)
Proteinuria	From CMQCC Preeclampsia Toolkit (approved 12/20/2013)
Treatment for Acute-onset Severe Hypertension during Pregnancy and the Postpartum Period	AIM FAQ topic (08/30/2016)

Standards for educating women on signs/symptoms of hypertension and preeclampsia

Resource(s)	Comments
Discharge Information for Patients with Diagnosis of Preeclampsia, HELLP Syndrome or Eclampsia	Appendix Q from CMQCC Preeclampsia Toolkit (approved 12/20/2013)
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 our 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).
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)
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.

RESPONSE: Every case of severe hypertension/preeclampsia

Standard protocols for hypertensive disorders

Resource(s)	Comments
Daily Assessment for Delivery versus Continuing Pregnancy	From the CMQCC Preeclampsia Toolkit (approved 12/20/2013)
Eclampsia algorithm
Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period	ACOG Committee Opinion No. 623. February 2015.
Hydralazine algorithm
Labetalol algorithm
OB Hypertension	This is a sample order set provided by Fort Healthcare.
Oral nifedipine algorithm
Preeclampsia Early Recognition Tool (PERT)
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.
Severe hypertension checklist
Suspected preeclampsia algorithm

Support plan for patients, families, and staff for ICU admissions and serious complications

Resource(s)	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: Arabic English Mandarin Chinese Spanish

REPORTING/SYSTEMS LEARNING: Every unit

Establishing a culture of huddles and post-event debriefs

Resource(s)	Comments
ACOG Simulation Eclampsia Formative Eval
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.
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)
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)

Multidisciplinary review for systems issues

Resource(s)	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

Resource(s)	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)

INFORMATION FOR EMERGENCY DEPARTMENT PROVIDERS

Readiness

Resource(s)	Comments
Are you pregnant…?	A sign to support awareness
Triage Decisions Involving Pregnancy-Capable Patients: Educational Deficits and Emergency Nurses’ Perceptions of Risk	Wolf LA, Delao AM, Evanovich Zavotsky K, Baker KM. J Contin Educ Nurs. 2021;52(1):21-29.

Recognition

Resource(s)	Comments
Emergency Department Recognition and Treatment: Focus on Delayed Postpartum Preeclampsia and Eclampsia	From the CMQCC Preeclampsia Toolkit (approved 12/20/2013)

Response

Resource(s)	Comments
Evaluation and Treatment of Antepartum and Postpartum Preeclampsia and Eclampsia in the Emergency Department	An algorithm from CMQCC
Need to Treat	The Ghostbuster-themed poster from the Illinois PQC

Reporting and systems learning

Resource(s)	Comments

AFTER HOSPITAL DISCHARGE

Follow-up for hypertension

Resource(s)	Comments
Patient perceptions, opinions and satisfaction of telehealth with remote blood pressure monitoring postpartum	Thomas NA, Drewry A, Racine Passmore S, Assad N, Hoppe KK. BMC Pregnancy Childbirth [Internet]. 2021 Feb 19 [cited 2021 May 14];21.
Telehealth with remote blood pressure monitoring for postpartum hypertension: A prospective single-cohort feasibility study	Hoppe KK, Williams M, Thomas N, Zella JB, Drewry A, Kim K, et al. Pregnancy Hypertens. 2019 Jan;15:171–6.

Well-woman care (Under Construction)

Resource(s)	Comments