This document is designed to assist tracking measures.
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.
The section describing the Severe Maternal Hypertension Initiative contains useful information.
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.
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.
The QI Project Charter provides a rationale and roadmap for team to clarify thinking about what needs to be done and why.
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.
This document integrates the AIM Improving Severe Hypertension Treatment and Reducing Racial/Ethnic Disparities bundles.
This link provides PDFs of the AIM bundle, complete and supplemental resource listings, and other materials.
Comorbid hypertension and diabetes are more common among non-Hispanic black women and less likely to be diagnosed.
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.
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.
Multi-modal applications that combine texting with self-guided interactive content show promise for culturally tailored mHealth.
Black women were at higher risk for severe morbidity and mortality associated with preeclampsia.
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.
Racial residential segregation was associated with greater prevalence of hypertensive disorder of pregnancy among those living in higher poverty neighborhoods.
Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non-Hispanic whites.
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.
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.
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.
In this study, greenness was associated with lower hypertensive disorders of pregnancy odds.
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.
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.
A sample nursing policy for the Modified Early Obstetric Warning System (MEOWS) from Crawford Memorial Hospital.
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.
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.
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.
The sensitivity of obstetric early warning system at its best was 72% for pre-eclampsia, 52% for infection and 25% for postpartum haemorrhage.
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.
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.
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.
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.
This document is from the CMQCC Preeclampsia Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
A PowerPoint from the CMQCC Toolkit.
An updated version of the CMQCC toolkit is expected in 2021.
Appendix U from thee CMQCC Preeclampsia Toolkit.
An updated version of the CMQCC toolkit is expected in 2021.
From the CMQCC Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
Appendix S of the CMQCC Preeclampsia Toolkit (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
Component of CMQCC Preeclampsia Toolkit (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
This is an example of a hospital policy from Beaver Dam Community Hospitals (2019).
Patient care and treatment recommendation from CMQCC (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
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.
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.
Results indicate telehealth is a promising strategy for postpartum hypertension management to decrease maternal morbidity and hospital readmission.
This review provides an update on methods to assess blood pressure in pregnancy and appropriate technique to optimize accuracy.
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.
Many issues related to home blood pressure monitoring in pregnancy are currently unresolved, including technique, monitoring schedule and target values.
From CMQCC (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
AIM FAQ topic (08/30/2016)
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.
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)
Appendix Q from CMQCC Preeclampsia Toolkit (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.
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.
From the Council on Patient Safety in Women’s Health Care
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.
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.
Patient-oriented graphic from Froedtert and the Medical College of Wisconsin (07/19)
Patient information from ACOG District II
From CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
A brief video by the Preeclampsia Foundation.
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.
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.
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.
New interactive and accessible informational resources are needed to engage pregnant women and their partners in aspirin prophylactic therapy.
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.
From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
Appendix E from the CMQCC Preeclampsia Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
ACOG Committee Opinion No. 623. February 2015.
Appendix D from the CMQCC Preeclampsia Toolkit (approved 12/20/13).
An updated version of the CMQCC toolkit is expected in 2021.
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.
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.
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.
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.
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.
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.
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
From the Council on Patient Safety in Women’s Health Care. This is a recording of a live event on Oct 14, 2014.
This script provides suggested language for a range of topics.
This patient-focused document developed by AWHONN is available in:
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.
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.
From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
From the Council on Patient Safety in Women’s Health Care Safety Action Series (October 14, 2014)
Process for reviewing a severe maternal morbidity event from the Council on Patient Safety in Women’s Health Care (6/28/2016)
Process for reviewing a severe maternal morbidity event from the Council on Patient Safety in Women’s Health Care (6/28/2016)
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.
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.
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.
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.
A history of hypertension in pregnancy is an important prognostic risk factor for kidney disease.
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.
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.
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.
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.
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.
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.
An interdepartmental and collaborative approach can optimize the success of a simulation educational program.
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.
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.
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.
From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.
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.
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.
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.
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.
An algorithm from CMQCC.
An updated version of the CMQCC toolkit is expected in 2021.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
WAPC resource based on recommendations for Well-Woman Care — A Well-Woman Chart. Women’s Preventive Services Initiative.