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"The biggest barrier [to improvement] was low perception of risk, especially for patients who had severe-range hypertension but no other subjective symptoms."
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Changing Assumptions About the Dangers of Hypertension in Pregnant Women

By IHI Multimedia Team | Tuesday, March 10, 2020

Changing Assumptions About the Dangers of Hypertension in Pregnant Women

Photo by Ewa Urban | Pixabay

Insufficient identification and treatment of hypertension are leading causes of preventable maternal mortality and morbidity. To address this problem, in June of 2015, Northwestern Medicine Central DuPage Hospital (Central DuPage) began working to ensure that all pregnant women delivering in their facility receive appropriate screening and treatment for hypertension. Central DuPage was supported in this improvement work by the Illinois Perinatal Quality Collaborative (ILPQC). ILPQC is a nationally recognized statewide network of hospital teams, perinatal clinicians, patients, public health leaders, and policymakers committed to improving health care and outcomes for mothers and babies across Illinois.

The team at Central DuPage set a goal to consistently administer IV/anti-hypertensive medication when appropriate, within 30-60 minutes of identification of severe hypertension. (Severe hypertension is defined as systolic blood pressure greater than or equal to 160 and/or diastolic blood pressure greater than or equal to 110). To move toward this goal, they formed a multidisciplinary team consisting of pharmacists, clinical directors, obstetricians, perinatologists, and staff nurses with occasional representation from the emergency department (ED).

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The team began with staff education, using tools such as presentations, newsletters, and rounding. They also worked on assembling an Electronic Health Record (EHR) report, which looked at vital signs and facilitated data collection. To guide their work, the team focused on the questions: Are we evaluating and treating the severe-range hypertensive patients? Are we reliably administering anti-hypertensive medications?

They made several changes to their protocols and procedures. For example, the pharmacists on the team recommended using pre-filled 20-mg syringes for administering labetalol, a beta-blocker used in severe cases of hypertension. The staff greatly appreciated these pre-filled syringes, which made the medication easier and safer to administer. Staff nurses used a Severe Hypertension Bedside Checklist with instructions on how to respond to various situations. Another area of emphasis was developing standard patient education. They used materials from the Preeclampsia Foundation and embedded them into discharge paperwork to increase standard education about postpartum symptoms.

Although the staff were making progress, they still faced some major challenges. The biggest barrier was low perception of risk, especially for patients who had severe-range hypertension but no other subjective symptoms. When a patient’s blood pressure was in the severe range, RNs sometimes attributed the result to anxiety, pain, or chronic hypertension, and did not notify the provider. If they did notify the provider, the provider did not always order appropriate or timely treatment. And if a patient’s blood pressure was within the moderate range (defined as systolic blood pressure greater than or equal to 140 and/or diastolic blood pressure greater than or equal to 90), staff did not always check again in 15 minutes as per the protocol. Staff nurse and clinical practice partner Maggie Colliander said, “We had to work on changing the mindset that this is an acute event, it’s severe.”

Unfortunately, in the spring of 2017, an adverse event caused the staff to revisit the reliability of their procedures. A patient had been admitted for monitoring of preeclampsia at 33 weeks of gestation. The patient’s blood pressure was checked regularly but high readings were attributed to other factors such as anxiety, and no treatment was started. The day next day, as the care teams handed-off to each other, the patient’s blood pressure remained high, but still, no treatment was started. Eventually, the team started the patient on an IV anti-hypertensive, but her condition had already begun to deteriorate. Due to a suspected placental abruption, the patient was induced, and following an unsuccessful labor, delivered via a Cesarean birth. The baby required resuscitation but fortunately recovered and went home in good health along with the mother.

As a result of this adverse event, the staff felt increased urgency and realized they needed to be more creative and more reliable. “Education is not enough,” Colliander said. “We needed to change our perception of risk.”

At any given time, only one obstetrician is on call for the entire hospital and going through the standard hospital chain of command can take too much time. As a more efficient alternative, the team developed an escalation algorithm to quickly facilitate treatment orders. They also developed case studies for RNs with different examples of how these scenarios could play out, and opportunities to practice using the escalation algorithm. They required all staff to participate in simulations on a yearly basis.

For missed cases — that is, when patients with moderately high blood pressures did not have their blood pressure taken again within 15 minutes or if patients with severe blood pressures did not receive medication within 30-60 minutes — the hospital instituted procedures for follow-up. This follow-up includes a meeting between the nurse leader and the clinicians involved to review the hospital’s hypertension policy and expectations. The second occurrence results in coaching and, if needed, physicians are required to discuss their case using a peer-review process.

In addition, the team worked with a Patient-Family Advisor who had previously experienced an adverse outcome as a result of preeclampsia. She presented at a Lunch-and-Learn on effective ways to communicate with patients about the severity of the condition.

When Central DuPage first began this improvement work, they determined (with support from the ILPQC) that their baseline rate for timely treatment of hypertension was 38 percent. Following the improvements implemented after the adverse event in the spring of 2017, the rate jumped up temporarily. However, they were not able to sustain that increase. Since the introduction of the escalation algorithm, in the fall of 2017, the rate has improved, notwithstanding a few occasional dips, which the team attributes to staff turnover. Since July of 2019, the treatment rate has consistently been 90 to 100 percent.

The multidisciplinary team continues to look at the data frequently (every two weeks). They meet in person on a quarterly basis and communicate by email between meetings. The data also remains on a quality dashboard. Some of the staff members who were initially skeptical have become some of the most motivated. “They are now so proud of the improvements that we made,” said Colliander. “Keeping it at the forefront has been really vital.”

You may also be interested in:

The Better Maternal Outcomes Rapid Improvement Network is a free initiative focused on improving maternal outcomes and respectful care. Join a free informational call on Wednesday, March 18 to learn more about work focusing on care in rural hospitals.

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