Maternal Hypertension Change Package

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.

A resource from IHI.

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.

Patient care and treatment recommendation from CMQCC (approved 12/20/2013)
An updated version of the CMQCC toolkit is expected in 2021.

A poster from the Oklahoma PQIC

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.

Sample from Florida PQC (2/2016)

A brief video by the Preeclampsia Foundation.

Consumer-oriented resource from The Joint Commission.

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.

From ACOG

From AHRQ TeamSTEPPS Pocket Guide

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 ACOG District II

This is a four-step debrief tool.

From the CMQCC Preeclampsia Toolkit (approved 12/20/2013).
An updated version of the CMQCC toolkit is expected in 2021.

From the Illinois PQC

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)

From the Illinois PQC (2/15/2018)

From the Illinois PQC

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.

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.